Case 2:15-cv-05903-FMO-JEM Document 1 Filed 08/05/15 Page 1 of 9 Page ID #:1

1 LORETTA E. LYNCH

Attorne)" General

2 MARK J. KAPPELHOFF

Deputy Assistant Attorney General

3 Civil Rights Division

JUDITH C. PRESTON

4 Actif!g Chief, Special Litigation Section

LAURA COON, Special Counsel, Special Liti_gation Section

5 LUIS E. SAUCEDO, Counselor to tile Chief, Special Litigation Section

CATHLEEN S. TRAINOR, Trial Attorney

6 U.S. Department of Justice

Civil Rights Division

7 Special Litigation Section

950 Pennsylvania Avenue, N.W., PHB 5026

8

Washington, D.C. 20530

Tele_Rhone: (202) 514-6255

9

Emml: laura.coon@usdoj.gov; cathleen.trainor@usdoj.gov

10 EILEEN M. DECKER United States Attorney

11 LEON W. WEIDMAN Assistant United States Attorney

12 Chief, Civil Division

.

ROBYN-MARIE LYON MONTELEONE (State Bar No. 130005)

13 Assistant United States Attorney Assistant Division Chief, Civil Rights Unit Chief, Civil Division

14 JOANNA HULL (State Bar No. 227153) Assistant United States Attorn~y

15

300 North Los Angeles Street, Suite 7516

Los Angeles, California 90012

16

Telephone: (213) 894-2458/6585; Facsimile: (213) 894-7819

E-mail: Robby.Monteleone@usdoj .gov; Joanna.Hull@usdoj .gov

17 Attorneys for Plaintiff

18 UNITED STATES OF AMERICA

19

UNITED STATES DISTRICT COURT

20

FOR THE CENTRAL DISTRICT OF CALIFORNIA

21

WESTERN DIVISION

22 UNITED STATES OF AMERICA,

No.CV 15-5903

23

Plaintiff,

24

v.

25 COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF
26 JIM MCDONNELL, in his official capacity;
27 Defendants.
28

COMPLAINT
IFor violations of the Civil Rights of
nstitutionalized Persons Act, 42 U.S.C. &§ 1997-l997j; and the Violent Crime
C19o9nt4r,o4l2aund.sL.ca.w§E1n4fo14rc1e]ment Act of

1

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1

Plaintiff, UNITED STATES OF AMERICA ("Plaintiff), by its undersigned

2 attorneys, hereby alleges upon information and belief:

3

1. The Attorney General files this Complaint on behalf of the United States of

4 America pursuant to the Civil Rights of Institutionalized Persons Act of 1980,42 U.S.C.

5 § 1997, to enjoin the named Defendants from depriving persons incarcerated at the Los

6 Angeles County Jails ("Jails"), located in Los Angeles County, California, of rights,

7 privileges, or immunities secured or protected by the Constitution and laws of the United

8 States. This Complaint is also filed pursuant to the Violent Crime Control and Law

9 Enforcement Act of 1994, 42 U.S.C. § 14141 ("§ 14141"), which gives the Attorney

10 General authority to file suit to remedy a pattern or practice of misconduct by law

11 enforcement officers that deprives persons of rights, privileges, or immunities secured or

12 protected by the Constitution and laws of the United States.

13

JURISDICTION AND VENUE

14

2. This Court has jurisdiction over this action under 28U.S.C. § 1345.

15

3. The United States is authorized to initiate this action pursuant to 42 U.S.C.

16 § 1997a and§ 14141.

17

4. The Attorney General has certified that all pre-filing requirements specified

18 in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is

19 appended to this Complaint as Attachment A and is incorporated herein.

20

5. Venue in the United States District Court for the Central District of

21 California is proper pursuant to 28 U.S.C. § 1391. Defendants reside in the Central

22 District of California, and the claim arose in this District.

23

PARTIES

24

6. Plaintiff is the United States of America.

25

7. Defendant LOS ANGELES COUNTY (the "County") is a governmental

26 subdivision created under the laws of the State of California and governed by the Los

27 Angeles County Board of Supervisors. Defendant LOS ANGELES COUNTY owns

28 and, through Defendant LOS ANGELES COUNTY SHERIFF JIM MCDONNELL,

2

Case 2:15-cv-05903-FMO-JEM Document 1 Filed 08/05/15 Page 3 of 9 Page ID #:3

1 operates the Jails, which consist of eight facilities located throughout Los Angeles

2 County. Defendant LOS ANGELES COUNTY, through the Los Angeles County Board

3 of Supervisors, has responsibility for funding the operations of the Jails.

4

8. Defendant LOS ANGELES COUNTY SHERIFF JIM MCDONNELL, is

5 the Los Angeles County Sheriff, an independently-elected constitutional officer not

6 under the authority of the County Board of Supervisors. CA. Const. Art. 11, § 1(b).

7 SHERIFF MCDONNELL has responsibility for the security and custody operations of

8 the Jails and to protect the safety of prisoners in the Jails. SHERIFF MCDONNELL is

9 sued in his official capacity only.

10

9. Defendants LOS ANGELES COUNTY and SHERIFF MCDONNELL are

11 together responsible for the conditions of confinement and health and safety of persons

12 incarcerated at the Jails. LOS ANGELES COUNTY, through its Department of Mental

13 Health, provides mental health services to prisoners in the Jails.

14

10. Defendants are legally responsible, in whole or in part, for the operation and

15 conditions of the Jails, and for the health and safety of persons incarcerated there.

16 Defendant LOS ANGELES COUNTY owns the Jails; Defendant SHERIFF

17 MCDONNELL is responsible for maintaining the Jails; Defendant SHERIFF

18 MCDONNELL is responsible for the security and custody operations of the Jails;

19 Defendant LOS ANGELES COUNTY, through its Department of Mental Health, is

20 responsible for providing mental health care services to prisoners in the Jails; and

21 Defendant LOS ANGELES COUNTY is responsible for funding the operations and

22 maintenance of the Jails. This action concerns the administration of persons confined at

23 the Jails, which houses adult male and female prisoners who are felons, gross

24 misdemeanants, misdemeanants, pre-trial detainees, witnesses, or others being detained

25 in protective custody.

26

11. At all relevant times, Defendants or their predecessors in office have acted

27 or failed to act, as alleged herein, under color of state law.

28

3

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1

FACTUAL ALLEGATIONS

2

12. The Jails is an institution within the meaning of 42 U.S.C. § 1997(1).

3

13. Sheriff's Department custody staff assigned to the Jails are law enforcement

4 officers within the meaning of§ 14141.

5

14. Persons confined to the Jails include both pre-trial detainees and sentenced

6 prisoners.1

7

15. Defendants have repeatedly and consistently disregarded known or serious

8 risks of harm to prisoners at the Jails.

9

16. In June 1996, the Department of Justice notified the County and Sheriff that

10 it was opening an investigation under CRIPA, 42 U.S.C. § 1997, to determine whether

11 the conditions in the Jails violate the constitutional rights of its prisoners.

12

17. In September 1997, the Department of Justice issued a findings letter

13 alleging that mental health care at the Jails violated prisoners' constitutional rights. The

14 letter further alleged that systemic deficiencies contributed to the violations, including

15 inadequate: (I) intake screening and evaluation, (2) diagnosis, (3) referral to mental

16 health professionals, (4) treatment plans, (5) administration of medications, (6) suicide

17 prevention, (7) tracking and medical record keeping, (8) staffing, (9) communication,

18 and ( 10) quality assurance.

19

18. In December 2002, following extensive negotiations and additional site

20 visits, the Parties entered into a Memorandum of Agreement ("MOA") that outlined a

21 series of reforms to ensure that adequate and reasonable mental health care services are

22 provided at the Jails. The MOA also included measures to protect prisoners with mental

23 illness from abuse and mistreatment.

24

19. Under the MOA, the County and the Sheriff have made significant

25 This Complaint refers to all individuals housed in the Jails, including pre-
26 trial detainees and individuals who have been convicted of a criminal offense, as 27 "prisoners."

28

4

Case 2:15-cv-05903-FMO-JEM Document 1 Filed 08/05/15 Page 5 of 9 Page ID #:5

1 improvements to the delivery of mental health care at the Jails, including implementing

2 electronic medical records, increasing mental health staffing, and developing roving

3 evaluation teams composed of mental health professionals and specially-trained custody

4 staff. Despite considerable progress, systemic deficiencies remain related to suicide

5 prevention and mental health care that violate prisoners' constitutional rights. The

6 Department of Justice notified the County and the Sheriff of these conclusions in a letter

7 dated June 4, 2014, following on-site evaluations with expert consultants.

8

20. In September 2013, the Department of Justice opened a separate

9 investigation of the Jails under CRIPA and 42 U.S.C. § 14141 ("Section 14141") to

10 address allegations of use of excessive force against all prisoners at the Jails, not just

11 prisoners with mental illness.

12

21. As a result of these investigations, the United States alleges:

13

22. Defendants have repeatedly failed to take reasonable measures to protect

14 prisoners against the serious harm from suicide and self-harm due to, but not limited to:

15 ( 1) inadequate suicide prevention measures; (2) lack of appropriate screening by custody

16 and mental health staff to assess suicide risk; (3) lack of appropriate supervision,

17 observation, and monitoring of prisoners, including those identified as at risk of suicide;

18 (4) inadequate communication between mental health care and custody staff; (5) lack of

19 appropriate multi-disciplinary treatment plans; and (6) an inadequate suicide or critical

20 incident review process.

21

23. Defendants have repeatedly failed to provide adequate mental health

22 services, including psychological and psychiatric services, to prisoners with serious

23 psychiatric needs that are known or obvious due to, but not limited to, insufficient and

24 inadequate: (1) in-patient care for those in need; (2) crisis intervention; (3) therapy,

25 clinical contacts, and group programming; (4) treatment and referrals for prisoners in

26 general population; (5) medication administration practices, including treatment to

27 prisoners refusing medication; and (6) discharge planning.

28

24. Defendants have maintained a physical environment at the Jails that causes

5

Case 2:15-cv-05903-FMO-JEM Document 1 Filed 08/05/15 Page 6 of 9 Page ID #:6

1 harm and poses an unreasonable risk of serious harm to prisoners' health and safety by

2 failing to correct facility housing and maintenance problems in addition to inadequate

3 housekeeping and sanitation that causes harm or poses a risk of harm to the prisoners and

4 staffwithin the facility.

5

25. Defendants, through their acts or omissions, have engaged in a pattern or

6 practice of conduct by Sheriffs Department custody staff of using excessive force

7 against prisoners in the Jails. The use of excessive force includes, but is not limited to:

8

a. use of force disproportionate to the amount of resistance encountered,

9

including use of force against unresisting or handcuffed prisoners;

10

b. use of force to punish or retaliate against prisoners; and

11

c. failure to attempt to de-escalate potential force incidents.

12

26. Defendants, through their acts or omissions, have engaged in a pattern or

13 practice of systemic deficiencies that resulted in the pattern or practice by Sheriffs

14 Department custody staff of uses of excessive force, described in paragraph 25, above.

15 These systemic deficiencies include, but are not limited to:

16

a. failure to implement and enforce policies, procedures, and practices

17

regarding use of force that appropriately guide and monitor the

18

actions of individual Sheriffs Department custody staff;

19

b. failure to train and supervise adequately Sheriffs Department

20

custody staff to prevent the occurrence of misconduct;

21

c. deficient use of force reporting and review;

22

d. failure to investigate adequately incidents in which Sheriffs

23

Department custody staff uses force;

24

e. failure to discipline adequately Sheriffs Department custody staff

25

who engage in misconduct or to monitor adequately Sheriffs

26

Department custody staff who engage in or may be likely to engage

27

in misconduct;

28

f. inadequate video surveillance; and

6

Case 2:15-cv-05903-FMO-JEM Document 1 Filed 08/05/15 Page 7 of 9 Page ID #:7

1

g. failure to implement policies and procedures whereby complaints and

2

other allegations of deputy misconduct are adequately received and

3

investigated.

4

27. Defendants have repeatedly failed to take reasonable measures to prevent

5 staff from inflicting serious harm on prisoners, even in the face of the obvious and

6 substantial risk that staff will inflict such harm and the multiple occasions on which Jails

7 staff have in fact inflicted such harm.

8

28. The factual allegations set forth in paragraphs 12 through 27 have been

9 known to Defendants for a substantial period of time, yet Defendants have failed to

10 adequately address the conditions described.

11

VIOLATIONS ALLEGED

12

29. The allegations of Paragraphs 1 through 28 are hereby re-alleged and

13 incorporated by reference.

14

30. Through the acts and omissions alleged in paragraphs 21 through 27,

15 Defendants have violated the rights, privileges, and immunities of persons confined in

16 the Jails secured or protected by the Eighth and Fourteenth Amendments to the

17 Constitution of the United States.

18

31. Through the acts and omissions alleged in paragraphs 21 through 27,

19 Defendants have engaged in a pattern or practice of conduct that deprives persons

20 confined in the Jails of rights, privileges, or immunities secured or protected by the

21 Constitution (including the Eighth and Fourteenth Amendments) or the laws of the

22 United States, in violation of 42 U.S.C. § 14141.

23

32. Unless restrained by this Court, Defendants will continue to engage and/or

24 will revert to engaging in the acts and omissions, set forth in paragraphs 21 through 27,

25 that deprive persons confined in the Jails of rights, privileges, or immunities secured or

26 protected by the Constitution of the United States and cause them irreparable harm.

27

PRAYER FOR RELIEF

28

33. The Attorney General is authorized under 42 U.S.C. § 1997 et seq. and§

7

Case 2:15-cv-05903-FMO-JEM Document 1 Filed 08/05/15 Page 8 of 9 Page ID #:8

1 14141 to seek equitable and declaratory relief.

2

WHEREFORE, Plaintiff United States prays that the Court enter an order

3 permanently enjoining Defendants, their officers, agents, employees, subordinates,

4 successors in office, and all those acting in concert or participation with them from

5 continuing the acts, omissions, and practices set forth in paragraphs 20 through, and that

6 this Court require Defendants to take such actions as will ensure lawful conditions of

7 confinement are afforded to prisoners at the Jails. The United States further prays that

8 this Court grant such other and further equitable relief as it may deem just and proper.

9 II
10 DATED: ~~ JoJ J.i:Jt ~...

Respectfully submitted,

11 12 FOR THE UNITED STATES: 13 14

~#&[.~ LORETTA E. LYNC Attorney General

15

16

17

18

19

20

21

22

23

24

25
26

I &uJ___

EILEEN DECKER

27

United States Attorney: Central District of California

28

LEON W. WEIDMAN Assistant United States Attorney

ti!:12Ef!bl?
Deputy: Assistant Attorney General Civil Rights Division
8

Case 2:15-cv-05903-FMO-JEM Document 1 Filed 08/05/15 Page 9 of 9 Page ID #:9

1 Chief, Civil Division

~~ 2
3

~tl-~ (b4st:1)

R

-MARIE LYON MONTELEONE

ITH C. PRESTON

4 Assistant United States Attorney

Acting Chief, Special Litigation Section

Assistant Division Chief 5 Civil Rights Unit Chief, Civil Division

Civil Rights Division

6

7
8

J~u

LAURA COON

9

Ass1stant United States Attorney U.S. Attorney's Office for the

D~_12uty Chief LUIS E. SAUCEDO

10

Central District of California

Counselor to the Chief CATHLEEN S. TRAINOR

11

300 North Los Angeles Street, Suite 7516 Los Angeles, California 900 12

Trial Attorney U.S. Department of Justice

12

Civil Rights Division Special Litigation Section

13

950 Pennsyfvania Avenue, NW, PHB 5026 Washington, D.C. 20530

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

9

 
 Case 2:15-cv-05903-DDP-JEM Document 13 Filed 09/03/15 Page 1 of 3 Page ID #:97

LORETTA E. LYNCH 1 Attorney General

MARK J. KAPPELHOFF 2 Deputy Assistant Attorney General
Civil Rights Division 3 JUDITH C. PRESTON

Acting Chief 4 LAURA L. COON, Special Counsel

LUIS E. SAUCEDO, Counselor to the Chief 5 CATHLEEN S. TRAINOR, Senior Trial Attorney
U.S. Department of Justice 6 Civil Rights Division

Special Litigation Section

7

950 Pennsylvania Avenue, N.W., PHB 5026

Washington, D.C. 20530

8

Telephone: (202) 514-6255

Email: laura.coon@usdoj.gov; cathleen.trainor@usdoj.gov

9

EILEEN M. DECKER 10 United States Attorney

LEON W. WEIDMAN 11 Assistant United States Attorney
Chief, Civil Division 12 ROBYN-MARIE LYON MONTELEONE (State Bar No. 130005)

Assistant United States Attorney 13 Assistant Division Chief, Civil Rights Unit Chief, Civil Division

JOANNA HULL (State Bar No. 227153)

14 Assistant United States Attorney

300 North Los Angeles Street, Suite 7516

15

Los Angeles, California 90012

Telephone: (213) 894-2458/6585; Facsimile: (213) 894-7819

16

E-mail: Robby.Monteleone@usdoj.gov; Joanna.Hull@usdoj.gov

17 Attorneys for Plaintiff UNITED STATES OF AMERICA
18

UNITED STATES DISTRICT COURT 19

FOR THE CENTRAL DISTRICT OF CALIFORNIA 20

WESTERN DIVISION 21

UNITED STATES OF AMERICA, 22

No. CV 15-05903 DDP (JEMx)

Plaintiff, 23
v. 24

ORDER APPROVING AND ENTERING JOINT SETTLEMENT AGREEMENT AS AN

COUNTY OF LOS ANGELES AND 25 LOS ANGELES COUNTY SHERIFF
JIM MCDONNELL, in his official 26 capacity;

ORDER [NO JS-6]

27

Defendants.

28
HOA.1183206.1

Case 2:15-cv-05903-DDP-JEM Document 13 Filed 09/03/15 Page 2 of 3 Page ID #:98

1

ORDER APPROVING AND ENTERING

2

JOINT SETTLEMENT AGREEMENT AS AN ORDER

3

AND NOW, upon consideration of the Complaint of the United States of

4 America, the Parties’ attached Joint Settlement Agreement Regarding the Los Angeles 5 County Jails (“Agreement”), as modified by the court with the consent of the parties1;

6 and the Stipulated [Proposed] Order Approving and Entering Joint Settlement

7 Agreement as an Order, the Court hereby FINDS that:

8

(a) the Agreement is fair, adequate, and reasonable and furthers the purpose of the

9

Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, and the Violent

10

Crime Control and Law Enforcement Act, 42 U.S.C. § 14141, in vindicating

11

the federal constitutional rights of prisoners at the Jails, and

12

(b) although this matter was not actually litigated or resolved on the merits, the

13

prospective relief in the Agreement is narrowly drawn, extends no further than

14

necessary to correct the violations of federal rights as alleged by the United

15

States, and is the least intrusive means necessary to correct those alleged

16

violations, as required by the Prison Litigation Reform Act, 18 U.S.C. §

17

3626(a) & (c).

18 THEREFORE, it is hereby ORDERED, ADJUDGED, AND DECREED that the

19 Agreement is APPROVED and the Agreement is hereby entered as an Order of the

20 Court. The Court retains complete jurisdiction of this matter to enforce the terms of the

21 Agreement until the Defendants have fulfilled their obligations therein.

22

23 DATED: September 03, 2015

24

25 UNITED STATES DISTRICT JUDGE
26

27

1 See Agreement, Error! Main Document Only.¶ 83.

28

HOA.1183206.1

2

Case 2:15-cv-05903-DDP-JEM Document 13 Filed 09/03/15 Page 3 of 3 Page ID #:99

1 ///

2 ///
3 Respectfully submitted this 5th day of August, 2015. FOR THE UNITED STATES:
4

5

LORETTA E. LYNCH

6

Attorney General

7 EILEEN M. DECKER
8 United States Attorney Central District of California
9 LEON W. WEIDMAN
10 Assistant United States Attorney Chief, Civil Division
11

MARK J. KAPPELHOFF Deputy Assistant Attorney General Civil Rights Division JUDITH C. PRESTON Acting Chief, Special Litigation Section Civil Rights Division

12 __________________________________ ________________________________

13 ROBYN-MARIE LYON MONTELEONE LAURA L. COON

Assistant United States Attorney

Special Counsel

14 Assistant Division Chief

LUIS E. SAUCEDO

Civil Rights Unit Chief, Civil Division Counselor to the Chief

15

CATHLEEN S. TRAINOR

JOANNA HULL

Senior Trial Attorney

16 Assistant United States Attorney

U.S. Department of Justice

17

18 For the COUNTY OF LOS ANGELES and the LOS ANGELES COUNTY SHERIFF,
19 in his official capacity:

20

_____/s/________________________

MARY C. WICKHAM

21

Interim County Counsel

County of Los Angeles 22

23

_____/s/_________________________

24

RODRIGO A. CASTRO-SILVA

Senior Assistant County Counsel

25

County of Los Angeles

26

27

28

HOA.1183206.1

3

 
 Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 1 of 57 Page ID #:100

1

2

3

4

JS-6

5

6

7

UNITED STATES DISTRICT COURT

8

FOR THE CENTRAL DISTRICT OF CALIFORNIA

9

WESTERN DIVISION

10

11 UNITED STATES OF AMERICA,

12

Plaintiff,

13

v.

14 COUNTY OF LOS ANGELES AND

15

LOS ANGELES COUNTY SHERIFF JIM MCDONNELL, in his Official

16 Capacity,

17

Defendants.

CV No. 15-05903 DDP (JEMx) JOINT SETTLEMENT AGREEMENT REGARDING THE LOS ANGELES COUNTY JAILS; AND STIPULATED ORDER OF RESOLUTION

18

19

I. INTRODUCTION

20

1. The United States of America, acting through the United States

21 Department of Justice (“United States”), the County of Los Angeles (“County”)

22 and Sheriff Jim McDonnell, in his official capacity (“Sheriff”), (collectively, the

23 “Parties”) share a mutual interest in treating all members of the community with

24 respect, promoting safe and effective custodial care, protecting public safety, and

25 upholding the constitutional rights of prisoners.1

26

27 1 “Prisoners” is a defined term in Section III of this Agreement and includes 28 pre-trial detainees and individuals convicted of a criminal offense.

1

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 2 of 57 Page ID #:101

1

2. The Los Angeles County Jails (“Jails”) are an integral part of the

2 public safety system in Los Angeles County, California. Together, the Jails form

3 the largest jail system in the nation and house among the highest populations of

4 prisoners with mental illness. Maintaining these facilities is an immensely

5 complex enterprise -- approximately 15,500 to 19,500 prisoners are held in custody

6 daily, spread across multiple custody facilities, numerous patrol stations, and over

7 29 courthouses. These facilities’ primary function is to incarcerate individuals

8 accused or convicted of committing a crime. In doing so, these facilities provide

9 food, shelter, and clothing, but must also address the serious medical and mental

10 health needs of the prisoners and ensure their reasonable safety.

11

3. The United States acknowledges that the County and the Sheriff have

12 demonstrated a renewed commitment to reforming the Jails and have begun to

13 implement improved policies and practices designed to enhance the treatment and

14 care of prisoners with mental illness. The County and the Sheriff are also

15 exploring strategies to safely divert individuals with mental illness from the

16 criminal justice system, whenever possible. The United States further

17 acknowledges that the number of suicides at the Jails decreased in 2014 from the

18 previous year. In addition, the County and the Sheriff have made significant

19 commitments to protect prisoners from abuse and excessive force by staff that

20 further the Parties’ mutual interest. Finally, the United States acknowledges that

21 some of the needed changes the County and the Sheriff seek to implement through

22 this Agreement will require the allocation of additional resources to the Sheriff’s

23 Department and the Los Angeles County Department of Mental Health (“DMH”).

24

4. Accordingly, this Joint Settlement Agreement Regarding the Los

25 Angeles County Jails (“Agreement”) is intended to build upon measures that are

26 underway and to sustain systemic improvements that are designed to protect

27

28

2

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 3 of 57 Page ID #:102

1 prisoners from conditions in custody that place them at unreasonable risk of harm

2 from suicide, self-injurious behavior, or unlawful injury by others, in accordance

3 with their constitutional rights. This Agreement also is expected to have collateral

4 benefits that promote public safety, improve confidence in the County’s criminal

5 justice system, and support the County’s and the Sheriff’s collaborative efforts to

6 expand comprehensive and effective mental health diversion and re-entry programs

7 that are designed to lead to more positive outcomes in the care and custody of

8 individuals with serious mental illness who are also participants in the criminal

9 justice system.

10

II. BACKGROUND

11

5. The County owns and funds the operations of the Jails. The Sheriff’s

12 Department is responsible for providing care, custody, and control of prisoners at

13 the Jails. The Sheriff’s Department Medical Services Bureau provides medical

14 care within the Jails. DMH is responsible for providing mental health care in the

15 Jails through its Jail Mental Health Services program.

16

6. The Sheriff is an elected official who is responsible for operating and

17 exercising authority over the Jails.

18

7. In June 1996, the Department of Justice notified the County and

19 Sheriff that it was opening an investigation under the Civil Rights of

20 Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997, to determine whether

21 the conditions in the Jails violate the constitutional rights of its prisoners.

22

8. In September 1997, the Department of Justice issued a findings letter

23 alleging that mental health care at the Jails violated prisoners’ constitutional rights.

24 The letter further alleged that systemic deficiencies contributed to the violations,

25 including inadequate: (1) intake screening and evaluation; (2) diagnosis; (3)

26 referral to mental health professionals; (4) treatment plans; (5) administration of

27 medications; (6) suicide prevention; (7) tracking and medical record keeping;

28 (8) staffing; (9) communication; and (10) quality assurance.

3

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 4 of 57 Page ID #:103

1

9. In December 2002, following extensive negotiations and additional

2 site visits, the Parties entered into a Memorandum of Agreement (MOA) that

3 outlined a series of reforms to ensure that adequate and reasonable mental health

4 care services are provided at the Jails. The MOA also included measures to protect

5 prisoners with mental illness from abuse and mistreatment.

6

10. Under the MOA, the County and the Sheriff have made significant

7 improvements to the delivery of mental health care at the Jails, including

8 implementing electronic medical records, increasing mental health staffing, and

9 developing roving evaluation teams composed of mental health professionals and

10 specially-trained custody staff. Despite considerable progress, the United States

11 alleges that systemic deficiencies remain related to suicide prevention and mental

12 health care that violate prisoners’ constitutional rights. The Department of Justice

13 notified the County and the Sheriff of these allegations in a letter dated June 4,

14 2014, following on-site evaluations with expert consultants.

15

11. In September 2013, the Department of Justice opened a separate

16 investigation of the Jails under CRIPA and 42 U.S.C. § 14141 (“Section 14141”)

17 to address allegations of use of excessive force against all prisoners at the Jails, not

18 just prisoners with mental illness. During the course of the investigation, the

19 County and the Sheriff entered into a comprehensive settlement agreement to

20 resolve Rosas v. McDonnell, Case No. CV 12-0428-DDP (C.D. Ca. filed on Jan.

21 18, 2012) (hereinafter “Rosas”), a class action lawsuit alleging abuse and excessive

22 force by staff at certain Jails located in downtown Los Angeles. As part of the

23 Rosas settlement agreement, the County and the Sheriff have agreed to implement

24 significant measures to protect prisoners from excessive force by staff, including

25 improvements in policies, training, incident tracking and reporting, investigations,

26 resolution of prisoner grievances, prisoner and staff supervision, and

27 accountability.

28

4

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 5 of 57 Page ID #:104

1

12. This Agreement addresses remaining allegations concerning suicide

2 prevention and mental health care at the Jails resulting from the partial

3 implementation of the 2002 MOA and current conditions within the Jails. This

4 Agreement also extends the remedial measures in the Implementation Plan of the

5 Rosas settlement agreement to fully resolve the Department of Justice’s CRIPA

6 findings regarding alleged mistreatment of prisoners with mental illness and claims

7 under Section 14141 regarding alleged excessive force against prisoners at all of

8 the Jails.

9

13. As indicated in Section VII of this Agreement, the Parties consent to a

10 finding that this Agreement complies in all respects with the provisions of the

11 Prison Litigation Reform Act, 18 U.S.C. § 3626(a).

12

14. Except to enforce, modify, or terminate this Agreement, this

13 Agreement, and any findings made to effectuate this Agreement, will not be

14 admissible against either the County or the Sheriff in any court for any purpose.

15 Moreover, this Agreement is not an admission of any liability on the part of the

16 County or the Sheriff, and/or either of its employees, agents, and former employees

17 and agents, or any other persons, and will not constitute evidence of any pattern or

18 practice of wrongdoing.

19

III. DEFINITIONS

20

15. The following definitions will apply to terms in this Agreement:

21

(a) “Sheriff’s Department” refers to the Los Angeles County Sheriff’s

22

Department, which is responsible for all custody, corrections, and

23

security functions within the Los Angeles County Jails system,

24

including the provision of medical care to prisoners through the

25

Sheriff’s Department Medical Services Bureau.

26

(b) “Jails” refers to the Los Angeles County Jails system, and shall

27

include Men’s Central Jail (“MCJ”), Twin Towers Correctional

28

Facility (“TTCF”), Inmate Reception Center (“IRC”), Century

5

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1

Regional Detention Facility (“CRDF”), North County Correctional

2

Facility (“NCCF”), Pitchess Detention Center (“PDC”), and other

3

facilities in which prisoners are detained or held in custody by the

4

County and the Sheriff, including lockup facilities and courthouse

5

holding areas as well as any visiting area in the facility, and any

6

facility that is built, leased, or otherwise used, to replace or

7

supplement the current Jails or any part of the Jails.

8

(c) “United States” or “DOJ” refers to the United States Department of

9

Justice, specifically the Special Litigation Section of the Civil Rights

10

Division and the United States Attorney’s Office for the Central

11

District of California, which represent the United States in this matter.

12

(d) “The County” refers to the County of Los Angeles, the Los Angeles

13

County Sheriff’s Department, the Los Angeles County Department of

14

Mental Health, and the agents and employees of the Sheriff’s

15

Department and the Department of Mental Health. The Department

16

of Mental Health (“DMH”) includes any successor County department

17

that assumes the duties and responsibilities of DMH.

18

(e) “Sheriff” refers to the Los Angeles County Sheriff, currently Jim

19

McDonnell, an independently-elected constitutional officer, in his

20

official capacity, and any predecessors or successors in office,

21

including any designated acting or interim Sheriff.

22

(f) “Custody staff” means sworn deputy sheriffs and custody assistants.

23

(g) “Days” are measured in calendar days; weekend days and County

24

holidays are included.

25

(h) “Normal business work days” means all days except for weekend days

26

and County holidays.

27

(i) “Describe” means provide a clear and detailed description of

28

something done, experienced, seen, or heard.

6

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1

(j) “Document” when used in this Agreement as a verb means

2

completing a record of information either in hard copy or in electronic

3

format.

4

(k) “Effective Date” means the date the Court enters the signed

5

Agreement as an order of the Court, or July 1, 2015, whichever is

6

earlier.

7

(l) “Emergency maintenance needs” means a need that if left unattended

8

could result in imminent danger to the life, safety, or health of

9

prisoners.

10

(m) An “emergent” or “urgent” mental health need, as used in this

11

Agreement, is one which the Arrestee Medical Screening Form (SH-

12

R-422) or its equivalent and/or the Medical/Mental Health Screening

13

Questionnaire indicate that immediate action is required to preserve

14

life, prevent serious bodily harm, or relieve significant suffering.

15

(n) “Good cause” means fair and honest reasons, regulated by good faith

16

on the part of either party, that are not arbitrary, capricious, trivial, or

17

pretextual.

18

(o) “Implement” or “implementation” means putting a remedial measure

19

into effect, including informing, instructing, or training impacted

20

personnel as required by this Agreement, and ensuring that policies or

21

procedures are in fact followed.

22

(p) “Include,” “includes,” or “including” means “include, but not be

23

limited to” or “including, but not limited to.”

24

(q) “Jail Reception Centers” mean all Sheriff’s Department processing

25

facilities that handle incoming bookings and arrests and that are

26

responsible for medical and mental health screenings and

27

classification, including the Inmate Reception Center and the Century

28

7

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1

Regional Detention Facility. This does not include Sheriff's

2

Department station jails.

3

(r) “Mental Health Housing” refers to prisoner housing areas in the Jails

4

that include only the Forensic In-Patient (FIP), High Observation

5

Housing (HOH), and Moderate Observation Housing (MOH) areas.

6

(i) “Correctional Treatment Center” or “CTC” refers to the

7

licensed health facility with a specified number of beds within

8

the Jails designated to provide health care to that portion of the

9

prisoner population that does not require a general acute care

10

level of services, but which is in need of professionally

11

supervised health care beyond that normally provided in the

12

community on an outpatient basis.

13

(ii) “Forensic In-Patient” or “FIP” can be used interchangeably

14

with Mental Health Unit of the Correctional Treatment Center

15

(MHU CTC). The FIP is located in the CTC and houses

16

prisoners who present an acute danger to self or others or are

17

gravely disabled due to a mental illness and require inpatient

18

care.

19

(iii) “High Observation Housing” or “HOH” refers to designated

20

areas for prisoners with mental illness who require an intensive

21

level of observation and care and/or safety precautions.

22

(iv) “Moderate Observation Housing” or “MOH” refers to

23

designated areas for prisoners with a broad range of mental

24

health diagnoses and functioning whose mental health needs

25

can be cared for in a less intensive and more open setting than

26

the HOH areas, but preclude general population housing.

27

28

8

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1

(s) “Monitor” or “Independent Monitor” means the individual selected by

2

the Parties whose duties, responsibilities, and authority are set forth in

3

Section VI of this Agreement.

4

(t) “Subject Matter Experts” or “SMEs” means the individuals selected

5

by the Parties whose duties, responsibilities, and authority are set forth

6

in Section VI of this Agreement.

7

(u) “Prisoners” or “Prisoner” is construed broadly to refer to one or more

8

individuals detained at, or otherwise housed, held, in the custody of,

9

or confined at the Jails based on arrests, detainers, criminal charges,

10

civil contempt charges, or convictions.

11

(v) “Psychotropic medication” means any substance used to treat mental

12

health problems or mental illness and is capable of modifying mental

13

activity or behavior.

14

(w) “Qualified Medical Staff” refers to physicians, physician assistants,

15

nurse practitioners, registered nurses, certified nursing assistants, and

16

licensed vocational nurses, each of whom is permitted by law to

17

evaluate and care for the medical needs of patients.

18

(x) “Qualified Mental Health Professional” or “QMHP” refers to

19

psychiatrists, psychologists, psychiatric social workers, psychiatric

20

nurses, and others who by virtue of their education, credentials, and

21

experience are permitted by law to evaluate and care for the mental

22

health needs of patients.

23

(y) “Clinical Restraints” is any device that limits a person’s ability to

24

move freely and has been ordered or approved by a licensed

25

psychiatrist for the purpose of managing behavior that appears to be

26

symptomatic of a mental illness.

27

28

9

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1

(z) “Security Restraints” is any device that limits a person’s ability to

2

move freely and has not been ordered by a licensed psychiatrist or

3

Qualified Medical Staff.

4

(aa) “Serious mental illness” includes psychotic disorders, major mood

5

disorders (including major depression and bipolar disorders), and any

6

other condition (excluding personality disorders, substance abuse and

7

dependence disorders, dementia, and developmental disability) that is

8

associated with serious or recurrent significant self-harm, suicidal

9

ideation, imminent danger to others, current grave disability, or

10

substantially impaired ability to understand routine instructions, or

11

that prevents access to available programs. Although personality

12

disorders alone generally do not qualify as serious mental illness,

13

personality disorders associated with serious or recurrent significant

14

self-harm do qualify as serious mental illnesses.

15

(bb) “Suicide attempt” means any serious effort to commit an act of self-

16

harm that can result in death and involving definite risk.

17

(cc) “Serious suicide attempt” means a suicide attempt that resulted in or

18

could have resulted in significant and life-threatening injury.

19

(dd) “Suicide Precautions” means any level of watch, observation, or

20

measures specifically intended to prevent suicide or self-harm and

21

includes both Suicide Watch and Risk Precautions as defined in this

22

Agreement.

23

(ee) “Suicide Watch” means the level of watch, observation, or measures

24

intended to identify and safely maintain prisoners who are imminently

25

suicidal and require admission to the Mental Health Unit of the

26

Correctional Treatment Center (MHU CTC or FIP) on a 72-hour hold,

27

in accordance with California Welfare and Institutions Code Section

28

5150.

10

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1

(ff) “Risk Precautions” means a level of watch, observation, or measures

2

used to identify and safely maintain those prisoners who require

3

heightened observation and daily re-evaluation, and require admission

4

to HOH but are not considered to pose an imminent risk of suicide.

5

(gg) “Suicide resistant location” means a housing assignment in which

6

known or apparent suicide hazards do not exist or have been removed.

7

(hh) “Self-injurious behavior” means any behavior that is self-directed and

8

deliberately results in injury or the potential for injury to oneself and

9

there is no evidence of suicidal intent.

10

(ii) “Serious self-injurious behavior” means self-injurious behavior where

11

the injury is significant enough that it could lead to loss of life or limb

12

or have serious medical complications.

13

(jj) “Direct constant observation” means continuous uninterrupted

14

observation of a prisoner within a proximity that ensures the observer

15

can both see and hear the prisoner to assure the prisoner’s well-being,

16

absent extraordinary circumstances.

17

(kk) “Unobstructed visual observation” means continuous but not

18

necessarily uninterrupted observation within a reasonable physical

19

distance of the prisoner(s).

20

(ll) “Train” means to instruct in skills to a level that the trainee has the

21

demonstrated proficiency, through an assessment or evaluation, to

22

implement those skills as and when called for. “Trained” means

23

proficient in the skills.

24

(mm) Throughout this Agreement, the following terms are used when

25

discussing compliance: substantial compliance, partial compliance,

26

and non-compliance. “Substantial Compliance” means that the

27

County and the Sheriff have achieved compliance with the material

28

components of the relevant provision of this Agreement in accordance

11

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1

with the Monitor and SMEs’ monitoring plan and compliance

2

measures. “Partial Compliance” means that the County and the

3

Sheriff have achieved compliance on some, but not all, of the material

4

components of the relevant provision of this Agreement. “Non-

5

compliance” means that the County and the Sheriff have not met most

6

or all of the material components of the relevant provision of this

7

Agreement. Non-compliance with mere technicalities, or temporary

8

failure to comply coupled with prompt and appropriate corrective

9

action during a period of otherwise sustained compliance, will not

10

constitute failure to maintain Substantial Compliance. At the same

11

time, temporary compliance during a period of otherwise sustained

12

Non-compliance will not constitute Substantial Compliance.

13

(nn) “Policy” or “Policies” mean regulations, directives, or manuals,

14

regardless of name, that have been approved by a senior executive

15

within the Sheriff's Department (“LASD”) or DMH and that describe

16

the duties, functions, or obligations of LASD or DMH staff and

17

provide specific direction in how to fulfill those duties, functions, or

18

obligations. References to “existing” policies mean those policies in

19

effect on the Effective Date of this Agreement, and include any

20

subsequent revisions or changes made to those policies after the

21

Effective Date of this Agreement.

22

IV. OVERALL OBJECTIVES AND GOALS

23

16. Consistent with constitutional standards, the County and the Sheriff

24 will provide prisoners at the Jails with safe and secure conditions and ensure their

25 reasonable safety from harm, including serious risk from self-harm and excessive

26 force, and ensure adequate treatment for their serious mental health needs. In order

27 to achieve and maintain these objectives, the County and the Sheriff agree to

28

12

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 13 of 57 Page ID #:112

1 continue, and where appropriate enhance, their current policies and practices, and

2 to implement the additional measures set forth in this Agreement.

3

17. The Parties recognize that the County and the Sheriff have made

4 considerable progress to improve conditions and the delivery of mental health care

5 at the Jails, but that additional measures are necessary to provide prisoners at the

6 Jails with safe and secure conditions, ensure their reasonable safety from harm,

7 including serious risk from self-harm and excessive force, and meet the serious

8 mental health needs of prisoners, in accordance with prisoners’ constitutional

9 rights. The measures set forth in this Agreement address the following areas: (1)

10 training; (2) suicide hazard inspections; (3) intake; (4) medical records; (5) mental

11 health referrals; (6) mental health follow-up; (7) suicide risk procedures; (8)

12 staffing; (9) environmental conditions; (10) allowable property privileges; (11)

13 communication related to mental health; (12) safety checks; (13) quality

14 improvement plan; (14) mental health housing; (15) medication; (16) restraints;

15 (17) suicide death reviews and critical incident reviews; (18) mental health

16 treatment; and (19) use of force. The County and the Sheriff agree to maintain an

17 adequate system of mental health screening, assessment, treatment planning, and

18 record-keeping as specifically set forth in this Agreement.

19

V. SUBSTANTIVE PROVISIONS

20 A. Training

21

18. Within three months of the Effective Date, the County and the Sheriff

22 will develop, and within six months of the Effective Date will commence

23 providing: (1) a four-hour custody-specific, scenario-based, skill development

24 training on suicide prevention, which can be part of the eight-hour training

25 described in paragraph 4.8 of the Implementation Plan in Rosas to all new

26 Deputies as part of the Jail Operations Continuum and to all new Custody

27 Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific,

28 scenario-based, skill development training on suicide prevention to all existing

13

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1 Deputies and Custody Assistants at their respective facilities, which can be part of

2 the eight-hour training described in paragraph 4.7 of the Implementation Plan in

3 Rosas, through in-service Intensified Formatted Training, which training will be

4 completed by December 31, 2016.

5

These trainings will include the following topics:

6

(a) suicide prevention policies and procedures, including observation and

7

supervision of prisoners at risk for suicide or self-injurious behavior;

8

(b) discussion of facility environments and staff interactions and why

9

they may contribute to suicidal behavior;

10

(c) potential predisposing factors to suicide;

11

(d) high-risk suicide periods and settings;

12

(e) warning signs and symptoms of suicidal behavior;

13

(f) case studies of recent suicides and serious suicide attempts;

14

(g) emergency notification procedures;

15

(h) mock demonstrations regarding the proper response to a suicide

16

attempt, including a hands-on simulation experience that incorporates

17

the challenges that often accompany a jail suicide, such as cell doors

18

being blocked by a hanging body and delays in securing back-up

19

assistance;

20

(i) differentiating between suicidal and self-injurious behavior; and

21

(j) the proper use of emergency equipment.

22

19. Commencing July 1, 2015, the County and the Sheriff will provide:

23

(a) Custody-specific, scenario-based, skill development training to new

24

Deputies during their Jail Operations training, and to existing

25

Deputies assigned to Twin Towers Correctional Facility, Inmate

26

Reception Center, Men’s Central Jail, the Mental Health Housing

27

Units at Century Regional Detention Facility, and the Jail Mental

28

14

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1

Evaluation Teams (“JMET”) at North County Correctional Facility as

2

follows:

3

(i) 32 hours of Crisis Intervention and Conflict Resolution as

4

described in paragraphs 4.6 and 4.9 of the Implementation Plan

5

in Rosas to be completed within the time frames established in

6

that case (currently December 31, 2016). Deputies at these

7

facilities will receive an eight hour refresher course consistent

8

with paragraph 4.6 of the Implementation Plan in Rosas every

9

other year until termination of court jurisdiction in that case and

10

then a four hour refresher course every other year thereafter.

11

(ii) Eight hours identifying and working with mentally ill prisoners

12

as described in paragraph 4.7 of the Implementation Plan in

13

Rosas to be completed by December 31, 2016. This training

14

requirement may be a part of the 32-hour training described in

15

the previous subsection. Deputies at these facilities will receive

16

a four hour refresher course consistent with paragraph 4.7 of the

17

Implementation Plan in Rosas every other year thereafter.

18

(b) Commencing July 1, 2015, the County and the Sheriff will ensure that

19

new Custody Assistants receive eight hours of training in the Custody

20

Assistant academy, and that all existing Custody Assistants receive

21

eight hours of training, related to identifying and working with

22

mentally ill prisoners as described in paragraph 4.7 of the

23

Implementation Plan in Rosas. This training will be completed by

24

December 31, 2016. Custody Assistants will receive a four hour

25

refresher course consistent with paragraph 4.7 of the Implementation

26

Plan in Rosas every other year thereafter.

27

20. Commencing no later than July 1, 2017, the County and the Sheriff

28 will provide:

15

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1

(a) Custody-specific, scenario-based, skill development training to

2

existing Deputies assigned to North County Correctional Facility,

3

Pitchess Detention Center, and the non-Mental Health Housing Units

4

in Century Regional Detention Facility as follows:

5

(i) 32 hours of Crisis Intervention and Conflict Resolution as

6

described in paragraphs 4.6 and 4.9 of the Implementation Plan

7

in Rosas to be completed by December 31, 2019. Deputies at

8

these facilities will receive an eight hour refresher course

9

consistent with paragraph 4.6 of the Implementation Plan in

10

Rosas every other year until termination of court jurisdiction in

11

that case and then a four hour refresher course every other year

12

thereafter.

13

(ii) Eight hours identifying and working with mentally ill prisoners

14

as described in paragraph 4.7 of the Implementation Plan in

15

Rosas to be completed by December 31, 2019. This training

16

requirement may be a part of the 32-hour training described in

17

the previous subsection. Deputies at these facilities will receive

18

a four hour refresher course consistent with paragraph 4.7 of the

19

Implementation Plan in Rosas every other year thereafter.

20

21. Consistent with existing Sheriff’s Department policies regarding

21 training requirements for sworn personnel, the County and the Sheriff will ensure

22 that existing custody staff that have contact with prisoners maintain active

23 certification in cardiopulmonary resuscitation and first aid.

24

22. Within six months of the Effective Date and at least annually

25 thereafter, the County and the Sheriff will provide instructional material to all

26 Sheriff station personnel, Sheriff court personnel, custody booking personnel, and

27 outside law enforcement agencies on the use of arresting and booking documents,

28 including the Arrestee Medical Screening Form, to ensure the sharing of known

16

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1 relevant and available information on prisoners’ mental health status and suicide

2 risk. Such instructional material will be in addition to the training provided to all

3 custody booking personnel regarding intake.

4 B. Suicide Hazard Inspections

5

23. Within three months of the Effective Date, the County and the Sheriff

6 will commence a systematic review of all prisoner housing, beginning with the

7 Mental Health Unit of the Correctional Treatment Center, all High Observation

8 Housing areas, all Moderate Observation Housing areas, single-person discipline,

9 and areas in which safety precautions are implemented, to reduce the risk of self-

10 harm and to identify and address suicide hazards. The County and the Sheriff will

11 utilize a nationally-recognized audit tool for the review. From this tool, the County

12 and the Sheriff will:

13

(a) develop short and long term plans to reasonably mitigate suicide

14

hazards identified by this review; and

15

(b) prioritize planning and mitigation in areas where suicide precautions

16

are implemented and seek reasonable mitigation efforts in those areas.

17

24. The County and the Sheriff will review and inspect housing areas on

18 at least an annual basis to identify suicide hazards.

19 C. Intake

20

25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s

21 Department station jail who verbalizes or who exhibits a clear and obvious

22 indication of current suicidal intent will be transported to IRC, CRDF, or a medical

23 facility as soon as practicable. Pending transport, such prisoners will be under

24 unobstructed visual observation, or in a suicide resistant location with safety

25 checks every 15 minutes.

26

26. Consistent with existing Sheriff’s Department policies, the County

27 and the Sheriff will follow established screening procedures to identify prisoners

28 with emergent or urgent mental health needs based upon information contained in

17

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1 the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the

2 Medical/Mental Health Screening Questionnaire and to expedite such prisoners for

3 mental health evaluation upon arrival at the Jail Reception Centers and prior to

4 routine screening. Prisoners who are identified as having emergent or urgent

5 mental health needs, including the need for emergent psychotropic medication, will

6 be evaluated by a QMHP as soon as possible but no later than four hours from the

7 time of identification.

8

27. Consistent with existing Sheriff’s Department policies, the County

9 and the Sheriff will ensure that all prisoners are individually and privately screened

10 by Qualified Medical Staff or trained custody personnel as soon as possible upon

11 arrival to the Jails, but no later than 12 hours, barring an extraordinary

12 circumstance, to identify a prisoner’s need for mental health care and risk for

13 suicide or self-injurious behavior. The County and the Sheriff will ensure that the

14 Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening

15 Form (SH-R-422) or its equivalent, and/or the Confidential Medical Mental Health

16 Transfer Form are in the prisoner’s electronic medical record or otherwise

17 available at the time the prisoner is initially assessed by a QMHP.

18

28. The County and the Sheriff will ensure that any prisoner who has been

19 identified during the intake process as having emergent or urgent mental health

20 needs as described in Paragraph 26 of this Agreement will be expedited through

21 the booking process. While the prisoner awaits evaluation, the County and the

22 Sheriff will maintain unobstructed visual observation of the prisoner when

23 necessary to protect his or her safety, and will conduct 15-minute safety checks if

24 the prisoner is in a cell.

25

29. The County and the Sheriff will ensure that a QMHP conducts a

26 mental health assessment of prisoners who have non-emergent mental health needs

27 within 24 hours (or within 72 hours on weekends and legal holidays) of a

28 registered nurse conducting an intake nursing assessment at IRC or CRDF.

18

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1

30. Consistent with existing DMH policies, the initial mental health

2 assessment will include a brief initial treatment plan. The initial treatment plan

3 will address housing recommendations and preliminary discharge information.

4 During the initial assessment, a referral will be made for a more comprehensive

5 mental health assessment if clinically indicated. The initial assessment will

6 identify any immediate issues and determine whether a more comprehensive

7 mental health evaluation is indicated. The Monitor and SMEs will monitor

8 whether the housing recommendations in the initial treatment plan have been

9 followed.

10 D. Medical Records

11

31. Consistent with existing DMH and Sheriff’s Department policies, the

12 County and the Sheriff will maintain electronic mental health alerts in prisoners’

13 electronic medical records that notify medical and mental health staff of a

14 prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the

15 following risk factors:

16

(a) current suicide risk;

17

(b) hoarding medications; and

18

(c) prior suicide attempts.

19

32. Information regarding a serious suicide attempt will be entered in the

20 prisoner’s electronic medical record in a timely manner.

21

33. The County will require mental health supervisors in the Jails to

22 review electronic medical records on a quarterly basis to assess their accuracy as

23 follows:

24

(a) Supervisors will randomly select two prisoners from each clinician’s

25

caseload in the prior quarter;

26

(b) Supervisors will compare records for those prisoners to corroborate

27

clinician attendance, units of service, and any unusual trends,

28

including appropriate time spent with prisoners, recording more units

19

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1

of service than hours worked, and to determine whether contacts with

2

those prisoners are inconsistent with their clinical needs;

3

(c) Where supervisors identify discrepancies through these reviews, they

4

will conduct a more thorough review using a DMH-developed

5

standardized tool and will consider detailed information contained in

6

the electronic medical record and progress notes;

7

(d) Serious concerns remaining after the secondary review will be

8

elevated for administrative action in consultation with DMH’s

9

centralized Human Resources.

10

34. The County and the Sheriff will conduct discharge planning and

11 linkage to community mental health providers and aftercare services for all

12 prisoners with serious mental illness as follows:

13

(a) For prisoners who are in Jail seven days or less, a preliminary

14

treatment plan, including discharge information, will be developed.

15

(b) For prisoners who are in Jail more than seven days, a QMHP will also

16

make available:

17

(i) for prisoners who are receiving psychotropic medications, a 30-

18

day prescription for those medications will be offered either

19

through the release planning process, through referral to a re-

20

entry resource center, or through referral to an appropriate

21

community provider, unless clinically contraindicated;

22

(ii) in-person consultation to address housing, mental

23

health/medical/substance abuse treatment, income/benefits

24

establishment, and family/community/social supports. This

25

consultation will also identify specific actions to be taken and

26

identify individuals responsible for each action;

27

(iii) if the prisoner has an intense need for assistance, as described in

28

DMH policies, the prisoner will further be provided direct

20

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1

linkage to an Institution for Mental Disease ("IMD"), IMD-

2

Step-down facility, or appropriately licensed hospital;

3

(iv) if the prisoner has a moderate need for assistance, as described

4

in DMH policies, and as clinically appropriate to the needs of

5

the prisoner, the prisoner will be offered enrollment in Full

6

Service Partnership or similar program, placement in an Adult

7

Residential Facility (“Board and Care”) or other residential

8

treatment facility, and direct assistance accessing community

9

resources; and

10

(v) if the prisoner has minimal needs for assistance, as described in

11

DMH policies, the prisoner will be offered referrals to routine

12

services as appropriate, such as General Relief, Social Security,

13

community mental health clinics, substance abuse programs,

14

and/or outpatient care/support groups.

15

(c) The County will provide a re-entry resource center with QMHPs

16

available to all prisoners where they may obtain information about

17

available mental health services and other community resources.

18 E. Mental Health Referrals

19

35. Consistent with existing DMH and Sheriff’s Department policies, the

20 County and the Sheriff will ensure that custody staff, before the end of shift, refer

21 prisoners in general or special populations who are demonstrating a potential need

22 for routine mental health care to a QMHP or a Jail Mental Evaluation Team

23 (“JMET”) member for evaluation, and document such referrals. Custody staff will

24 utilize the Behavior Observation and Referral Form.

25

36. Consistent with existing DMH policies, the County and the Sheriff

26 will ensure that a QMHP performs a mental health assessment after any adverse

27 triggering event, such as a suicide attempt, suicide threat, self-injurious behavior,

28 or any clear decompensation of mental health status. For those prisoners who

21

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1 repeatedly engage in self-injurious behavior, the County will perform such a

2 mental health assessment only when clinically indicated, and will, when clinically

3 indicated, develop an individualized treatment plan to reduce, and minimize

4 reinforcement of, such behavior. The County and the Sheriff will maintain an on-

5 call system to ensure that mental health assessments are conducted within four

6 hours following the notification of the adverse triggering event or upon notification

7 that the prisoner has returned from a medical assessment related to the adverse

8 triggering event. The prisoner will remain under unobstructed visual observation

9 by custody staff until a QMHP has completed his or her evaluation.

10

37. Sheriff’s Court Services Division staff will complete a Behavioral

11 Observation and Mental Health Referral Form and forward it to the Jail’s mental

12 health and/or medical staff when the Court Services Division staff obtains

13 information that indicates a prisoner has displayed obvious suicidal ideation or

14 when the prisoner exhibits unusual behavior that clearly manifests self-injurious

15 behavior, or other clear indication of mental health crisis. Pending transport, such

16 prisoner will be under unobstructed visual observation or subject to 15-minute

17 safety checks.

18

38. Consistent with existing DMH policies and National Commission on

19 Correctional Health Care standards for jails, the County and the Sheriff will ensure

20 that mental health staff or JMET teams make weekly cell-by-cell rounds in

21 restricted non-mental health housing modules (e.g., administrative segregation,

22 disciplinary segregation) at the Jails to identify prisoners with mental illness who

23 may have been missed during screening or who have decompensated while in the

24 Jails. In conducting the rounds, either the clinician, the JMET deputy, or the

25 prisoner may request an out-of-cell interview. This request will be granted unless

26 there is a clear and documented security concern that would prohibit such an

27 interview or the prisoner has a documented history of repeated, unjustified requests

28 for such out-of-cell interviews.

22

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1

39. The County and the Sheriff will continue to use a confidential self-

2 referral system by which all prisoners can request mental health care without

3 revealing the substance of their request to custody staff or other prisoners.

4

40. The County and the Sheriff will ensure a QMHP will be available on-

5 site, by transportation of the prisoner, or through tele-psych 24 hours per day,

6 seven days per week (24/7) to provide clinically appropriate mental health crisis

7 intervention services.

8 F. Mental Health Follow Up

9

41. Consistent with existing DMH policies, the County and the Sheriff

10 will implement step-down protocols that provide clinically appropriate transition

11 when prisoners are discharged from FIP after being the subject of suicide watch.

12 The protocols will provide:

13

(a) intermediate steps between highly restrictive suicide measures (e.g.,

14

clinical restraints and direct constant observation) and the

15

discontinuation of suicide watch;

16

(b) an evaluation by a QMHP before a prisoner is removed from suicide

17

watch;

18

(c) every prisoner discharged from FIP following a period of suicide

19

watch will be housed upon release in the least restrictive setting

20

deemed clinically appropriate unless exceptional circumstances

21

affecting the facility exist; and

22

(d) all FIP discharges following a period of suicide watch will be seen by

23

a QMHP within 72 hours of FIP release, or sooner if indicated, unless

24

exceptional circumstances affecting the facility exist.

25

42. Consistent with existing DMH policies, the County and the Sheriff

26 will implement step-down protocols to ensure that prisoners admitted to HOH and

27 placed on risk precautions are assessed by a QMHP. As part of the assessment, the

28

23

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1 QMHP will determine on an individualized basis whether to implement “step-

2 down” procedures for that prisoner as follows:

3

(a) the prisoner will be assessed by a QMHP within three Normal

4

business work days, but not to exceed four Days, following

5

discontinuance of risk precautions;

6

(b) the prisoner is counseled to ameliorate the negative psychological

7

impact that any restrictions may have had and in ways of dealing with

8

this impact;

9

(c) the prisoner will remain in HOH or be transferred to MOH, as

10

determined on a case by case basis, until such assessment and

11

counseling is completed, unless exceptional circumstances affecting

12

the facility exist; and

13

(d) the prisoner is subsequently placed in a level of care/housing as

14

determined by a QMHP.

15

43. Within six months of the Effective Date, the County and the Sheriff

16 will develop and implement written policies for formal discipline of prisoners with

17 serious mental illness incorporating the following:

18

(a) Prior to transfer, custody staff will consult with a QMHP to determine

19

whether assignment of a prisoner in mental health housing to

20

disciplinary housing is clinically contraindicated and whether

21

placement in a higher level of mental health housing is clinically

22

indicated, and will thereafter follow the QMHP’s recommendation;

23

(b) If a prisoner is receiving psychotropic medication and is placed in

24

disciplinary housing from an area other than mental health housing, a

25

QMHP will meet with that prisoner within 24 hours of such placement

26

to determine whether maintenance of the prisoner in such placement is

27

clinically contraindicated and whether transfer of the prisoner to

28

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1

mental health housing is clinically appropriate, and custody staff will

2

thereafter follow the QMHP’s recommendation;

3

(c) A QMHP will participate in weekly walks, as specified in Paragraph

4

38, in disciplinary housing areas to observe prisoners in those areas

5

and to identify those prisoners with mental health needs;

6

(d) Prior to a prisoner in mental health housing losing behavioral credits

7

for disciplinary reasons, the disciplinary decision-maker will receive

8

and take into consideration information from a QMHP regarding the

9

prisoner’s underlying mental illness, the potential effects of the

10

discipline being considered, and whether transfer of the prisoner to a

11

higher level of mental health housing is clinically indicated.

12 G. Suicide Risk Procedures

13

44. Within six months of the Effective Date, the County and the Sheriff

14 will install protective barriers that do not prevent line-of-sight supervision on the

15 second floor tier of all High Observation Housing areas to prevent prisoners from

16 jumping off of the second floor tier. Within six months of the Effective Date, the

17 County and the Sheriff will also develop a plan that identifies any other areas in

18 mental health housing where such protective barriers should be installed.

19

45. Consistent with existing Sheriff’s Department policies, the County

20 and the Sheriff will provide both a Suicide Intervention Kit that contains an

21 emergency cut-down tool and a first-aid kit in the control booth or officer’s station

22 of each housing unit. All custody staff who have contact with prisoners will know

23 the location of the Suicide Intervention Kit and first-aid kit and be trained to use

24 their contents.

25

46. The County and the Sheriff will immediately interrupt, and if

26 necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-

27 injurious behavior.

28 H. Staffing

25

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1

47. The County and the Sheriff will ensure there are sufficient custodial,

2 medical, and mental health staff at the Jails to fulfill the terms of this Agreement.

3 Within six months of the Effective Date, and on a semi-annual basis thereafter, the

4 County and the Sheriff will, in conjunction with the requirements of Paragraph 92

5 of this Agreement, provide to the Monitor and DOJ a report identifying the steps

6 taken by the County and the Sheriff during the review period to implement the

7 terms of this Agreement and any barriers to implementation, such as insufficient

8 staffing levels at the Jails, if any. The County and the Sheriff will retain staffing

9 records for two years to ensure that for any critical incident or non-compliance

10 with this Agreement, the Monitor and DOJ can obtain those records to determine

11 whether staffing levels were a factor in that critical incident and/or non-

12 compliance.

13 I. Environmental Conditions

14

48. Within three months of the Effective Date, the County and the Sheriff

15 will have written housekeeping, sanitation, and inspection plans to ensure the

16 proper cleaning of, and trash collection and removal in, housing, shower, and

17 medical areas, in accordance with California Code of Regulations (“CCR”) Title

18 15 § 1280: Facility Sanitation, Safety, and Maintenance.

19

49. Within three months of the Effective Date, the County and the Sheriff

20 will have a maintenance plan to respond to routine and emergency maintenance

21 needs, including ensuring that shower, toilet, sink, and lighting units, and heating,

22 ventilation, and cooling systems are adequately maintained and installed. The plan

23 will also include steps to treat large mold infestations.

24

50. Consistent with existing Sheriff’s Department policies regarding

25 control of vermin, the County and the Sheriff will provide pest control throughout

26 the housing units, medical units, kitchen, and food storage areas.

27

51. Consistent with existing Sheriff’s Department policies regarding

28 personal care items and supplies for inmates, the County and the Sheriff will

26

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1 ensure that all prisoners have access to basic hygiene supplies, in accordance with

2 CCR Title 15 § 1265: Issue of Personal Care Items.

3 J. Allowable Property Privileges

4

52. The County and the Sheriff will implement policies governing

5 property restrictions in High Observation Housing that provide:

6

(a) Except when transferred directly from FIP, upon initial placement in

7

HOH:

8

(i) Suicide-resistant blankets, gowns, and mattresses will be

9

provided until the assessment set forth in section (a)(ii) below is

10

conducted, unless clinically contraindicated as determined and

11

documented by a QMHP.

12

(ii) Within 24 hours, a QMHP will make recommendations

13

regarding allowable property based upon an individual clinical

14

assessment.

15

(b) Property restrictions in HOH beyond 24 hours will be based on

16

clinical judgment and assessment by a QMHP as necessary to ensure

17

the safety and well-being of the prisoner and documented in the

18

Electronic Medical Record.

19

53. If otherwise eligible for an education, work, or similar program, a

20 prisoner’s mental health diagnosis or prescription for medication alone will not

21 preclude that prisoner from participating in said programming.

22

54. Prisoners who are not in Mental Health Housing will not be denied

23 privileges and programming based solely on their mental health status or

24 prescription for psychotropic medication.

25 K. Communication Related to Mental Health

26

55. Relevant custody, medical, and mental health staff in all High

27 Observation Housing units will meet on Normal business work days and such staff

28 in all Moderate Observation Housing units will meet at least weekly to ensure

27

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1 coordination and communication regarding the needs of prisoners in mental health

2 housing units as outlined in Custody Services Division Directive(s) regarding

3 coordination of mental health treatment and housing. When a custody staff

4 member is serving as a member of a treatment team, he or she is subject to the

5 same confidentiality rules and regulations as any other member of the treatment

6 team, and will be trained in those rules and regulations.

7

56. Consistent with existing DMH and Sheriff’s Department policies, the

8 County and the Sheriff will ensure that custody, medical, and mental health staff

9 communicate regarding any change in a prisoner’s housing assignment following a

10 suicide threat, gesture, or attempt, or other indication of an obvious and serious

11 change in mental health condition.

12 L. Safety Checks

13

57. Within three months of the Effective Date, the County and the Sheriff

14 will revise and implement their policies on safety checks to ensure a range of

15 supervision for prisoners housed in Mental Health Housing. The County and the

16 Sheriff will ensure that safety checks in Mental Health Housing are completed and

17 documented in accordance with policy and regulatory requirements as set forth

18 below:

19

(a) Custody staff will conduct safety checks in a manner that allows staff

20

to view the prisoner to assure his or her well-being and security.

21

Safety checks involve visual observation and, if necessary to

22

determine the prisoner’s well-being, verbal interaction with the

23

prisoner;

24

(b) Custody staff will document their checks in a format that does not

25

have pre-printed times;

26

(c) Custody staff will stagger checks to minimize prisoners’ ability to

27

plan around anticipated checks;

28

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1

(d) Video surveillance may not be used to replace rounds and supervision

2

by custodial staff unless new construction is built specifically with

3

constant video surveillance enhancements and could only be used to

4

replace 15 minute checks in non-FIP housing, subject to approval by

5

the Monitor;

6

(e) A QMHP, in coordination with custody (and medical staff if

7

necessary), will determine mental health housing assignments.

8

(f) Supervision of prisoners in mental health housing will be conducted at

9

the following intervals:

10

(i) FIP: Custody staff will perform safety checks every 15

11

minutes. DMH staff will perform direct constant observation or

12

one-to-one observation when determined to be clinically

13

appropriate;

14

(ii) High Observation Housing: Every 15 minutes;

15

(iii) Moderate Observation Housing: Every 30 minutes.

16

58. Within three months of the Effective Date, the County and the Sheriff

17 will revise and implement their policies on safety checks. The County and the

18 Sheriff will ensure that safety checks in non-mental health housing units are

19 completed and documented in accordance with policy and regulatory requirements

20 as set forth below:

21

(a) At least every 30 minutes in housing areas with cells;

22

(b) At least every 30 minutes in dormitory-style housing units where the

23

unit does not provide for unobstructed direct supervision of prisoners

24

from a security control room.

25

(c) Where a dormitory-style housing unit does provide for unobstructed

26

direct supervision of prisoners, safety checks must be completed

27

inside the unit at least every 60 minutes;

28

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1

(d) At least every 60 minutes in designated minimum security dormitory

2

housing at PDC South, or other similar campus-style unlocked

3

dormitory housing;

4

(e) Custody staff will conduct safety checks in a manner that allows staff

5

to view the prisoner to assure his or her well-being and security.

6

Safety checks involve visual observation and, if necessary to

7

determine the prisoner’s well-being, verbal interaction with the

8

prisoner;

9

(f) Custody staff will document their checks in a format that does not

10

have pre-printed times;

11

(g) Custody staff will stagger checks to minimize prisoners’ ability to

12

plan around anticipated checks; and

13

(h) Video surveillance may not be used to replace rounds and supervision

14

by custodial staff.

15

59. Consistent with existing Sheriff’s Department policies regarding

16 uniform daily activity logs, the County and the Sheriff will ensure that a custodial

17 supervisor conducts unannounced daily rounds on each shift in the prisoner

18 housing units to ensure custodial staff conduct necessary safety checks and

19 document their rounds.

20 M. Quality Improvement Plan

21

60. Within six months of the Effective Date, the Department of Mental

22 Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this

23 Agreement, will implement a quality improvement program to identify and address

24 clinical issues that place prisoners at significant risk of suicide or self-injurious

25 behavior.

26

61. The quality improvement program will review, collect, and aggregate

27 data in the following areas and recommend corrective actions and systemic

28 improvements:

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1

(a) Suicides and serious suicide attempts:

2

(i) Prior suicide attempts or other serious self-injurious behavior

3

(ii) Locations

4

(iii) Method

5

(iv) Lethality

6

(v) Demographic information

7

(vi) Proximity to court date;

8

(b) Use of clinical restraints;

9

(c) Psychotropic medications;

10

(d) Access to care, timeliness of service, and utilization of the Forensic

11

In-patient Unit; and

12

(e) Elements of documentation and use of medical records.

13

62. The County and the Sheriff’s Unit described in Paragraph 77 of this

14 Agreement will develop, implement, and track corrective action plans addressing

15 recommendations of the quality improvement program.

16 N. Mental Health Housing

17

63. The County and the Sheriff will maintain adequate High Observation

18 Housing and Moderate Observation Housing sufficient to meet the needs of the jail

19 population with mental illness, as assessed by the County and the Sheriff on an

20 ongoing basis. The County will continue its practice of placing prisoners with

21 mental illness in the least restrictive setting consistent with their clinical needs.

22

64. Within six months of the Effective Date, the County and the Sheriff

23 will develop a short-term plan addressing the following 12-month period, and

24 within 12 months of the Effective Date, the County and the Sheriff will develop a

25 long-term plan addressing the following five-year period, to reasonably ensure the

26 availability of licensed inpatient mental health care for prisoners in the Jails. The

27 County and the Sheriff will begin implementation of each plan within 90 days of

28 plan completion. These plans will describe the projected capacity required,

31

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1 strategies that will be used to obtain additional capacity if it is needed, and identify

2 the resources necessary for implementation. Thereafter, the County and the Sheriff

3 will review, and if necessary revise, these plans every 12 months.

4 O. Medication

5

65. Consistent with existing Sheriff’s Department policies, the County

6 and the Sheriff will ensure that psychotropic medications are administered in a

7 clinically appropriate manner to prevent misuse, hoarding, and overdose.

8

66. Consistent with existing DMH policies, prisoners in High Observation

9 Housing and Moderate Observation Housing, and those with a serious mental

10 illness who reside in other housing areas of the Jails, will remain on an active

11 mental health caseload and receive clinically appropriate mental health treatment,

12 regardless of whether they refuse medications.

13

67. Within three months of the Effective Date, the County and the Sheriff

14 will implement policies for prisoners housed in High Observation Housing and

15 Moderate Observation Housing that require:

16

(a) documentation of a prisoner’s refusal of psychotropic medication in

17

the prisoner’s electronic medical record;

18

(b) discussion of a prisoner’s refusal in treatment team meetings;

19

(c) the use of clinically appropriate interventions with such prisoners to

20

encourage medication compliance;

21

(d) consideration of the need to transfer non-compliant prisoners to higher

22

levels of mental health housing; and

23

(e) individualized consideration of the appropriateness of seeking court

24

orders for involuntary medication pursuant to the provisions of

25

California Welfare and Institutions Code sections 5332-5336 and/or

26

California Penal Code section 2603(a).

27

68. Within six months of the Effective Date, the County and the Sheriff

28 will develop and implement a procedure for contraband searches on a regular, but

32

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1 staggered basis in all housing units. High Observation Housing cells will be

2 visually inspected prior to initial housing of inmates with mental health issues.

3

4 P. Restraints

5

69. Consistent with existing DMH policies regarding use of clinical

6 restraints, the County and the Sheriff will use clinical restraints only in the

7 Correctional Treatment Center and only with the approval of a licensed psychiatrist

8 who has performed an individualized assessment and an appropriate Forensic

9 Inpatient order. Use of clinical restraints in CTC will be documented in the

10 prisoner’s electronic medical record. The documentation will include the basis for

11 and duration of the use of clinical restraints and the performance and results of the

12 medical welfare checks on restrained prisoners. When applying clinical restraints,

13 custody staff will ensure a QMHP is present to document and monitor the

14 condition of the prisoner being placed in clinical restraints.

15

70. Within three months of the Effective Date, the County and the Sheriff

16 will have policies and procedures regarding the use of Security Restraints in HOH

17 and MOH. Such policies will provide that:

18

(a) Security Restraints in these areas will not be used as an alternative to

19

mental health treatment and will be used only when necessary to

20

insure safety;

21

(b) Security Restraints will not be used to punish prisoners, but will be

22

used only when there is a threat or potential threat of physical harm,

23

destruction of property, or escape;

24

(c) Custody staff in HOH and MOH will consider a range of security

25

restraint devices and utilize the least restrictive option, for the least

26

amount of time, necessary to provide safety in these areas;

27

(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s

28

Department policy, and appears to be in a mental health crisis,

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1

Custody staff will request a sergeant and immediately refer the

2

prisoner to a QMHP.

3

71. The County and the Sheriff will ensure that any prisoner subjected to

4 clinical restraints in response to a mental health crisis receives therapeutic services

5 to remediate any effects from the episode(s) of restraint.

6 Q. Suicide Death Reviews and Critical Incident Reviews

7

72. The County and the Sheriff will develop and implement policies and

8 procedures that ensure that incidents involving suicide and serious self-injurious

9 behavior are reported and reviewed to determine: (a) whether staff engaged in any

10 violations of policies, rules, or laws; and (b) whether any improvements to policy,

11 training, operations, treatment programs, or facilities are warranted. These policies

12 and procedures will define terms clearly and consistently to ensure that incidents

13 are reported and tracked accurately by DMH and the Sheriff’s Department.

14

73. Depending on the level of severity of an incident involving a prisoner

15 who threatens or exhibits self-injurious behavior, a custody staff member will

16 prepare a detailed report (Behavioral Observation and Mental Health Referral

17 Form, Inmate Injury Report, and/or Incident Report) that includes information

18 from individuals who were involved in or witnessed the incident as soon as

19 practicable, but no later than the end of shift. The report will include a description

20 of the events surrounding the incident and the steps taken in response to the

21 incident. The report will also include the date and time that the report was

22 completed and the names of any witnesses. The Sheriff’s Department will

23 immediately notify the County Office of Inspector General of all apparent or

24 suspected suicides occurring at the Jails.

25

74. The Sheriff’s Department will ensure that there is a timely, thorough,

26 and objective law enforcement investigation of any suicide that occurs in the Jails.

27 Investigations shall include recorded interviews of persons involved in, or who

28 witnessed, the incident, including other prisoners. Sheriff’s Department personnel

34

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1 who are investigating a prisoner suicide or suspected suicide at the Jails will ensure

2 the preservation of all evidence, including physical evidence, relevant witness

3 statements, reports, videos, and photographs.

4

75. Within three months of the Effective Date, the County and the Sheriff

5 will review every suicide attempt that occurs in the Jails as follows:

6

(a) Within two working days, DMH staff will review the incident, the

7

prisoner’s mental health status known at the time of the incident, the

8

need for immediate corrective action if any, and determine the level of

9

suicide attempt pursuant to the Centers for Disease Control and

10

Prevention’s Risk Rating Scale;

11

(b) Within 30 working days, and only for those incidents determined to be

12

a serious suicide attempt by DMH staff after the review described in

13

subsection (a) above, management and command-level personnel

14

from DMH and the Sheriff’s Department (including Custody Division

15

and Medical Services Bureau) will meet to review relevant

16

information known at that time, including the events preceding and

17

following the incident, the prisoner’s incarceration, mental health, and

18

health history, the status of any corrective actions taken, and the need

19

for additional corrective action if necessary;

20

(c) The County and the Sheriff will document the findings that result

21

from the review of serious suicide attempts described in subsection (b)

22

above; and

23

(d) The County and the Sheriff will ensure that information for all suicide

24

attempts is input into a database for tracking and statistical analysis.

25

76. The County and the Sheriff will review every apparent or suspected

26 suicide that occurs in the Jails as follows:

27

(a) Within no more than two working days, management and command-

28

level personnel from DMH and the Sheriff’s Department (including

35

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1

Custody Division and Medical Services Bureau) will meet to review

2

and discuss the suicide, the prisoner’s mental health status known at

3

the time of the suicide, and the need for immediate corrective or

4

preventive action if any;

5

(b) Within seven working days, and again within 30 working days,

6

management and command-level personnel from DMH and the

7

Sheriff’s Department (including Custody Division and Medical

8

Services Bureau) will meet to review relevant information known at

9

that time, including the events preceding and following the suicide,

10

the prisoner’s incarceration, mental health, and health history, the

11

status of any corrective or preventive actions taken, and the need for

12

additional corrective or preventive action if necessary;

13

(c) Within six months of the suicide, the County and the Sheriff will

14

prepare a final written report regarding the suicide. The report will

15

include:

16

(i) time and dated incident reports and any supplemental reports

17

with the same Uniform Reference Number (URN) from custody

18

staff who were directly involved in and/or witnessed the

19

incident;

20

(ii) a timeline regarding the discovery of the prisoner and any

21

responsive actions or medical interventions;

22

(iii) copies of a representative sample of material video recordings

23

or photographs, to the extent that inclusion of such items does

24

not interfere with any criminal investigation;

25

(iv) a reference to, or reports if available, from the Sheriff’s

26

Department Homicide Bureau;

27

(v) reference to the Internal Affairs Bureau or other personnel

28

investigations, if any, and findings, if any;

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1

(vi) a Coroner’s report, if it is available at the time of the final

2

report, and if it is not available, a summary of efforts made to

3

obtain the report;

4

(vii) a summary of relevant information discussed at the prior review

5

meetings, or otherwise known at the time of the final report,

6

including analysis of housing or classification issues if relevant;

7

(viii) a clinical mortality review;

8

(ix) a Psychological Autopsy utilizing the National Commission on

9

Correctional Health Care’s standards; and

10

(x) a summary of corrective actions taken and recommendations

11

regarding additional corrective actions if any are needed.

12

77. The County and the Sheriff will create a specialized unit to oversee,

13 monitor, and audit the County’s jail suicide prevention program in coordination

14 with the Department of Mental Health. The Unit will be headed by a Captain, or

15 another Sheriff’s Department official of appropriate rank, who reports to the

16 Assistant Sheriff for Custody Operations through the chain of command. The Unit

17 will be responsible for:

18

(a) Ensuring the timely and thorough administrative review of suicides

19

and serious suicide attempts in the Jails as described in this

20

Agreement;

21

(b) Identifying patterns and trends of suicides and serious suicide

22

attempts in the Jails, keeping centralized records and inputting data

23

into a unit database for statistical analysis, trends, and corrective

24

action, if necessary;

25

(c) Ensuring that corrective actions are taken to mitigate suicide risks at

26

both the location of occurrence and throughout the concerned system

27

by providing, or obtaining where appropriate, technical assistance to

28

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1

other administrative units within the Custody Division when such

2

assistance is needed to address suicide-risk issues;

3

(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and

4

mental health service delivery issues as they relate to suicides and

5

serious suicide attempts to identify the need for corrective action

6

where appropriate; and recommend remedial measures, including

7

policy revisions, re-training, or staff discipline, to address the

8

deficiencies and ensure implementation; and

9

(e) Participating in meetings with DMH to develop, implement, and track

10

corrective action plans addressing recommendations of the quality

11

improvement program.

12

78. The County and the Sheriff will maintain a county-level Suicide

13 Prevention Advisory Committee that will be open to representatives from the

14 Sheriff’s Department Custody Division, Court Services, Custody Support Services,

15 and Medical Services Bureau; the Department of Mental Health; the Public

16 Defender’s Office; County Counsel’s Office; the Office of the Inspector General;

17 and the Department of Mental Health Patients’ Rights Office. The Suicide

18 Prevention Advisory Committee will meet twice per year and will serve as an

19 advisory body to address system issues and recommend coordinated approaches to

20 suicide prevention in the Jails.

21 R. Mental Health Treatment

22

79. (a) Unless clinically contraindicated, the County and the Sheriff will

23 offer prisoners in mental health housing:

24

(i) therapeutically appropriate individual visits with a QMHP;

25

(ii) therapeutically appropriate group programming conducted by a

26

QMHP or other appropriate provider that does not exceed 90

27

minutes per session;

28

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1

(b) The County and the Sheriff will provide prisoners outside of mental

2 health housing with medication support services when those prisoners are

3 receiving psychotropic medications and therapeutically appropriate individual

4 monthly visits with a QMHP when those prisoners are designated as Seriously

5 Mentally Ill.

6

(c) The date, location, topic, attendees, and provider of programming or

7 therapy sessions will be documented. A clinical supervisor will review

8 documentation of group sessions on a monthly basis.

9

80. (a) The County and the Sheriff will continue to make best efforts to

10 provide appropriate out-of-cell time to all prisoners with serious mental illness,

11 absent exceptional circumstances, and unless individually clinically

12 contraindicated and documented in the prisoner’s electronic medical record. To

13 implement this requirement, the County and the Sheriff will follow the schedule

14 below:

15

(i) By no later than six months after the Effective Date, will offer

16

25% of the prisoners in HOH ten hours of unstructured out-of-

17

cell recreational time and ten hours of structured therapeutic or

18

programmatic time per week;

19

(ii) By no later than 12 months after the Effective Date, will offer

20

50% of the prisoners in HOH ten hours of unstructured out-of-

21

cell recreational time and ten hours of structured therapeutic or

22

programmatic time per week;

23

(iii) By no later than 18 months after the Effective Date, will offer

24

100% of the prisoners in HOH ten hours of unstructured out-of-

25

cell recreational time and ten hours of structured therapeutic or

26

programmatic time per week.

27

(b) No later than six months after the Effective Date, the County and the

28 Sheriff will record at the end of each day which prisoners in HOH, if any, refused

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1 to leave their cells that day. That data will be presented and discussed with DMH

2 staff at the daily meeting on the following Normal business work day. The data

3 will also be provided to the specialized unit described in Paragraph 77 and to

4 DMH’s quality improvement program to analyze the data for any trends and to

5 implement any corrective action(s) deemed necessary to maximize out-of-cell time

6 opportunities and avoid unnecessary isolation.

7 S. Use of Force

8

81. Except as specifically set forth in Paragraphs 18-20 of this

9 Agreement, and except as specifically identified below, the County and the Sheriff

10 will implement the following paragraphs of the Implementation Plan in Rosas at all

11 Jails facilities, including the Pitchess Detention Center and the Century Regional

12 Detention Facility, by no later than the dates set forth in the Implementation Plan

13 or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force

14 policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10

15 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of

16 force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner

17 supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-

18 10.2 (management presence in housing units); 11.1 (management review of force);

19 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to

20 be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff

21 discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7

22 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-

23 17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning

24 system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).

25

82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the

26 County and the Sheriff will ensure that Sheriff's Department personnel responsible

27 for collecting prisoners’ grievances as set forth in that paragraph are also co-

28 located in the Century Regional Detention Facility.

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1

83. The County and the Sheriff will install closed circuit security cameras

2 throughout all Jails facilities’ common areas where prisoners engage in

3 programming, treatment, recreation, visitation, and intra-facility movement

4 (“Common Areas”), including in the Common Areas at the Pitchess Detention

5 Center and the Century Regional Detention Facility. The County and the Sheriff

6 will install a sufficient number of cameras in Jails facilities that do not currently

7 have cameras to ensure that all Common Areas of these facilities have security-

8 camera coverage. The installation of these cameras will be completed no later than

9 June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF

10 completed by March 1, 2016; and the remaining facilities completed by June 30,

11 2018. The County and the Sheriff will also ensure that all video recordings of

12 force incidents are adequately stored and retained for a period of at least one year

13 after the force incident occurs or until all investigations and proceedings related to

14 the use of force are concluded, whichever happens later.

15

84. The Sheriff will continue to maintain and implement policies for the

16 timely and thorough investigation of alleged staff misconduct related to use of

17 force and for timely disciplinary action arising from such investigations.

18 Specifically:

19

(a) Sworn custody staff subject to the provisions of California

20

Government Code section 3304 will be notified of the completion of

21

the investigation and the proposed discipline arising from force

22

incidents in accordance with the requirements of that Code section;

23

and

24

(b) All non-sworn Sheriff’s Department staff will be notified of the

25

proposed discipline arising from force incidents in time to allow for

26

the imposition of that discipline.

27

28

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1

85. The County and the Sheriff will ensure that Internal Affairs Bureau

2 management and staff receive adequate specialized training in conducting

3 investigations of misconduct.

4

86. Within three months of the Effective Date, the County and the Sheriff

5 will develop and implement policies and procedures for the effective and accurate

6 maintenance, inventory, and assignment of chemical agents and other security

7 equipment. The County and the Sheriff will develop and maintain an adequate

8 inventory control system for all weapons, including OC spray.

9

VI. IMPLEMENTATION, COMPLIANCE ASSESSMENT,

10

ENFORCEMENT, AND TERMINATION

11 A. Review and Implementation of Policies, Procedures, and Programs

12

87. The County and the Sheriff are committed to continuous quality

13 improvement and have taken significant steps to review and update policies and

14 procedures to protect the constitutional and federal rights of prisoners at the Jails.

15 Where necessary, the County and the Sheriff will maintain existing policies,

16 procedures, and practices to support the substantive provisions in this Agreement.

17

88. The County and the Sheriff will review all relevant policies,

18 procedures, and other written executive-approved directives within four months of

19 the Effective Date to ensure that they are consistent with the terms of this

20 Agreement, unless they were reviewed and revised for such purposes within six

21 months preceding the Effective Date.

22

89. (a) If the County or the Sheriff create or materially revise a policy

23 related to this Agreement after the Effective Date, the following process will be

24 followed before implementation:

25

(1) the County and Sheriff will provide a copy of the proposed policy to

26

the Monitor and DOJ prior to its implementation;

27

(2) the Monitor and DOJ will have 30 days to review the policy and

28

submit comments, if any, to the County and the Sheriff;

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1

(3) if the Monitor and DOJ do not submit any comments within the 30-

2

day period, the County and the Sheriff will begin implementation of

3

the policy no later than 180 days after the expiration of the 30 day-

4

review period or notice that no comments will be forthcoming;

5

(4) if the Monitor or DOJ objects to the proposed policy, the Monitor or

6

DOJ will note the objection in writing to all Parties within the

7

respective review period;

8

(5) if there is any objection to the proposed policy, the County and the

9

Sheriff will have 30 days to address the objection(s);

10

(6) if the Monitor and the Parties cannot resolve the objection(s), either

11

Party may ask the Court to resolve the matter;

12

(7) the Monitor may extend any time frame within this paragraph by up to

13

15 additional days. Further extensions may be granted by the Monitor

14

with the agreement of both Parties when necessary to permit amicable

15

resolution of objections.

16

(b) If after the Effective Date, the County or the Sheriff is confronted with a

17 critical circumstance requiring immediate action, the County or the Sheriff may

18 create or substantially revise, and then implement, a policy related to this

19 Agreement without the prior review of the Monitor and DOJ, so long as the

20 review, comment, and objection procedures set forth above in subparagraph (a) are

21 followed immediately upon implementation.

22

90. The County and the Sheriff will provide relevant staff with any policy

23 that is created or materially revised after the Effective Date if it relates to the

24 provisions of this Agreement. The County and the Sheriff will further document

25 that any such policy has been received by that staff and that such staff has been

26 trained, instructed, or briefed, as appropriate, on that policy.

27

28

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1 B. Compliance Coordination Unit

2

91. The County and the Sheriff will establish and maintain a compliance

3 coordination unit for the duration of this Agreement. The unit will:

4

(a) serve as a liaison between the Parties and the Monitor and assume

5

primary responsibility for collecting information the Monitor requires

6

to carry out the duties assigned to the Monitor;

7

(b) maintain sufficient records to document that the requirements of this

8

Agreement are being properly implemented (e.g., census summaries,

9

policies, procedures, protocols, training materials, investigations,

10

incident reports, tier logs, use-of-force reports);

11

(c) provide written answers by electronic mail or other format when

12

necessary and any documents requested by the Monitor or DOJ

13

concerning implementation of this Agreement in a timely manner;

14

(d) coordinate and monitor compliance and implementation activities,

15

including coordination between Custody and DMH staff, and assist

16

managers in assigning compliance tasks to County or Sheriff

17

personnel; and

18

(e) ensure that the County and the Sheriff notify DOJ and the Monitor of

19

any suspected or apparent suicide within 24 hours and make related

20

reports available to the Monitor and DOJ for inspection.

21 C. Self-Assessments and Reports

22

92. (a) Fifteen days before the end of the reporting period described in

23 Paragraph 109 of this Agreement, the County and the Sheriff will provide the

24 Monitor and DOJ a Self-Assessment Status Report that includes:

25

(1) the actions taken by the County and the Sheriff during the review

26

period to implement this Agreement including the status of ongoing

27

and continuous improvement activities;

28

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1

(2) responses to concerns or recommendations made in prior reports by

2

the Monitor;

3

(3) a summary of any audits related to the provisions of this Agreement

4

that were completed in the reporting period; and

5

(4) relevant trend data including the information described in Paragraphs

6

61 and 77(a).

7

(b) Self-Assessment Status Reports prepared pursuant to this Paragraph will

8 be treated as confidential and not further disclosed or attached to any court

9 document, unless filed under seal with Court approval, without the consent of the

10 County and the Sheriff or by order of the Court. The Monitor, SMEs, and other

11 monitoring staff, however, will be permitted to use the information contained in

12 the Self-Assessment Status Reports to prepare the Monitor's reports to the Court.

13 D. Independent Monitor

14

93. In order to assess and report on the implementation of this Agreement

15 and whether the implementation is having the intended beneficial impact on

16 conditions at the Jails, the Monitor, the SMEs, and their staff will:

17

(a) conduct the audits, reviews, and assessments specified in this

18

Agreement;

19

(b) review County and Sheriff policies, procedures, training curricula, and

20

other documents related to this Agreement developed and

21

implemented pursuant to this Agreement;

22

(c) conduct such additional audits, reviews, and assessments consistent

23

with this Agreement as the Monitor and the Parties jointly agree are

24

appropriate, or in the case of a dispute which the Parties cannot in

25

good faith resolve, as ordered by the Court; and

26

(d) evaluate the implementation of Section V.S. of this Agreement

27

concerning use of force consistent with the Settlement Agreement and

28

Implementation Plan approved in Rosas.

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1

94. The Parties have selected Richard Drooyan as the Independent

2 Monitor. The Monitor and his staff will not, and are not intended to, replace or

3 assume the role and duties of the County or the Sheriff and will have only the

4 duties, responsibilities, and authority conferred by this Agreement.

5

To assess and report whether the provisions of this Agreement have been

6 implemented, and whether the County and the Sheriff are in compliance with the

7 substantive provisions of this Agreement, the Monitor will:

8

(a) evaluate the implementation of Section V (“Substantive Provisions”)

9

of this Agreement and, where applicable, the Settlement Agreement

10

and Implementation Plan approved in Rosas;

11

(b) conduct specific audits, reviews, and assessments consistent with this

12

Agreement or otherwise if the Parties agree in writing; and

13

(c) prepare reports as provided in this Agreement.

14

95. The Parties have also selected Bruce C. Gage, M.D., and Manuel

15 David Romero as Subject Matter Experts (“SMEs”). The SMEs and their staff will

16 not, and are not intended to, replace or assume the role and duties of the County or

17 the Sheriff and will have only the duties, responsibilities, and authority conferred

18 by this Agreement. The SMEs will, in conjunction with the Monitor, assess

19 compliance with the substantive provisions of this Agreement by providing

20 expertise within the scope of their subject matters.

21

96. The Monitor and/or SMEs may hire or contract with additional

22 persons with knowledge or expertise not already provided by the SMEs, or where

23 delegation to a subordinate staff member would be appropriate, as reasonably

24 necessary to perform the tasks assigned by this Agreement. The Monitor will

25 notify the County, the Sheriff, and DOJ in writing when the Monitor or SMEs are

26 considering such additional persons. The Parties will have an opportunity, if

27 desired, to interview the candidate(s) and request reasonable information about the

28 candidate’s background and experience. If the Parties agree to the Monitor’s

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1 proposal, the Monitor or SMEs will be authorized to hire or contract such

2 additional persons. If the Parties do not agree to the proposal, the Parties will have

3 ten business days to disagree with the proposal in writing. The Parties will not

4 unreasonably withhold approval. If the Parties are unable to reach agreement

5 within ten business days of receiving notice of this disagreement, the Court will

6 resolve the dispute.

7

97. If not already developed by the Monitor and SMEs and agreed-to by

8 the Parties before the execution of this Agreement, within three months of the

9 appointment of the Monitor and SMEs by the Court, the Monitor and SMEs will

10 develop a plan for conducting the above audits, reviews, and assessments, and will

11 submit that plan to the Parties for review and approval. The plan will:

12

(a) set out a methodology for reviewing each of the substantive

13

provisions of this Agreement, including which provisions will be

14

assessed together, if any, and the thresholds for achieving Substantial

15

Compliance; and

16

(b) set out a schedule for conducting the assessments required by this

17

Agreement.

18

98. The Monitor, SMEs, and any person hired or contracted to assist the

19 Monitor or SMEs will be subject to (a) the supervision and orders of the Court

20 consistent with the terms of this Agreement; (b) the terms of this Agreement; (c)

21 any applicable law; and (d) any security protocols while in the Jails.

22

99. The County and the Sheriff will bear all reasonable fees and costs of

23 the Monitor, the SMEs, and their staff. Travel, lodging, and per diem expenses

24 will be reimbursed at the same rate as provided for County employees. In the

25 event that any dispute arises regarding the reasonableness or payment of the

26 Monitor’s, SMEs', or their staff's fees and costs, the Parties and the Monitor will

27 attempt to resolve the dispute cooperatively before seeking the assistance of the

28 Court.

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1

100. At the request of the County and the Sheriff, and with the consent of

2 the DOJ, the Monitor, SMEs, and their staff may provide technical assistance.

3 Such assistance may not interfere with the Monitor’s or SMEs’ duties under this

4 Agreement, create additional duties or obligations that are enforceable under this

5 Agreement, or otherwise alter or modify the terms of this Agreement.

6 Additionally, whenever the County or the Sheriff identifies and implements its

7 own quality improvement measures that are not related to any of the terms of this

8 Agreement, those quality improvement measures will not be monitored or enforced

9 under this Agreement.

10

101. Should all the Parties agree that the Monitor, a SME, or a member of

11 their staff has exceeded his or her authority or is not fulfilling his or her duties in

12 accordance with this Agreement, the Parties may petition the Court for the

13 immediate removal and replacement of the Monitor, SME, or staff person. After

14 good faith attempts to resolve such issues informally, any Party may petition the

15 Court for the removal of the Monitor, a SME, or any member of their staff, for

16 good cause, which may include, but is not limited to: gross neglect of duties;

17 willful misconduct; inappropriate personal relationship with a Party, any Party

18 employee, or prisoner; conflicts of interest; any criminal conduct; or any

19 significant violations of security protocols during the pendency of this Agreement.

20

102. The Parties recognize the Monitor and SMEs may have existing

21 clients who may now be, or in the future may be, adverse to the County or the

22 Sheriff in transactions or litigation. For the duration of this Agreement, however,

23 unless such conflict is waived by all Parties, the Monitor, the SMEs, and their staff

24 will not accept any new employment or retention for consulting services regarding

25 alleged actions or inactions by the County or the Sheriff, or any County or Sheriff's

26 employee, including any actions or inactions involving any prisoner that present a

27 conflict of interest with the Monitor’s, SME’s, or staff member's responsibilities

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

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1 current or future litigant or claimant, or such litigant’s or claimant’s attorney, in

2 connection with a claim or suit against the County, the Sheriff, or their

3 departments, officers, agents, or employees. Similarly, the Monitor, the SMEs,

4 and their staff will not accept employment or provide consulting services (on a

5 paid or unpaid basis) by any Defendant to this matter to act as a defense witness in

6 connection with a private claim or suit against the County, the Sheriff, or their

7 departments, officers, agents, or employees. This provision does not apply to any

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

9 monitoring this Agreement.

10 E. Access and Confidentiality

11

103. With the exception of documents within the attorney-client and

12 attorney-work-product privileges, and notwithstanding the confidentiality

13 restrictions of the Health Insurance Portability and Accountability Act (“HIPAA”),

14 the California Confidentiality of Medical Information Act (Civil Code § 56, et

15 seq.), and California Welfare and Institutions Code § 5328 (related to

16 confidentiality of mental health records), the Monitor, SMEs, their staff, and the

17 United States, its attorneys, consultants, and agents will have full and complete

18 access to the Jails and all relevant individuals, facilities, prisoner medical and

19 mental health records, documents, data, and meetings related to the provisions of

20 this Agreement.

21

104. Other than as expressly provided in this Agreement, the Monitor, the

22 SMEs, their staff, and DOJ will maintain confidential all, and will not distribute or

23 disclose any, non-public information provided by the County and the Sheriff

24 pursuant to this Agreement. This Agreement will not be deemed a waiver of any

25 privilege or right the County or the Sheriff may assert, including those recognized

26 at common law or created by statute, rule, or regulation, against any other person

27 or entity with respect to the disclosure of any document or information.

28

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1 F. Public Statements, Testimony, and Records

2

105. Except as required by the terms of this Agreement, an order from the

3 Court, the express written agreement of all Parties, or at meetings of the County of

4 Los Angeles Board of Supervisors, the Monitor, SMEs, and their staff will not

5 make any public or press statements (at a conference or otherwise), issue findings,

6 offer expert opinion, or testify in any other litigation or proceeding regarding any

7 matter or subject that he or she may have learned as a result of his or her

8 performance under this Agreement. If the Monitor, SMEs, or any of their staff

9 receive a subpoena, he or she will promptly notify the Parties and thereafter advise

10 the subpoenaing court of the terms of this Agreement.

11

106. The Monitor, SMEs, and their staff will be permitted to initiate and

12 receive ex parte communications with all Parties.

13

107. The Monitor, SMEs, and their staff are not a State, County, or local

14 agency, or an agent thereof, and accordingly, the records maintained by them, or

15 any of them, will not be deemed public records subject to public inspection. If the

16 Monitor, SMEs, or any of their staff receive a request for inspection of their

17 records related to this Agreement, he or she will promptly notify the Parties.

18

108. This Agreement is enforceable only by the Parties. No person or

19 entity is intended to be a third-party beneficiary of the provisions of this

20 Agreement for purposes of any civil, criminal, or administrative action, and

21 accordingly, no person or entity may assert any claim or right as a beneficiary or

22 protected class under this Agreement.

23 G. Monitoring Reports

24

109. Every six months, the Monitor will file public written reports with the

25 Court describing the steps taken by the County and the Sheriff to implement this

26 Agreement and evaluating the extent to which the County and the Sheriff have

27 complied with this Agreement. Specifically, the Monitor and SMEs will evaluate

28 the status of compliance for each substantive provision of this Agreement using the

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1 following standards: (1) Substantial Compliance; (2) Partial Compliance; and (3)

2 Non-compliance. In order to assess compliance, the Monitor and SMEs will

3 review a sufficient number of pertinent documents to accurately assess current

4 conditions, interview all relevant staff, interview a sufficient number of prisoners

5 to accurately assess current conditions, and take other reasonable actions consistent

6 with this Agreement, as needed, to fulfill their responsibilities under this

7 Agreement. The Monitor, the SMEs, and their staff will be responsible for

8 independently verifying representations from the County or the Sheriff regarding

9 progress toward compliance, and examining supporting documentation. Each

10 monitoring report will describe the steps taken by members of the monitoring team

11 to analyze conditions and assess compliance, including reference to the documents

12 reviewed and individuals interviewed, and the factual basis for the Monitor’s and

13 SMEs' findings. Such reports and findings will not be admissible by or against the

14 County or the Sheriff in any proceeding other than a proceeding related to the

15 enforcement of this Agreement initiated and handled exclusively by the County,

16 the Sheriff, or the United States.

17

110. At least 30 days before the anticipated filing of such reports, the

18 Monitor will provide the Parties with a draft copy and an opportunity to respond.

19 The Monitor will consider the Parties’ responses and make appropriate changes, if

20 any, before filing. The Parties may file separate responses with the Court within

21 15 days after the filing by the Monitor although nothing in this Agreement will be

22 construed to require the filing of such responses. All public court filings by the

23 Monitor and any Party will be written with due regard for the privacy interests of

24 individual prisoners and staff and the interest of the County and the Sheriff in

25 protecting against disclosure of information not permitted by this Agreement.

26

111. Except for the provisions of Section V.S. of this Agreement that have

27 different Compliance Periods under the Settlement Agreement, Implementation

28 Plan, and Monitoring Protocols approved in Rosas, upon the Monitor’s and SMEs’

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1 conclusion that the County and the Sheriff have achieved and maintained

2 Substantial Compliance with a substantive provision of this Agreement for a period

3 of twelve (12) consecutive months, the Monitor and SMEs will no longer be

4 required to assess or report on that provision. Where the Monitor and SMEs

5 conclude that the County and the Sheriff have achieved and maintained Substantial

6 Compliance with a substantive provision of this Agreement, as described

7 immediately above, at one Jail facility but not at other facilities, the Monitor and

8 SMEs will no longer be required to assess or report on that provision as it applies

9 to the facility found to be in sustained compliance. The Parties expect that there

10 will be multiple independent operative compliance periods under the supervision

11 of the Monitor.

12

112. If the Monitor identifies a critical and time sensitive issue that the

13 County or the Sheriff should address during a six-month reporting period and that

14 should not be delayed until the time the Monitor must provide the Parties with a

15 draft copy of the monitoring report, the Monitor will provide the Parties with a

16 verbal report on the critical issue as soon as possible, and the Monitor will provide

17 a written report to the Parties within 30 days of the Monitor's identification of the

18 critical issue.

19 H. Court Jurisdiction, Modification, Enforcement, and Termination

20

113. The Court shall retain jurisdiction over the implementation of this

21 Agreement at the existing Jails or any other facility used to replace or supplement

22 the Jails for all purposes.

23

114. The County and the Sheriff will ensure that all of the terms in this

24 Agreement are implemented. Unless otherwise provided in a specific provision of

25 this Agreement, the implementation of this Agreement will begin immediately

26 upon the Effective Date.

27

28

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1

115. Unless otherwise agreed to under a specific provision of this

2 Agreement, the County and the Sheriff will implement all provisions of this

3 Agreement within six months of the Effective Date.

4

116. To ensure that the substantive provisions of this Agreement are

5 implemented in accordance with the terms of this Agreement, the Court will retain

6 jurisdiction to enforce this Agreement only until either:

7

(a) the County and the Sheriff have achieved and maintained Substantial

8

Compliance with each and every substantive provision of this

9

Agreement for a period of twelve (12) consecutive months (or other

10

time period provided in a specific provision of this Agreement or the

11

relevant Compliance Period under the Settlement Agreement,

12

Implementation Plan, and Monitoring Protocols approved in Rosas);

13

or

14

(b) the Monitor, with Court approval, determines that the overall

15

objectives and goals of this Agreement have been met even where the

16

specific requirements of substantive provisions of this Agreement may

17

be only in Partial Compliance.

18

Either of the conditions described in sub-paragraphs (a) or (b) above will be

19 deemed to fully satisfy this Agreement. At that time, the County and the Sheriff

20 may seek to terminate this Agreement with the Court consistent with the

21 requirements of the Prison Litigation Reform Act, 18 U.S.C. § 3626(b).

22

117. The United States acknowledges the good faith of the County and the

23 Sheriff in committing to the reforms set forth in this Agreement. The United

24 States, however, reserves the right to seek enforcement of the provisions of this

25 Agreement with the Court if it determines that the County or the Sheriff has failed

26 to substantially comply with any substantive provisions of this Agreement. Before

27 pursuing any remedy with the Court, the United States agrees to give written notice

28 to the County and the Sheriff in accordance with the Local Rules of the Central

53

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 54 of 57 Page ID #:153

1 District of California. The County and the Sheriff will have 30 days from receipt

2 of such notice to cure the alleged failure (or such additional time as is reasonable

3 due to the nature of the issue and agreed upon by the Parties). During the 30-day

4 period, the Parties will meet and confer in good faith to resolve any disputes

5 regarding the alleged failure or to otherwise explore a joint resolution. The

6 Monitor and SMEs may assist the Parties in reaching a mutually agreeable

7 resolution to the alleged compliance failure, including facilitating conference

8 meetings and providing relevant factual assessments.

9

118. In case of an emergency posing an imminent and serious threat to the

10 health or safety of any prisoner or staff member at the Jails, the United States may

11 omit the notice and cure requirements set forth above and seek enforcement of the

12 Agreement with the Court.

13

119. The Parties may jointly stipulate to make changes, modifications, and

14 amendments to this Agreement, which will be effective absent further action from

15 the Court, 30 days after a stipulation signed by all of the Parties has been filed with

16 the Court. Any Party may seek to modify this Agreement with the Court if that

17 Party establishes by a preponderance of the evidence that a significant change in

18 the law or factual conditions warrant the modification and that the proposed

19 modification is suitably tailored to the changed circumstances.

20

120. The Parties agree to defend the provisions of this Agreement. The

21 Parties will notify each other of any court or administrative challenge to this

22 Agreement. In the event any provision of this Agreement is challenged in any state

23 court, removal to a federal court shall be sought by the Parties.

24

121. The County and the Sheriff agree to promptly notify DOJ if any term

25 of this Agreement becomes the subject of collective bargaining consultation and to

26 consult with DOJ in a timely manner regarding the position the County or the

27 Sheriff takes in any collective bargaining consultation connected with this

28 Agreement.

54

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 55 of 57 Page ID #:154

1

122. This Agreement will constitute the entire integrated agreement of the

2 Parties and will supersede the 2002 Memorandum of Agreement Between the

3 United States and Los Angeles County, California, Regarding Mental Health

4 Services at the Los Angeles County Jail ("2002 MOA"). No prior or

5 contemporaneous communications, oral or written, will be relevant or admissible

6 for purposes of determining the meaning of any provisions herein, in this litigation

7 or in any other proceeding.

8

123. The Agreement will be applicable to, and binding upon, all Parties,

9 their officers, agents, employees, assigns, and their successors in office.

10

124. Failure by any Party to enforce this entire Agreement or any provision

11 thereof with respect to any deadline or any other provision herein will not be

12 construed as a waiver of the Party’s right to enforce other deadlines or provisions

13 of this Agreement.

14

VII. STIPULATION PURSUANT TO THE PRISON LITIGATION

15

REFORM ACT, 18 U.S.C. § 3626

16

125. The Parties stipulate and the Court finds, pursuant to 18 U.S.C. §

17 3626(a), that although this matter was not actually litigated or resolved on the

18 merits, the prospective relief in this Agreement is narrowly drawn, extends no

19 further than necessary to correct the violations of federal rights as alleged by the

20 United States in its Complaint, is the least intrusive means necessary to correct

21 those alleged violations, and will not have an adverse impact on public safety or

22 the operation of a criminal justice system. If the Court does not make the requisite

23 findings and the United States' Complaint is dismissed with prejudice, the Parties

24 agree that this Agreement will become a binding Memorandum of Agreement that

25 will supersede the 2002 MOA. Any admission made for purposes of this

26 Agreement is not admissible if presented by third parties in another proceeding.

27

28

55

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 56 of 57 Page ID #:155

1 Respectfully submitted this ___ day of _____, 2015.

2

3

4 For the UNITED STATES OF AMERICA:

5

LORETTA E. LYNCH

6

Attorney General

7

8 EILEEN M. DECKER 9 United States Attorney
10 LEON W. WEIDMAN 11 Assistant United States Attorney 12 Chief, Civil Division

__________________________ MARK KAPPELHOFF Acting Deputy Assistant Attorney General

13 _______________________________

______________________________

14 ROBYN-MARIE LYON MONTELEONE JUDITH C. PRESTON

Assistant United States Attorney 15 Assistant Division Chief

Acting Chief

16 Civil Rights Unit Chief, Civil Division

17

18 ___________________________

19

JOANNA HULL Assistant United States Attorney

20

U.S. Attorney’s Office for the Central District of California

21

300 North Los Angeles Street, Suite 7516 Los Angeles, California 90012

22

23

24

________________________ LAURA L. COON Special Counsel LUIS E. SAUCEDO CATHLEEN S. TRAINOR Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW
PHB 5026 Washington, D.C. 20530

25

26

27

28

56

Case 2:15-cv-05903-DDP-JEM Document 14 Filed 09/03/15 Page 57 of 57 Page ID #:156

1 For the COUNTY OF LOS ANGELES and the LOS ANGELES COUNTY

2 SHERIFF, in his official capacity:

3

______________________________

4

JIM MCDONNELL

5

Sheriff

6

_____________________________

7

MARY C. WICKHAM

8

Interim County Counsel

County of Los Angeles

9

10

______________________________

RODRIGO A. CASTRO-SILVA

11

Senior Assistant County Counsel

12

County of Los Angeles

13

14

15 IT SO ORDERED

16

17 DATED: September 03, 2015

18

19

________________________________

20

UNITED STATES DISTRICT JUDGE

21

22

23

24

25

26

27

28

57

 
 1

2

3

O

4

5

6

7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

11 UNITED STATES AMERICA,

12

Plaintiff,

13

v.

14 COUNTY OF LOS ANGELES et al.,
15 Defendants.
16 ___________________________
17

) Case No. CV 15-05903 DDP (JEMx) ) ) ) ORDER GRANTING MOTION TO ) INTERVENE ) ) [DOCKET NUMBER 17] ) ) ) ) )

18

Presently before the court is a Motion to Intervene filed by

19 Teresa Powers, David Penn, Timothy Polk, Mark Sarni, Derrick

20 Thomas, Darsel Whitfield, Royal Williams, and Lepriest Valentine

21 (collectively, “Intervenors”). Intervenors assert that one

22 paragraph of the executed settlement agreement between Plaintiff

23 (“the government”) and Defendant (“the County”) violates the

24 Americans with Disabilities Act (“ADA”) and Intervenors’ Fourth and

25 Eigth Amendment rights. Having considered the submissions of the

26 parties and heard oral argument, the court grants the motion and

27 adopts the following Order.

28 ///

1

I. Background

2

On August 5, 2015, the government filed a Complaint against

3 the County under the Civil Rights of Institutionalized Persons Act

4 (“CRIPA”), 42 U.S.C. §§ 1997-1997j, and the Violent Crime Control 5 and Law Enforcement Act of 1994, 42 U.S.C. § 14141.1 The Complaint

6 alleged repeated and systemic violations of prisoners’ constitional

7 rights in the Los Angeles County jail system. The alleged

8 violations included constitutionally deficient mental health care

9 and related services, such as suicide prevention, psychological and

10 pyschiatric services, and discharge planning, as well as inadequate

11 housing and sanitation practices and a pattern of excessive force

12 against prisoners. (Complaint ¶¶ 22-26.)

13

The same day the Complaint was filed, the government and the

14 County filed a stipulated settlement of this matter. The

15 stipulated Settlement Agreement (“Agreement”), which spans 125

16 paragraphs and nearly sixty pages, provides for a series of new or

17 enhanced policies and practices across nineteen subject areas

18 intended to ensure that the County will provide “prisoners at the

19 Jails with safe and secure conditions and ensure their reasonable

20 safety from harm, including serious risk from self-harm and

21 excessive force, and ensure adequate treatment for their serious

22 mental health needs.” (Agreement ¶ 16.) Among the stipulated

23 terms is a provision regarding discharge planning (“Paragraph

24 34.”). That provision states:

25

34. The County and the Sheriff will conduct discharge

planning and linkage to community mental health

26

27

28

1 The Complaint also named Los Angeles County Sheriff Jim McDonnell as a Defendant, in his official capacity.

2

1

providers and aftercare services for all prisoners

with serious mental illness as follows:

2

(a) For prisoners who are in Jail seven days or

3

less, a preliminary treatment plan, including

discharge information, will be developed.

4

(b) For prisoners who are in Jail more than seven

5

days, a [Qualified Mental Health Professional]

will also make available:

6

(i)

for prisoners who are receiving

7

psychotropic medications, a 30-day

prescription for those medications

8

will be offered either through the

release planning process, through

9

referral to a re-entry resource

center, or through referral to an

10

appropriate community provider,

unless clinically contraindicated;

11

(ii)

in-person consultation to address

12

housing, mental

health/medical/substance abuse

13

treatment, income/benefits

establishment, and

14

family/community/social supports.

This consultation will also identify

15

specific action to be taken and

identify individuals responsible for

16

each action;

17

(iii)

if the prisoner has an intense need

for assistance, as described in

18

[County Mental Health] policies, the

prisoner will further be provided

19

direct linkage to an Institution for

Mental Disease (“IMD”), IMD-Step-down

20

facility, or appropriately licensed

hospital;

21

(iv)

if the prisoner has a moderate need

22

for assistance, as described in

[County Mental Health] policies, and

23

as clinically appropriate to the

needs of the prisoner, the prisoner

24

will be offered enrollment in Full

Service Partnership or similar

25

program, placement in an Adult

Residential Facility (“Board and

26

Care”) or other residential treatment

facility, and direct assistance

27

accessing community resources;

28

3

1

(v)

if the prisoner has minimal needs for

assistance, as described in [County

2

Mental Health] policies, the prisoner

will be offered referrals to routine

3

services as appropriate, such as

General Relief, Social Security,

4

community mental health clinics,

substance abuse programs, and/or

5

outpatient care/support groups.

6

(c) The County will provide a re-entry resource

center with QMHPs available to all prisoners

7

where they may obtain information about

available mental health services and other

8

community resources.

9 (Agreement ¶ 34.)

10

This court approved the Agreement on September 3, 2015. On

11 September 28, 2015, Intervenors first sought to intervene in this

12 matter. Intervenors later filed a First Amended Complaint in

13 Intervention, which alleges that Paragraph 34 violates the

14 Americans with Disabilities Act (“ADA”) and the Fourth and Eighth

15 Amendments to the Constitution. Intervenors allege, for example,

16 that Paragraph 34 facially discriminates against disabled prisoners

17 whose disability stems from personality disorders, substance abuse

18 and dependence disorders, dementia, or developmental disabilities,

19 as well as all disabled prisoners who spend seven days or fewer in 20 jail.2 (Agreement ¶ 34, 34(a).) Intervenors further allege, in

21 essence, that Paragraph 34's discharge procedures are inadequate,

22 as many disabled prisoners will be unable to obtain needed

23 medication or services if provided with nothing more than a

24 prescription or list of referrals upon discharge.

25 ///

26

27

2 The Agreement’s definition of “serious mental illness” expressly excludes these substantive categories, with the exception

28

of personality disorders that are “associated with serious or recurrent significant self-harm.” (Agreement ¶ 15(aa).)

4

1

II. Legal Standard

2

Federal Rule of Civil Procedure 24 governs motions to

3 intervene. An applicant may intervene as of right if (1)

4 the motion is timely; (2) the applicant has a “significantly

5 protectable” interest relating to the action; (3) disposition of

6 the action may, as a practical matter, impair or impede the

7 applicant’s ability to protect that interest; and (4) the

8 applicant’s interest is inadequately represented by the parties to

9 the action. California ex rel. Lockyer v. United States, 450 F.3d

10 436, 440 (9th Cir. 2006); Fed. R. Civ. P. 24(a)(2). Courts

11 construe rule 24(a) liberally in favor of intervention. Id.

12

III. Discussion

13

A. Timeliness

14

In determining whether a motion to intervene is timely, courts

15 weigh (1) the stage of the proceedings; (2) the prejudice to the

16 parties; and (3) the length of and reason for any delay. United

17 States v. Alisal Water Corp., 370 F.3d 915, 921 (9th Cir. 2004).

18 Here, Intervenors did not seek to intervene until after the

19 Agreement was reached and entered as a court order, closing the

20 case. That fact, however, carries less weight under the unusual

21 circumstances here, where the Complaint and Settlement Agreement

22 were filed more or less concurrently. The court is not persuaded

23 by the government’s contention that the fact that the CRIPA

24 investigation was covered in the media somehow obligated

25 Intervenors to “take steps” during the investigatory process or

26 some other, earlier stage. Intervenors did not delay in any

27 significant degree by filing their motion approximately three weeks

28 after the approval of the Settlement Agreement.

5

1

Further, it does not appear to the court that intervention

2 would prejudice the parties. The court gives little weight to the

3 parties’ assertion that they would be prejudiced by intervention

4 because their collective ability to implement the remaining

5 provisions of the Agreement will be compromised if they are forced

6 to divert any attention to the issues raised by Intervenors.

7 First, Intervenors challenge but a single paragraph of the 125-

8 paragraph Agreement. Second, the provisions of Paragraph 34 are

9 not yet being implemented, and as even the parties acknowledge,

10 need not necessarily comprise the entirety of whatever discharge

11 policy the County ultimately adopts. Further, as the parties also

12 recognize, other provisions of the Agreement are already being

13 implemented. Indeed, Intervenors themselves have expressed strong

14 support for the remainder of the Agreement. There appears,

15 therefore, to be little threat to the settlement in its entirety.

16 See Alisal, 370 F.3d at 922. The court is satisfied that

17 Intervenors’ motion is timely.

18

B. “Significantly Protectable” Interest

19

A proposed intervenor’s interest is sufficient for purposes of

20 Rule 24(a)(2) if “the interest is protectable under some law, and

21 [] there is a relationship between the legally protected interest

22 and the claims at issue.” Wilderness Society v. United States

23 Forest Service, 630 F.3d 1173, 1179 (9th Cir. 2011) (quotation

24 marks and citation omitted). Neither party appears to dispute that

25 Intervenors have a legally protectable interest. Although The

26 government expressly concedes that Intervenors have a significant,

27 protectable interest, it argues that such ADA-related interests are

28 unrelated to the subject matter of this action. The crux of the

6

1 government’s contention is that this case is, and the government’s

2 investigation was, limited to CRIPA and Section 14141 violations.

3 This court is mindful that CRIPA and Section 14141 were the driving

4 force behind the investigation, and that the government did not

5 necessarily intend to give its imprimatur to a discharge or ADA

6 policy comprised entirely of the terms of Paragraph 34. Rule 24,

7 however, does not require that Intervenors’ protectable interest be

8 the same as that implicated in the existing action, only that there

9 be some relationship between the issues. Wilderness Society 630

10 F.3d at 1179. Where, as here, the stipulated solution to the

11 problems underlying the government’s Complaint allegedly violate

12 Plaintiff’s ADA and constitutional rights, a sufficient 13 relationship exists for purposes of intervention.3

14

C. Intervors’ Ability to Protect Their Interests

15

The parties argues that Intervenors’ interests would not be

16 impaired by the denial of this motion because Intervenors can file

17 a separate, freestanding lawsuit. Although Intervenors could so

18 proceed, intervention as of right is not limited to instances in

19 which applicants have no other recourse. Rather, review under Rule

20 24(a) “is guided primarily by practical considerations . . . .”

21 Southwest Center for Biological Diversity v. Berg, 268 F.3d 810,

22 818 (9th Cir. 2001) (internal quotation and citation omitted).

23 This focus on practical and equitable concerns “serves both

24 efficient resolution of issues and broadened access to the courts.”

25

26

3 Nothing in this Order shall be read to suggest that this court takes any position on either the merits of Intervenors’

27

claims or the government’s arguments on the merits, including the argument that Paragraph 34 does not violate the ADA because it

28

comprises only a portion of County ADA and discharge planning policy.

7

1 United States v. City of Los Angeles, 288 F.3d 391, 397-398 (9th

2 Cir. 2002) (quotation marks and citation omitted). The parties’

3 approach would not “prevent or simplify future litigation involving 4 related issues,” but rather multiply it.4 5 Id. at 398.

5

D. Adequacy of Representation

6

“Normally, a presumption of adequate representation generally

7 arises when the representative is a governmental body or officer

8 charged by law with representing the interests of the absentee.”

9 City of Los Angeles, 288 F.3d at 401 (internal quotations omitted).

10 Inquiries into adequate representation, however, look to

11 (1) whether a party will “undoubtedly make all of a proposed

12 intervenor’s arguments; (2) whether the present party is capable

13

14

4 The County focuses the majority of its opposition on the

15

argument that Intervenors lack standing. In the Ninth Circuit, however, “[i]n general, an applicant for intervention need not

16

establish Article III standing to intervene.” Perry v. Schwarzenegger, 630 F.3d 898, 906 (9th Cir. 2011) (per curiam);

17

Vivid Entm’t, LLC v. Fielding, No. CV-13-190 DDP, 2013 WL 1628704 at *2 (C.D. Cal. Apr. 16, 2013). Even if standing were required,

18

Intervenors have demonstrated at least a “credible threat of future injury.” See City of Los Angeles v. Lyons, 461 U.S. 95, 106

19

(1983). Intervenors have presented evidence that they are caught up in a tragic cycle of homelessness and incarceration perpetuated

20

and punctuated by manifestations of mental illness and unbroken by any adequate treatment.

21

5 Alisal is not to the contrary. Although the court did

22

conclude that the applicant’s interest was not impaired because alternate process was available, that alternate process only

23

required the applicant to obtain court approval to seek to enforce a judgment lien. Alisal, 370 F.3d at 921. Intervenors’ task would

24

be far more complicated here, as they would have to litigate freestanding ADA and constitutional claims from scratch, and then

25

only after Paragraph 34 had already gone into effect. And although the City of Los Angeles court did find the possibility of

26

independent suits sufficient with respect to a proposed intervenor that did not contest a consent decree, it reversed the district

27

court’s denial of intervention to an applicant that sought to enjoin a consent decree that, like the Agreement here, was filed

28

the same day as the complaint. 396-397, 400-402.

City of Los Angeles, 288 F.3d at

8

1 and willing to make such arguments; and (3) whether a proposed

2 intervenor would offer any necessary elements to the proceeding

3 that other parties would neglect.” Arakaki v. Cayetano, 324 F.3d

4 1078, 1086 (9th Cir. 2003). Here, the presumption of adequate

5 representation is rebutted where the government has not only

6 declined to make some of the arguments Intervenors would make, but

7 has in fact taken a contrary position. The government cannot,

8 therefore, be said to adequately represent Intervenors’ significant

9 protectable interest.

10 IV. Conclusion

11

For the reasons stated above, the Motion to Intervene is

12 GRANTED.6 The court emphasizes, however, that nothing in this

13 Order shall be read as a commentary on the merits of Intervenors’

14 claims or on the sincerity of the parties’ attempts to address the

15 issues raised in either the Complaint or the First Amended

16 Complaint in Intervention. Indeed, in the court’s experience, both

17 parties, as well as Intervenors’ counsel, have proven to be deeply

18 committed, well-intentioned, and effective collaborators, even in

19 the face of difficult financial and political realities. The

20 mental health issues around which this matter revolves are public

21 safety issues as well as legal ones, and concern the well-being of

22 not only the prisoners and public servants directly involved, but

23 of the larger community as well. Mental health issues have

24 unfortunately, and self-evidently, risen to crisis levels, and the

25 Sheriff has been forced to assume a prominent role in the absence

26

27

6 Having concluded that Intervenors’ must be permitted to

28

intervene as of right, the court need not address permissive intervention.

9

1 of sufficient mental health resources. The court encourages all

2 parties to continue to work together to formulate and implement

3 policies that are not only constitutionally and legally adequate,

4 but efficacious and empathetic as well.

5

6 IT IS SO ORDERED.

7

8

9 Dated: December 15, 2015 10

DEAN D. PREGERSON United States District Judge

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

10

 
 Case 2:15-cv-05903-DDP-JEM Document 76 Filed 01/14/16 Page 1 of 33 Page ID #:1714

1 BRADLEY S. PHILLIPS (State Bar No. 85263) brad.phillips@mto.com
2 GRANT A. DAVIS-DENNY (State Bar No. 229335) grant.davis-denny@mto.com
3 EMILY R.D. MURPHY (State Bar No. 291022) emily.murphy@mto.com
4 THOMAS P. CLANCY (State Bar No. 295195) thomas.clancy@mto.com
5 M35U5 NSoGuEthR,GTraOnLdLAEvSen&ueO, L3S5tOh NFloLoLrP 6 Los Angeles, California 90071-1560
Telephone: (213) 683-9100 7 Facsimile: (213) 687-3702

8 MARK D. ROSENBAUM (SBN 59940) mrosenbaum@publiccounsel.org
9 GARY BLASI (SBN 70190) gblasi@publiccounsel.org
10 ANNE RICHARDSON (SBN 151541) arichardson@publiccounsel.org
11 ADELAIDE ANDERSON (SBN 270966) aanderson@publiccounsel.org
12 ALISA HARTZ (SBN 285141) ahartz@publiccounsel.org
13 PUBLIC COUNSEL LAW CENTER 610 S. Ardmore Avenue
14 Los Angeles, California 90005 Telephone: (213) 385-2977
15 Facsimile: (213) 385-9089

16 Attorneys for Plaintiff-Intervenors

17

UNITED STATES DISTRICT COURT

18

CENTRAL DISTRICT OF CALIFORNIA, WESTERN DIVISION

19 UNITED STATES OF AMERICA,

Case No. 15-cv-05903

20

Plaintiff,

21

vs.

22

COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF JIM

23 MCDONNELL, in his Official Capacity ,

PLAINTIFF-INTERVENORS’ FIRST AMENDED COMPLAINT IN INTERVENTION

24

Defendants.

TERESA POWERS, DAVID PENN,

25 TIMOTHY POLK, MARK SARNI, DERRICK THOMAS, DARSEL

26 WHITFIELD, ROYAL WILLIAMS, AND LEPRIEST VALENTINE

27 Plaintiff-Intervenors.

28

FIRST AMENDED COMPLAINT IN INTERVENTION

15-cv-05903

Case 2:15-cv-05903-DDP-JEM Document 76 Filed 01/14/16 Page 2 of 33 Page ID #:1715

1

INTRODUCTION1

2

1. Plaintiff-Intervenors are individuals with mental illnesses and

3 disabilities whom Los Angeles County frequently cycles between its jails and

4 streets. They seek to intervene in this matter to remedy violations of the Americans

5 with Disabilities Act (“ADA”) and the United States Constitution in the County and

6 Department of Justice’s Joint Settlement Agreement (“Settlement”). Paragraph 34 of

7 the Settlement dictates how persons with mental disabilities will be discharged from

8 the County’s jails—the most important stage of the County’s jail-to-streets-to-jail

9 cycle.

10

2. Left uncorrected, the discharge provisions of Paragraph 34 will lead to

11 pervasive ADA violations in at least three ways:

12

3. First, the Settlement facially discriminates against people with certain

13 mental disabilities by limiting the class of individuals who are eligible for discharge

14 planning to those who have a “serious mental illness” as defined in the Settlement.

15 Settlement ¶ 34. That definition expressly excludes those individuals whose mental

16 disabilities are the result of personality disorders (except when “associated with

17 serious or recurrent significant self-harm”), substance abuse and dependence

18 disorders, dementia, or developmental disabilities. Id. ¶ 15(aa). The Settlement also

19 excludes from most discharge planning those who have been in jail for seven days

20 or fewer. Id. ¶ 34(a). These arbitrary exclusions violate the ADA’s prohibition on

21

22

23 1 On September 28, 2015, Plaintiff-Intervenors moved to intervene in this case and
24 lodged a Complaint in Intervention. ECF Doc. 17; 17-3. On October 14, 2105, Plaintiff-Intervenors lodged with the Court a [First Amended Proposed] Complaint
25 In Intervention, which added a third claim for relief. ECF Doc. 37. On December
26 15, 2015, this Court granted Plaintiff-Intervenors’ motion to intervene. ECF Doc. 75. As such, Plaintiff-Intervenors now file their First Amended Complaint In
27 Intervention, which was initially lodged with the Court under the title [First
28 Amended Proposed] Complaint In Intervention.

-1-
FIRST AMENDED COMPLAINT IN INTERVENTION

15-cv-05903

Case 2:15-cv-05903-DDP-JEM Document 76 Filed 01/14/16 Page 3 of 33 Page ID #:1716

1 “[p]rovid[ing] different or separate … services …to any class of individuals with

2 disabilities than is provided to others ….” 28 C.F.R. § 35.130(b)(1)(i), (iv).

3

4. Second, the discharge provisions in Paragraph 34 run afoul of the ADA

4 because they deny disabled persons meaningful access to public services and

5 benefits in at least two ways: (1) the Settlement’s plan for connecting released

6 prisoners with needed medication and services—that is, by merely handing out a

7 prescription or a referral—is meaningless for many people with serious mental

8 disabilities because, owing to their disabilities, they have no realistic hope of finding

9 their way to those who can fulfill their medication or service needs; and (2) the

10 Settlement allows the County to refer seriously mentally ill individuals to services

11 without requiring that the County confirm that such services are available. The

12 Settlement therefore contravenes the ADA’s prohibition on “failure[s] to make

13 reasonable modifications in … procedures … necessary to afford … services … to

14 individuals with disabilities.” 42 U.S.C. § 12182(b)(2)(A).

15

5. Third, the Settlement violates the integration mandate of the ADA to

16 deliver “services, programs, and activities in the most integrated setting appropriate

17 to the needs of qualified individuals with disabilities.” 28 C.F.R. § 35.130(d).

18 Paragraph 34(b)(iii) of the Settlement contemplates that the County will provide

19 “direct linkage” to restrictive institutional settings for persons with “intense need for

20 assistance” (a category that is undefined within the Settlement). This provision, if

21 implemented, would lead to the placement of certain disabled individuals in non-

22 integrated environments in violation of the ADA’s integration mandate.

23

6. Moreover, left uncorrected, the discharge provisions of Paragraph 34 of

24 the Settlement will lead to violations of the Eighth and Fourteenth Amendments of

25 the United States Constitution, as the policies provided for in Paragraph 34

26 demonstrate a deliberate indifference to the serious medical needs of Plaintiff-

27 Intervenors and other incarcerated individuals with mental illness.

28

-2-
FIRST AMENDED COMPLAINT IN INTERVENTION

15-cv-05903

Case 2:15-cv-05903-DDP-JEM Document 76 Filed 01/14/16 Page 4 of 33 Page ID #:1717

1

7. As a result, under the terms of the Settlement, the County will be able

2 to continue its current practices of discharging mentally disabled individuals from

3 the County jails without their medication and without ensuring that they obtain

4 desperately needed medical and psychiatric services to ameliorate their mental

5 illnesses. Severely mentally disabled people will continue to be left to wander and

6 attempt to survive our community's meanest streets in no state to do so. The

7 mentally disabled can still be handed referral lists to services that they may be

8 incapable of deciphering, with no resources to access them even if they could.

9 However well-intentioned the decree, it does not reflect the daily lives of the

10 mentally disabled who live on our streets for lack of anywhere else to reside, or the

11 service providers and community advocates who work heroically to try to make the

12 lives of the mentally disabled more tolerable.

13

8. The narratives of the Intervenors illustrate the harsh consequences of

14 nonexistent or inadequate discharge planning. Each is severely mentally disabled:

15 schizophrenic, bipolar, addicted, often with co-occurring disabilities. They have at

16 best minimal financial or family resources to draw upon and, as a result, get by as

17 they must on the streets. In the past, they have been discharged many times with, as

18 under the Settlement, no or functionally no access to the care and services their

19 conditions require. Their conditions only deteriorate further, their chances for

20 survival diminished with each discharge, unless they have a lucky break of getting

21 connected with a caring individual who will navigate them through the complex web

22 of existing services and benefits. Making it back to mental health and a stable living

23 situation becomes all but impossible without individualized assistance.

24

JURISDICTION AND VENUE

25

9. The Court has subject matter jurisdiction over this case pursuant to 28

26 U.S.C. § 1331 because it arises under the Constitution and laws of the United States.

27

10. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b)-(c).

28

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1

PARTIES

2

11. Plaintiff is the United States of America.

3

12. Plaintiff-Intervenor Teresa Powers is a 45 year-old homeless woman

4 who lives in the County of Los Angeles. She has been incarcerated at least four

5 times, most recently in the Century Regional Detention Center, and she has been

6 arrested over 15 times (primarily for drug offenses), including four times in the past

7 year. She is on probation and lives on the streets. She suffers from paranoid

8 schizophrenia, bipolar disorder, cancer and heart problems. Because of the number

9 and nature of her offenses, her continued homelessness, her mental illness, and her

10 history of substance abuse, she has a very high chance of being incarcerated again at

11 which point the discharge language in the Settlement Agreement makes it not only

12 likely but certain that she will again suffer injury in violation of the ADA and the

13 Eighth and Fourteenth Amendments of the Constitution.

14

13. Plaintiff-Intervenor Royal Williams is a 44 year-old homeless man who

15 lives in the County of Los Angeles. He has been arrested five to seven times

16 (primarily for drug offenses), including once this year, and is on probation. He has

17 been homeless or incarcerated for 20 years; he currently has a bed at a shelter. He

18 suffers from “bipolar schizophrenia,” depression, and asthma and has a history of

19 substance abuse. Because of the number and nature of his offenses, his continued

20 homelessness, his mental illness and his history of substance abuse, he has a very

21 high chance of being incarcerated again at which point the discharge language in the

22 Settlement Agreement makes it not only likely but certain that he will again suffer

23 injury in violation of the ADA and the Eighth and Fourteenth Amendments of the

24 Constitution.

25

14. Plaintiff-Intervenor Lepriest Valentine is a 42 year-old homeless man

26 who lives in the County of Los Angeles. He has been incarcerated at least three

27 times for petty thefts of small items he could sell to buy food and was last released

28 in November 2014. He is on probation. He has lived in Skid Row since 2013 and

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1 currently has a bed at a shelter. He suffers from depression, schizophrenia, and

2 bipolar disorder and has a history of substance abuse. Because of the nature of his

3 offenses, his continued homelessness, his mental illness, and his history of substance

4 abuse, he has a very high chance of being incarcerated again at which point the

5 discharge language in the Settlement Agreement makes it not only likely but certain

6 that he will again suffer injury in violation of the ADA and the Eighth and

7 Fourteenth Amendments of the Constitution.

8

15. Plaintiff-Intervenor Mark Sarni is a 54 year-old homeless man who

9 lives in the County of Los Angeles. He has been arrested hundreds of times,

10 primarily for drug offenses. He currently has a bed at a shelter. He suffers from

11 paranoid schizophrenia, bipolar disorder, depression, anxiety, and kidney failure. He

12 was addicted to heroin for forty years and still struggles with addiction to crack

13 cocaine. Because of the number and nature of his offenses, his continued

14 homelessness, his mental illness, and his history of substance abuse, he has a very

15 high chance of being incarcerated again at which point the discharge language in the

16 Settlement Agreement makes it not only likely but certain that he will again suffer

17 injury in violation of the ADA and the Eighth and Fourteenth Amendments of the

18 Constitution.

19

16. Plaintiff-Intervenor Derrick Thomas is a 55 year-old homeless man

20 who lives in the County of Los Angeles. He has been arrested about 20 times,

21 primarily for drug offenses. He has served four jail terms since 2013 and is on

22 probation. He currently has a bed at a shelter. He suffers from paranoid

23 schizophrenia, post-traumatic stress disorder, and traumatic brain injury and has a

24 history of substance abuse. Because of the number and nature of his offenses, his

25 continued homelessness, his mental illness, and his history of substance abuse, he

26 has a very high chance of being incarcerated again at which point the discharge

27 language in the Settlement Agreement makes it not only likely but certain that he

28

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1 will again suffer injury in violation of the ADA and the Eighth and Fourteenth

2 Amendments of the Constitution.

3

17. Plaintiff-Intervenor Darsel Whitfield is a 50 year-old homeless woman

4 who lives in the County of Los Angeles. She has been in County jail about seven

5 times, primarily for drug offenses, most recently in 2014. She is on probation. She

6 currently has a bed at a shelter. She suffers from bipolar disorder, anxiety, and

7 schizoaffective disorder and has a history of substance abuse. Because of the nature

8 of her offenses, her continued homelessness, her mental illness, and her history of

9 substance abuse, she has a very high chance of being incarcerated again at which

10 point the discharge language in the Settlement Agreement makes it not only likely

11 but certain that she will again suffer injury in violation of the ADA and the Eighth

12 and Fourteenth Amendments of the Constitution.

13

18. Plaintiff-Intervenor David Penn is a 46 year-old homeless man who

14 lives in the County of Los Angeles. He has served five sentences in jail and four

15 sentences in prison, primarily for drug offenses. He began using crack cocaine as a

16 teenager and continued until earlier this year. He was last released from Los Angeles

17 County jail in February 2015. He currently has a bed at a shelter. He suffers from

18 bipolar disorder, depression, and schizoaffective disorder. Because of the number

19 and nature of his offenses, his continued homelessness, his mental illness, and his

20 history of substance abuse, he has a very high chance of being incarcerated again at

21 which point the discharge language in the Settlement Agreement makes it not only

22 likely, but certain that he will again suffer injury in violation of the ADA and the

23 Eighth and Fourteenth Amendments of the Constitution.

24

19. Plaintiff-Intervenor Timothy Polk is a 54 year-old homeless man who

25 lives in the County of Los Angeles. He has been to Los Angeles County jail “dozens

26 and dozens” of times, most recently in June 2015. He currently has a bed at a

27 shelter. He suffers from epilepsy, bipolar disorder, and schizoaffective disorder.

28 Because of the number of his offenses, his continued homelessness, and his mental

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1 illness, he has a very high chance of being incarcerated again at which point the

2 discharge language in the Settlement Agreement makes it not only likely, but certain

3 that he will again suffer injury in violation of the ADA and the Eighth and

4 Fourteenth Amendments of the Constitution.

5

20. Because of their status as mentally ill persons with no permanent home,

6 some of whom have substance abuse issues, Plaintiff-Intervenors are at serious risk

7 of being arrested and re-incarcerated for any of the numerous municipal code

8 sections that outlaw certain behaviors in public, such as public urination, possession

9 of an open container of alcohol, keeping property on the sidewalk, violations of

10 probation, and similar infractions.

11

21. Defendant LOS ANGELES COUNTY (the “County”) is a

12 governmental subdivision created under the laws of the State of California and

13 governed by the Los Angeles County Board of Supervisors. The County owns and,

14 through Defendant LOS ANGELES COUNTY SHERIFF JIM MCDONNELL (the

15 “Sheriff”), operates, the Jails, which consist of eight facilities located throughout the

16 County. The County, through the Los Angeles County Board of Supervisors, has

17 responsibility for funding the operation of the Jails.

18

22. Defendant LOS ANGELES COUNTY SHERIFF JIM MCDONNELL

19 is the Los Angeles County Sheriff, an independently elected constitutional officer

20 not under the County Board of Supervisors. CA. Const. Art. 11, § 1(b). The Sheriff

21 has responsibility for the security and custody operations of the Jails and for

22 protecting the safety of prisoners in the Jails. The Sheriff is sued in his official

23 capacity only.

24

23. The County and the Sheriff are together responsible for the conditions

25 of confinement and health and safety of persons incarcerated at the Jails. The

26 County, through its Department of Mental Health, provides mental health services to

27 prisoners in the Jails.

28

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1

24. Defendants are legally responsible, in whole or in part, for the

2 operation and conditions of the Jails and for the health and safety of persons

3 incarcerated there. The County owns the Jails; the Sheriff is responsible for

4 maintaining the Jails; the Sheriff is responsible for the security and custody

5 operations of the Jails; the County, through its Department of Mental Health, is

6 responsible for providing mental health care services to prisoners in the Jails; and

7 the County is responsible for funding the operations and maintenance of the Jails.

8 This action concerns the administration of persons confined at the Jails, which

9 houses adult male and female prisoners who are felons, gross misdemeanants,

10 misdemeanants, pre-trial detainees, witnesses, or others being detained in protective

11 custody. Hereinafter, both Defendants shall be collectively referred to as “the

12 County.”

13

25. At all relevant times, Defendants or their predecessors in office have

14 acted or failed to act, as alleged herein, under color of state law.

15

INTERVENTION

16

26. Plaintiffs-Intervenors satisfy the Fed. R. Civ. P. 24(a) standard for

17 intervention as a matter of right: as set forth more fully below, (1) the request is

18 timely; (2) Plaintiffs-Intervenors claim a significant protectable interest relating to

19 the property or transaction that is the subject of the action; (3) Plaintiffs-Intervenors

20 are so situated that disposition of the action may as a practical matter impair or

21 impede their ability to protect their interests; and (4) Plaintiffs-Intervenors’ interests

22 are not adequately represented by the parties to the action.

23

27. Plaintiff-Intervenors are moving to intervene less than two months after

24 the action was filed, when Plaintiff-Intervenors first learned of the unlawful

25 settlement provisions.

26

28. Prior to the filing of this action and the Settlement, Plaintiff-Intervenors

27 had no notice of the negotiations leading to the Settlement. Upon learning of it,

28 Plaintiff-Intervenors diligently investigated and prepared to intervene to address the

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1 illegality of Paragraph 34 of the Settlement. The Court approved the Settlement,

2 however, less than a month after the undersigned first learned of its existence.

3 Plaintiff-Intervenors have intervened expeditiously and without delay at the earliest

4 practicable stage of the proceedings.

5

29. Plaintiff-Intervenors have significant interests in meaningful and

6 integrated access to public services that are protected by the ADA, which are

7 implicated by the Complaint in this matter, but which are impaired by Paragraph 34

8 of the Settlement. Absent intervention and subsequent modification, Paragraph 34 of

9 the Settlement will impair Plaintiff-Intervenors’ significant protected interests in

10 avoiding discrimination prohibited by Title II of the ADA, as set forth in paragraphs

11 76-93 of this Complaint.

12

30. Plaintiff-Intervenors also have significant interests in the continuing

13 provision of medical care for a transitional period after release from custody, as

14 guaranteed under the Eighth and Fourteenth Amendments of the Constitution.

15 Absent intervention and subsequent modification, Paragraph 34 of the Settlement

16 will impair Plaintiff-Intervenors’ significant protected interests in the provision of

17 needed medical care, as set forth in paragraphs 76-93 of this Complaint.

18

31. Plaintiff-Intervenors’ right to be free from ADA and Eighth and

19 Fourteenth Amendment violations will be impaired as a practical matter by

20 Paragraph 34 of the Settlement.

21

32. The present parties do not adequately represent Plaintiff-Intervenors.

22 Both the United States and the County have agreed to a Settlement that itself

23 violates Plaintiff-Intervenors’ rights under Title II of the ADA and the Eighth and

24 Fourteenth Amendments of the Constitution. Neither is an adequate representative

25 of the very persons whose rights are impaired by the Settlement to which they

26 agreed. The parties are also bound by Paragraph 120 of the Settlement to defend its

27 terms, including Paragraph 34, and thus each is bound to dispute that the Settlement

28 violates Plaintiff-Intervenors’ rights.
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1

33. Alternatively, Plaintiffs-Intervenors satisfy the Fed. R. Civ. P.

2 24(b)(1)(B) standard for permissive intervention. Plaintiff-Intervenors raise

3 cognizable ADA claims. The motion is timely, and permitting intervention at this

4 early stage of the lawsuit, less than two months after the Complaint and Settlement

5 papers were filed and as soon as possible after Plaintiff-Intervenors learned of the

6 action, would work no prejudice against the parties. Finally, the Court has an

7 independent basis for jurisdiction over the Plaintiff-Intervenors’ ADA and

8 constitutional claims under 28 U.S.C. § 1331.

9

PLAINTIFF-INTERVENORS

10 Teresa Powers

11

34. Plaintiff-Intervenor Teresa Powers (“Ms. Powers”) is 45 years old and

12 has not spoken to her children in 13 years. She has been diagnosed with paranoid

13 schizophrenia, bipolar disorder, and manic depressive disorder. Ms. Powers is an

14 alcoholic. Her other medical conditions include cancer and heart problems. Ms.

15 Powers constantly hears voices and sometimes talks to trees. She has been placed on

16 involuntary psychiatric holds pursuant to Welfare and Institutions Code § 5150

17 approximately 15 times. She has been arrested between 10 and 15 times during the

18 14 years that she has lived on the streets of Los Angeles—mostly for drug

19 offenses—including four times in the past year for alleged probation violations.

20

35. Earlier this year, Ms. Powers was incarcerated in the Century Regional

21 Detention Facility (“Lynwood”). She received psychotropic medications while she

22 was in jail. Upon release, she was given 15 pills, which she lost, and was not

23 referred to any medical, mental health, or social services. Ms. Powers has not had

24 access to medication since her release from jail, except during subsequent

25 hospitalizations, which were harrowing experiences for her. Ms. Powers self-

26 medicates with alcohol when she does not have access to medication. Ms. Powers

27 knows that she can get medication if she goes to Exodus, Eastside Urgent Care

28

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1 Center, which is a psychiatric urgent-care center, but she is afraid to go there

2 because she does not want to be locked up again.

3

36. Ms. Powers currently lives on the streets. Her mental health and

4 physical conditions continue to worsen.

5 Royal Williams

6

37. Plaintiff-Intervenor Royal Williams (“Mr. Williams”) has been

7 homeless or incarcerated for over 20 years. He is 44 years old, and has been arrested

8 five to seven times. He has been released from County jails at least twice, including

9 in 2015. Mr. Williams has been living on Skid Row since 2013. He has lived in a

10 tent and slept under cardboard.

11

38. Mr. Williams has been diagnosed with “bipolar schizophrenia” and

12 depression, and he takes psychotropic medications including Risperdal and Atarax.

13 In 2014, he was detained under an involuntary psychiatric hold pursuant to Welfare

14 and Institutions Code § 5150 after he tried to commit suicide. Mr. Williams believes

15 that his family does not trust him, and his mother has custody of his eight-year-old

16 son.

17

39. In approximately April of 2015, Mr. Williams was sitting in front of his

18 tent on Fifth Street near Crocker Street. A police car pulled up, and an officer asked

19 if he was on probation or parole. When the officers determined that Mr. Williams

20 was in violation of his probation, they arrested him. Mr. Williams was forced to

21 leave behind all of his belongings, including his medications.

22

40. In jail, Mr. Williams was housed in the mental health unit.

23

41. Upon release, Mr. Williams was handed several pamphlets with

24 referrals on them. He estimates that the pamphlets listed 50 referrals in total. Mr.

25 Williams did not know which referrals would be relevant to him or how to access

26 the services, so he threw the pamphlets away.

27

42. The jail provided Mr. Williams with a prescription for Risperdal, but

28 Mr. Williams did not have any money, his MediCal coverage had been suspended,

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1 and he did not know that there are places where he could fill the prescription for

2 free. As a result, Mr. Williams went without necessary psychotropic medication for

3 over six weeks. Without his medications and the discharge care he required, Mr.

4 Williams experienced suicidal ideation and sank into substance abuse, fighting, and

5 stealing.

6

43. Luckily, another homeless person told Mr. Williams about the Lamp

7 Community shelter. Mr. Williams then worked with his probation officer to obtain a

8 bed at Lamp Community. Mr. Williams is currently living at Lamp but has only a

9 shelter bed.

10 Lepriest Valentine

11

44. Plaintiff-Intervenor Lepriest Valentine (“Mr. Valentine”) is 42 years

12 old. He was about 35 years old when he began to experience debilitating depression

13 and anxiety and to hear his father’s voice telling him that he was worthless. Mr.

14 Valentine withdrew from his family and became homeless when he could no longer

15 work as a result of his mental condition. He has slept in shelters and on the street.

16

45. Mr. Valentine has been diagnosed with depression, schizophrenia, and

17 bipolar disorder, for which he takes or has taken Lithium, Risperdal, and Remeron.

18 When Mr. Valentine does not take his medications, he hears voices, cannot sleep,

19 cannot eat, and experiences anxiety.

20

46. Mr. Valentine has served three sentences in County facilities and been

21 arrested at least twice more in Los Angeles County. During his time in Skid Row,

22 Mr. Valentine has cycled in and out of jail for petty thefts: he stole batteries and

23 toiletries from drug stores so that he could sell them and use the money to buy food.

24 He has not been given discharge planning services on his release from jail. In fact,

25 on one occasion, he failed to appear in court because battling the symptoms of his

26 mental illness and needing to find food and shelter meant that court was not a

27 priority for him.

28

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1

47. The County housed Mr. Valentine in the mental health unit of Twin

2 Towers Correctional Facility (“Twin Towers”) and provided him with psychotropic

3 medication while he was incarcerated. The County did not provide Mr. Valentine

4 with any referrals, medications, or prescriptions when he was released. Mr.

5 Valentine simply asked another inmate how to get back to Skid Row and walked

6 there.

7

48. A cousin who is also homeless told Mr. Valentine about Lamp

8 Community. With a bed at Lamp Community, Mr. Valentine now takes his

9 medications regularly. He attends mental health classes, including a class on how to

10 be a peer advocate to other people with co-occurring disorders. After taking that

11 class, Mr. Valentine obtained a part-time job at a drop-in center, and he is saving up

12 for an apartment. Next spring, Mr. Valentine plans to enroll in a course to become a

13 certified substance abuse counselor.

14

49. Mr. Valentine has been cited for riding the Metro without paying a fare,

15 and he fears that he may have outstanding warrants as a result. He stays indoors at

16 night and avoids certain streets, in the hope that no police officers will stop him and

17 ask him if he is on probation or parole. He fears that, if he answers yes, they will run

18 his ID, find the warrants, and take him back to jail.

19 Mark Sarni

20

50. Plaintiff-Intervenor Mark Sarni (“Mr. Sarni”) is 54 years old and has

21 been homeless most of his life. He has been arrested hundreds of times in the past

22 35 years. In the 1990s, Mr. Sarni was diagnosed with paranoid schizophrenia,

23 bipolar disorder, depression, and anxiety. He now takes Thorazine, Remeron,

24 Seroquel, and Buspar.

25

51. Mr. Sarni was a heroin addict for forty years. He has served at least

26 three sentences in County facilities since 2013, all for violating his probation. In

27 2014, Mr. Sarni served 90 days in County jail. The County housed Mr. Sarni in the

28 mental health unit at the Twin Towers and provided him with psychotropic

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1 medications. While he was incarcerated, the County did blood tests on Mr. Sarni.

2 Just before his release, Mr. Sarni was told that there was something “seriously

3 wrong” with his blood and that he needed to go to an emergency room. The County

4 then released Mr. Sarni with only a prescription for his necessary psychotropic

5 medications.

6

52. Ten hours after his release onto the streets, Mr. Sarni flatlined. He had

7 gone to Pershing Square station to panhandle. The security guards kept telling him

8 to leave, and he kept falling down. Then Mr. Sarni died for four minutes. He was

9 revived by emergency medical services. Mr. Sarni is now on dialysis because of his

10 failed kidneys and likely has less than two years to live.

11

53. Mr. Sarni was given a referral to a housing program for which he did

12 not qualify.

13

54. Mr. Sarni has stopped using heroin. He is staying at Lamp Community

14 and is saving up for an apartment; he hopes to have stable housing in the next few

15 months. He has just been taken off probation. Lamp Community has helped Mr.

16 Sarni with matters such as obtaining ID and a copy of his birth certificate. Mr. Sarni

17 tries to be independent but appreciates that someone will assist him when he needs

18 help.

19 Derrick Thomas

20

55. Plaintiff-Intervenor Derrick Thomas (“Mr. Thomas”) is a 55-year-old

21 veteran of the Gulf War, in which he served two tours as a First Sergeant in the

22 Army. Mr. Thomas has been diagnosed with Post Traumatic Stress Disorder and 10

23 years ago was diagnosed with paranoid schizophrenia. Mr. Thomas is a former

24 boxer who has suffered numerous head injuries. He takes psychotropic medications,

25 including Seroquel and Celexa. Without his medications, Mr. Thomas cannot be in

26 crowds and may have potentially violent reactions to perceived threats.

27

56. Mr. Thomas has been arrested approximately 20 times and served four

28 sentences in County facilities since 2010. At least four of his sentences were for

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1 drug-related offenses, and several others were for probation violations. He has never

2 received mental health treatment while in jail, despite having prescriptions with him

3 upon arrest and telling County officials how to contact his previous health providers.

4 Without his medications, Mr. Thomas’s symptoms became unbearable to the point

5 that he wants to kill himself.

6

57. Mr. Thomas was released from jail earlier this year around 2:00 a.m.

7 without being offered any services. He had no help and did not know where to go. It

8 was cold out and he had only a t-shirt; none of his belongings, including his

9 identification and prescription medications, had been returned to him on his release.

10 For six weeks, he slept either under cardboard or in a shelter. He was unable to get

11 medication because he had no identification. Without identification he could not

12 prove who he was, and without money he could not get new identification. It took

13 Mr. Thomas 10 weeks to obtain more medication after he was released.

14

58. Mr. Thomas is saving up for an apartment and is working hard not to

15 come into contact with the police, so that he can be taken off probation at his next

16 hearing on October 28.

17 Darsel Whitfield

18

59. Plaintiff-Intervenor Darsel Whitfield (“Ms. Whitfield”) is 50 years old.

19 Ms. Whitfield has three daughters. She worked for over 25 years as a nursing

20 assistant and in other healthcare positions. Then, in 2010, her mental illness

21 overwhelmed her. She was depressed, could no longer be around other people, and

22 lost control of her emotional responses. In 1994, Ms. Whitfield was diagnosed with

23 manic depression, bipolar disorder, anxiety, and schizoaffective disorder. Since

24 then, she has taken Prozac, Seroquel, and various anxiety medications.

25

60. Ms. Whitfield has been in County jails about seven times. In fact, her

26 mental illness was first diagnosed while she was in jail. In early 2014, she spent a

27 month in Lynwood. Lynwood officials placed Ms. Whitfield in the mental health

28 unit but would not give her any of her medications. They would give her only

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1 Tylenol and even denied her Benadryl when she asked for it to help her sleep. Ms.

2 Whitfield was scared and frantic, and she paced and cried.

3

61. Upon release, Ms. Whitfield was not given any medications,

4 prescriptions, or information about where to go. She found herself living between

5 shelters and the streets. She felt completely desolate. A few months later, someone

6 in her Alcoholics Anonymous group happened to tell Ms. Whitfield about Lamp

7 Community. She has stayed at Lamp Community since June and is in the process of

8 obtaining a Single Room Occupancy unit. Lamp Community has also helped her

9 apply for Supplemental Security Income, and she is waiting for a response. This is

10 not the first time Ms. Whitfield has applied, but it is the first time she has been

11 stable and supported enough to be able to follow through with the application. Ms.

12 Whitfield hopes to move into her own apartment in the next few weeks.

13 David Penn

14

62. Plaintiff-Intervenor David Penn (“Mr. Penn”) is 46 years old and began

15 using drugs when he was nine years old. He has lived in Skid Row since 2010,

16 sleeping on the streets, in tents, and under trees. In 2011, Mr. Penn was diagnosed

17 with bipolar disorder and depression. While he was living on the street, Mr. Penn

18 often forgot to take his medication (Abilify and Zoloft) and had it stolen from him

19 while he slept. More recently, he was diagnosed with schizoaffective disorder, and

20 he now takes Seroquel.

21

63. Mr. Penn has been to jail five times and prison four times. In January

22 2015 he was arrested when he allegedly shoplifted toiletries for personal use. He

23 was housed in the mental health unit at Twin Towers for three weeks and then

24 abruptly released at 11:00 p.m. onto the street with no referrals or other assistance.

25 Mr. Penn immediately sought out drugs to help him forget the experience of being

26 incarcerated, including the fresh memories of another inmate trying to hang himself

27 and the sounds of him choking. He had nowhere to stay and walked the streets all

28 night.

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1

64. Since March 2015, Mr. Penn has had more stable housing. He stayed at

2 the Weingart Center for 90 days, slept on the streets for a few weeks, and then

3 obtained a bed at Lamp Community. He has been drug-free and sober since March.

4 As a result, he has reconnected with his family.

5

65. Mr. Penn is about to start learning a trade as an underwater welder, and

6 he writes poetry. He would like to make a documentary about Skid Row.

7 Timothy Polk

8

66. Plaintiff-Intervenor Timothy Polk (“Mr. Polk”) is 54 years old. He was

9 first institutionalized as a teenager and has been to prison seven times. He has been

10 incarcerated in County jails dozens of times.

11

67. Mr. Polk has been homeless for approximately 20 years and has been

12 diagnosed with epilepsy, bipolar disorder, and schizoaffective disorder. He has also

13 suffered traumatic brain injuries. He takes Depakote, Paxil, and Risperdal. Without

14 his medication, Mr. Polk experiences heightened anxiety and depression.

15

68. Most recently, Mr. Polk was arrested in June of 2015 for allegedly

16 violating his probation. He was released without medication or any connection to

17 community resources. He had no possessions because he had been forced to leave

18 them all—including his medications, ID, and tent—behind on the sidewalk. As a

19 result, he was worse off than when he was arrested and had to begin the exhausting

20 process of rebuilding his life from scratch. He still lacks ID.

21

69. Mr. Polk spent 10 days in the mental health unit at Twin Towers, where

22 he did not receive his psychotropic medications. The County did not provide Mr.

23 Polk with any assistance when he was released, and it took him several days to

24 obtain medication from Exodus. Mr. Polk relies on Exodus for most of his mental

25 health treatment.

26

THE SETTLEMENT PROVISIONS AT ISSUE

27

70. On August 5, 2015, the United States filed a Complaint against the

28 County of Los Angeles and Sheriff Jim McDonnell in his official capacity

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1 (collectively, “the County”) for violations of 42 U.S.C. §§ 1997-1997j (the Civil

2 Rights of Institutionalized Persons Act or “CRIPA”) and 42 U.S.C. § 14141 (the

3 Violent Crime Control and Law Enforcement Act of 1994). ECF Doc. 1. At the

4 same time, the United States and the County filed the Settlement, ECF Doc. 4-1, and

5 a Joint Stipulation and Proposed Order seeking the Court’s approval of the

6 Settlement. ECF. Doc 4. While Plaintiff-Intervenors were diligently investigating,

7 collecting evidence, and preparing intervention papers, the Court approved the

8 Settlement on September 3, 2015. ECF Docs. 13, 14.

9

71. A key aspect of the United States’ investigation and the resulting

10 Complaint and Settlement is the need for appropriate discharge planning and

11 services for mentally disabled prisoners. The United States alleges in its Complaint

12 that the County has “repeatedly failed to provide adequate mental health services,

13 including psychological and psychiatric services, to prisoners with serious

14 psychiatric needs that are known or obvious due to, but not limited to, insufficient

15 and inadequate … discharge planning.” ECF Doc. 1, Compl. ¶ 23 (emphasis added).

16

72. The Settlement purports to address the County’s inadequate discharge

17 planning in Paragraph 34, which provides in full:

18

The County and the Sheriff will conduct discharge planning and

19

linkage to community mental health providers and aftercare services for

20

all prisoners with serious mental illness as follows:

21

a. For prisoners who are in Jail seven days or less, a preliminary

22 treatment plan, including discharge information, will be developed.

23

b. For prisoners who are in Jail more than seven days, a QMHP

24 [Qualified Mental Health Professional] will also make available:

25

i. For prisoners who are receiving psychotropic medications,

26 a 30-day prescription for those medications will be offered either through the release

27 planning process, through referral to a re-entry resource center, or through referral to

28 an appropriate community provider, unless clinically contraindicated;
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1

ii. In person consultation to address housing, mental

2 health/medical/substance abuse treatment, income/benefits establishment, and

3 family/community/social supports. This consultation will also identify specific

4 action to be taken and identify individuals responsible for each action;

5

iii. If the prisoner has an intense need for assistance, as

6 described in [County Department of Mental Health] policies, the prisoner will

7 further be provided direct linkage to an Institution for Mental Disease (“IMD”),

8 IMD-Step-down facility, or appropriately licensed hospital;

9

iv. If the prisoner has a moderate need for assistance, as

10 described in [County Department of Mental Health] policies, and as clinically

11 appropriate to the needs of the prisoner, the prisoner will be offered enrollment in

12 Full Service Partnership or similar program, placement in an Adult Residential

13 Facility (“Board and Care”) or other residential treatment facility, and direct

14 assistance accessing community resources;

15

v. If the prisoner has minimal needs for assistance, as

16 described in [County Department of Mental Health] policies, the prisoner will be

17 offered referrals to routine services as appropriate, such as General Relief, Social

18 Security, community mental health clinics, substance abuse programs, and/or

19 outpatient care/support groups.

20

c. The County will provide a re-entry resource center with QMHPs

21 available to all prisoners where they may obtain information about available mental

22 health services and other community resources.

23

73. Paragraph 15(aa) defines “serious mental illness” as follows: “’Serious

24 mental illness’ includes psychotic disorders, major mood disorders (including major

25 depression and bipolar disorders), and any other condition (excluding personality

26 disorders, substance abuse and dependence disorders, dementia, and developmental

27 disability) that is associated with serious or recurrent significant self-harm, suicidal

28 ideation, imminent danger to others, current grave disability, or substantially

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1 impaired ability to understand routine instructions, or that prevents access to

2 available programs. Although personality disorders alone generally do not qualify as

3 serious mental illness, personality disorders associated with serious or recurrent

4 significant self-harm do qualify as serious mental illness.”

5

74. According to the County’s Criminal Justice Mental Health Advisory

6 Board Report “A Blueprint for Change,” (“MHAB Report”),2 Institutions for Mental

7 Disease (“IMD”) are “Licensed long term care psychiatric facilities which may be

8 locked, and are similar to hospital beds.”

9

75. The Settlement does not conform with applicable law because it

10 violates the ADA and Section 504 of the Rehabilitation Act.

11

FACTUAL ALLEGATIONS

12

Exclusion of Certain Disabled Persons

13

76. Paragraph 34 offers discharge planning only to persons with mental

14 disabilities of certain specified origins but expressly excludes others protected by

15 the ADA. It provides government services only to persons with “serious mental

16 illness,” while denying discharge planning to those with “substance abuse and

17 dependence disorders, dementia, and developmental disability.” Settlement

18 ¶¶ 15(aa), 34. Under the Settlement, it is not clear that persons with “substance

19 abuse and dependence disorders, dementia, and developmental disabilit[ies]” or with

20 personality disorders (except when “associated with serious or recurrent significant

21 self-harm”) would receive any discharge planning services at all.

22

77. Significant numbers of disabled individuals will be affected by the

23 Settlement’s arbitrary discrimination among classes of disabled persons.

24 Exclusion of Disabled Persons Who Have Been In Jail for Seven or Fewer Days

25

26

27 2 See MHAB Report, published summer 2015, available at 28 http://da.co.la.ca.us/about/reports.
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1

78. Prisoners who are in jail for seven or fewer days are excluded from

2 most of the Settlement’s discharge planning services and are entitled only to a

3 “preliminary treatment plan, including discharge information.” Settlement ¶ 34(a).

4 This line-drawing is arbitrary and will exclude from services many mentally

5 disabled persons. In fact, it may harm some of the most vulnerable individuals

6 because they will not have been stabilized through treatment in jail.

7

79. This exclusion is not mandated by any apparent practical necessities.

8 The Settlement requires prisoners to be screened for mental health needs within 12

9 hours after their arrival and to receive a mental health assessment within 24 hours or

10 within 72 hours on weekends and legal holidays, if not sooner. Id. ¶¶ 27, 29.

11 Prisoners with “emergent or urgent mental health needs” must be evaluated “as soon

12 as possible but no later than four hours from the time of identification.” Id. ¶ 26.

13 Thus, under the Settlement, all prisoners with mental health needs should be

14 identified and assessed within 24 hours (or 72 hours on weekends and holidays)

15 from arrival in jail. Once these persons are identified and their mental health needs

16 assessed, they should be eligible for discharge planning services congruent to their

17 level of needs, irrespective of the length of time they are incarcerated.

18 The Discharge Planning In Paragraph 34 Does Not Provide Meaningful Access To The Benefits It Purports To Offer
19

20

80. Paragraph 34(b) of the Settlement Agreement provides that prisoners

21 should be released either with a prescription for 30 days’ worth of psychotropic

22 medications or with a referral to obtain such a prescription. For many mentally

23 disabled individuals, including Plaintiff-Intervenors, this does not provide

24 meaningful access to necessary medication. Such individuals are often clinically

25 disorganized, meaning that their thoughts do not follow a logical progression. A

26 series of many successive steps must be taken in order to turn a prescription into

27 medication, posing significant barriers for individuals with mental disability.

28

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1

81. Paragraph 34(b) also allows mentally disabled prisoners to be

2 discharged not with a prescription but with a referral to a “re-entry resource center,

3 or . . . to an appropriate community provider.” This erects still more barriers that

4 prevent the mentally disabled from accessing the medications that they require to

5 treat their condition.

6

82. The failure to provide reasonable access to medications poses a grave

7 danger to released prisoners with mental disabilities. Without medication, they are

8 likely to become psychotic, manic, or depressive, which are conditions that pose

9 risks to the individuals suffering from them and to others nearby.

10

83. The Settlement’s vague terms of “linkage,” “referral,” and “making

11 available” a “consultation” appear to allow the County simply to hand a mentally

12 disabled person a pamphlet with a list of service providers. Handing a piece of paper

13 with a list of addresses or phone numbers to mentally disabled individuals such as

14 Plaintiff-Intervenors does not provide those persons with a meaningful discharge

15 plan or with meaningful access to services. People with serious mental disabilities

16 that impede organized thinking do not have the ability to navigate the complex

17 systems of services outside jail without individualized assistance.

18

84. In addition, there is no requirement that the County confirm that the

19 places to which it chooses to refer people in fact have services that are available and

20 appropriate for the person being released. Providing a mentally disabled person with

21 a discharge plan consisting of instructions that he or she cannot follow to services

22 that may or may not be available is not a meaningful discharge plan. In fact, it

23 causes an independent harm, over and above the harm from the lack of services. If

24 an individual attempts to seek services recommended to her and finds the door shut

25 in her face, she is much less likely to continue to seek essential services and obtain

26 the treatment she requires.

27

85. Because they are ineffective and do not immediately provide access to

28 needed medication and services, the discharge-planning protocols established by

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1 Paragraph 34 of the Settlement actually set up barriers to released prisoners with

2 mental illness, particularly for those who are homeless. While a list of referrals and

3 tasks may be an effective discharge plan for some people, for many mentally

4 disabled people being released from jail, such a list amounts to no discharge plan at

5 all. Such individuals often do not have the ability to navigate the complex system of

6 care outside of the jail. They need to be engaged by an individual case manager or a

7 service provider who is in a position to accommodate the released prisoner’s illness

8 and to help him or her to navigate the system.

9

86. County jails can and must provide an outgoing inmate with continuing

10 medical care and a sufficient supply of medication upon discharge to ensure that he

11 or she is receiving needed medical care during the period of time reasonably

12 necessary to permit him or her to consult a doctor and obtain other necessary

13 services.

14

87. Reasonable accommodations exist that will provide Plaintiff-

15 Intervenors meaningful access to the services contemplated by the Settlement

16 Agreement.

17

88. For example, County jails can connect a mentally disabled person upon

18 release with an individual in the community who has the capacity to address the

19 person’s essential needs. County jails can facilitate this process by providing this

20 service connector with essential medical, legal, and other information about the

21 released prisoner.

22

89. Models of this “warm handoff” have been implemented around the

23 country. For instance, the Critical Time Intervention (“CTI”) model is an evidence-

24 based practice, used around the world, that supports vulnerable people, such as

25 mentally disabled people being released from jail, during time-limited periods of 26 transition.3 In the model, a community-based caseworker builds a trusting

27 28 3 http://sssw.hunter.cuny.edu/cti/cti-model/
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1 relationship with a vulnerable client to help him or her navigate a complex and

2 fragmented system of care over a limited period of time. Supportive housing has

3 also been shown to be an effective accommodation to improve and promote physical

4 and mental health, reduce substance abuse, decrease incarceration, and lower overall

5 costs for services.

6

90. Defendants have direct experience with one such model. Project 50, a

7 housing-first project with the goal of permanently housing 50 of Skid Row’s most

8 chronic homeless individuals, successfully decreased incarceration rates, emergency 9 health care usage, and County costs.4 Los Angeles County Department of Health

10 Services’ pilot project called Housing for Health, which provides housing as part of

11 its health services, has also proven successful in improving outcomes and cutting 12 costs.5

13

Violation Of The ADA’s Integration Mandate

14

91. The post-release institutionalizations contemplated in Paragraph 34 of

15 the Settlement are not the most integrated setting appropriate to Plaintiff-

16 Intervenors’ needs. Specifically, Paragraph 34(b)(iii) provides prisoners with an

17 “intense need for assistance” with “direct linkage to an Institutional for Mental

18 Disease (‘IMD’), IMD-Step-down facility, or appropriately licensed hospital.”

19

92. The IMDs or “similarly restrictive facilities” contemplated in

20 Paragraph 34(b)(iii) of the Settlement would unnecessarily segregate and isolate

21 Plaintiff-Intervenors when reasonable alternatives, such as permanent supportive

22 housing, are available and are thus required to be provided to those for whom they

23 are clinically appropriate.

24

25 4 L.A. Times, Housing project for hard-core homeless pays off, http://articles.latimes.com/2012/jun/08/local/la-me-0608-homeless-savings-
26 20120608

27 5 Los Angeles County Department of Health Services, Housing for Health, 28 http://file.lacounty.gov/dhs/cms1_217171.pdf

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1

93. The Settlement does not describe whether or how mental health

2 professionals or public health professionals will determine whether community

3 placement is appropriate. The Settlement refers to institutionalizing prisoners who

4 have an “intense need for assistance” or a “moderate need for assistance, as

5 described in DMH policies.” Settlement ¶¶ 34(b)(iii)-(iv). These categories of need

6 are not defined in the Settlement or in DMH policies or glossaries that are readily

7 accessible to the public, and they are not terms familiar to experts who work in

8 relevant fields. The Settlement does not indicate who will make the critical

9 determination, what credentials that person will have, and what evaluative

10 instrument will be used.

11

FIRST CLAIM FOR RELIEF

12

(Violation of the Americans with Disabilities Act of 1990)

13

94. Plaintiff-Intervenors hereby re-allege and incorporate Paragraphs 1

14 through 93 as if fully set forth herein.

15

95. Defendants are a public entity under Title II of the Americans with

16 Disabilities Act.

17

96. Plaintiff-Intervenors each suffer from mental illnesses or disabilities

18 that substantially impair major life functions such as thinking, communicating, and

19 concentrating.

20

97. Plaintiff-Intervenors were and are qualified to participate in and receive

21 the benefit of discharge planning services upon release from a County jail facility

22 that would link them to critical benefits and services such as mental and medical

23 health treatment, housing assistance, and substance abuse treatment.

24

98. Defendants are or were on actual or constructive notice that Plaintiff-

25 Intervenors are disabled.

26

99. Plaintiff-Intervenors’ mental disabilities cause impairments that can

27 limit their abilities to access existing County benefits and services absent reasonable

28 accommodations. The discharge-planning services offered by Defendants under the

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1 Settlement to seriously mentally ill individuals being released from jail do not

2 reasonably accommodate these disabilities.

3

100. Solely by reason of their mental disabilities, each of the Plaintiff-

4 Intervenors has been denied and under the Settlement terms will continue to be

5 denied the benefit of discharge planning and services by Defendants, which impairs

6 their meaningful access to post-discharge benefits and services.

7

101. Defendants’ entry into and implementation of the Settlement violate the

8 rights of Plaintiff-Intervenors under Title II of the ADA, 42, U.S.C. § 12132, and its

9 implementing regulations, 28 U.S.C. § 35.130, in a number of ways, including but

10 not limited to the following:

11

a. providing different or separate services to a certain class of

12 individuals with disabilities than are provided to others (28 C.F.R. § 35.130(b)(1));

13

b. utilizing criteria or methods of administration that subject

14 qualified individuals with disabilities to discrimination (28 C.F.R. § 35.130(b)(3));

15

c. failing to make reasonable modifications to its policies, practice,

16 and procedures to connect released prisoners with medication and services (28

17 C.F.R. § 35.130(b)(7)); and/or

18

d. placing certain disabled individuals in non-integrated

19 environments (28 C.F.R. § 35.130(d)).

20

102. There are effective reasonable accommodations that Defendants could

21 implement by modifying the Settlement and that would provide Plaintiff-Intervenors

22 meaningful access to post-discharge benefits and services, including but not limited

23 to the following:

24

a. providing discharge planning to all prisoners with mental

25 disabilities, without regard to the length of time they are incarcerated;

26

b. providing discharge planning to all prisoners with a mental

27 disability, regardless of the type of disability;

28

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1

c. providing a reasonable supply of psychotropic medication where

2 clinically appropriate;

3

d. providing the released prisoner with the types of services or

4 programs described in paragraphs 84-86 of this Complaint that are reasonably

5 calculated to give them meaningful access to essential medical and mental health

6 services;

7

e. ensuring that released prisoners with mental disabilities are

8 offered placement in the most integrated post-release environment that is clinically

9 appropriate; and

10

f. ensuring that released prisoners with mental disabilities are

11 connected with post-discharge services that are not oversubscribed and are actually

12 available in a timely fashion.

13

103. Defendants have failed to implement any reasonable accommodations

14 that would allow the Plaintiff-Intervenors to enjoy the benefits of the jail’s discharge

15 plan and access to post-discharge benefits and services.

16

104. Because of this failure, Plaintiff-Intervenors have been denied benefits

17 and services solely on the basis of their disability.

18

SECOND CLAIM FOR RELIEF

19

(Violation of Section 504 of the Rehabilitation Act)

20

105. Plaintiff-Intervenors hereby re-allege and incorporate by reference

21 Paragraphs 1 through 104 as if fully set forth herein.

22

106. Defendants receive federal funding.

23

107. Plaintiff-Intervenors each suffer from mental illnesses or disabilities

24 that substantially impair major life functions such as thinking, communicating, and

25 concentrating.

26

108. Plaintiff-Intervenors were and are qualified to participate in and receive

27 the benefit of discharge-planning services upon release from a County jail facility

28

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1 that would link them to critical benefits and services such as mental and medical

2 health treatment, housing assistance, and substance abuse treatment.

3

109. Defendants are or were on actual or constructive notice that Plaintiff-

4 Intervenors are disabled.

5

110. Plaintiff-Intervenors’ mental disabilities cause impairments that can

6 limit their abilities to access post-discharge benefits and services under the

7 discharge-planning services offered by Defendants under the Settlement to prisoners

8 being released from jail.

9

111. Solely by reason of their mental disabilities, each of the Plaintiff-

10 Intervenors has been denied and under the Settlement terms will continue to be

11 denied the benefit of discharge planning and services, which impairs their

12 meaningful access to post-discharge benefits and services.

13

112. Defendants’ entry into and implementation of the Settlement violate the

14 rights of Plaintiff-Intervenors under 29 U.S.C. §§ 794 in a number of ways,

15 including but not limited to the following:

16

a. providing different or separate services to a certain class of

17 individuals with disabilities than are provided to others (28 C.F.R. § 35.130(b)(1));

18

b. utilizing criteria or methods of administration that subject

19 qualified individuals with disabilities to discrimination (28 C.F.R. § 35.130(b)(3));

20

c. failing to make reasonable modifications to its policies, practice,

21 and procedures to connect released prisoners with medication and services (28

22 C.F.R. § 35.130(b)(7)); and/or

23

d. placing certain disabled individuals in non-integrated

24 environments (28 C.F.R. § 35.130(d)).

25

113. There are effective reasonable accommodations that Defendants could

26 implement by modifying the Settlement that would provide Plaintiff-Intervenors

27 meaningful access to post-discharge benefits and services, including but not limited

28 to the following:

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1

a. providing discharge planning to all prisoners with mental

2 disabilities, without regard to the length of time they are incarcerated;

3

b. providing discharge planning to all prisoners with a mental

4 disability, regardless of the type of disability;

5

c. providing a reasonable supply of psychotropic medication where

6 clinically appropriate;

7

d. providing the released prisoner with the types of services or

8 programs described in paragraphs 84-86 of this Complaint that are reasonably

9 calculated to give them meaningful access to essential medical and mental health

10 services;

11

e. ensuring that released prisoners with mental disabilities are

12 offered placement in the most integrated post-release environment that is clinically

13 appropriate; and

14

f. ensuring that released prisoners with mental disabilities are

15 connected with post-discharge services that are not oversubscribed and are actually

16 available in a timely fashion.

17

114. Defendants have failed to implement reasonable accommodations that

18 would allow the Plaintiff-Intervenors to enjoy the benefits of the jail’s discharge

19 plan and access to post-discharge benefits and services.

20

115. Because of this failure, Plaintiff-Intervenors have been denied benefits

21 and services solely on the basis of their disability.

22

THIRD CLAIM FOR RELIEF

23

(Violation of the Eighth and Fourteenth Amendments to the United States

24

Constitution)

25

116. Plaintiff-Intervenors hereby re-allege and incorporate Paragraphs 1

26 through 115 as if fully set forth herein.

27

117. Plaintiff-Intervenors have a known and obvious need for ongoing

28 medical care after release from custody. Without adequate discharge planning

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1 during their incarceration, Plaintiff-Intervenors likely will have, post-release, no

2 immediate access to needed prescribed medication and other essential medical

3 and/or psychiatric services that they have received while incarcerated. Absent

4 medication and treatment, Plaintiff-Intervenors are likely upon release to suffer

5 significant and irreparable injury.

6

118. Through Paragraph 34 of the Settlement Agreement, Defendants have

7 adopted a policy and practice of failing to provide adequate discharge planning, and

8 thereby Defendants act with deliberate indifference to the serious medical needs of

9 Plaintiff-Intervenors, in violation of their rights under the Eighth and Fourteenth

10 Amendments of the United States Constitution.

11

119. Defendants act with a culpable state of mind in that they know of and

12 disregard the excessive risks to inmate health and safety caused by the failure to

13 provide adequate discharge planning, including immediate access to needed

14 medication and ongoing medical care.

15

120. Defendants’ systemic failure to provide adequate discharge planning

16 through the adoption of Paragraph 34 of the Settlement constitutes a substantial

17 departure from accepted professional standards for mental health and medical care.

18

121. The harm to Plaintiff-Intervenors resulting from the lack of discharge

19 planning significantly outweighs any government interest in denying them these

20 services.

21

22

REQUEST FOR RELIEF

23

WHEREFORE, Plaintiffs-Intervenors request the following relief:

24

122. A declaration that Defendants’ actions and omissions and their policies

25 and procedures complained of violate the Americans with Disabilities Act and/or

26 Section 504 of the Rehabilitation Act; and

27

28

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1

123. A declaration that Defendants’ actions and omissions and their policies

2 and procedures complained of violate the Eighth and Fourteenth Amendments of the

3 United States Constitution.

4

124. Appropriate injunctive relief requiring Defendants, among other things:

5

a. to implement reasonable accommodations in the form of policies

6 and procedures that will ensure that Plaintiff-Intervenors receive adequate discharge

7 planning, including but not limited to providing meaningful discharge planning to

8 all prisoners with mental disabilities;

9

b. to provide mentally disabled prisoners with a discharge plan that

10 is reasonably calculated to give them meaningful access to essential medical and

11 mental health services upon their release; and

12

c. to ensure that released prisoners with mental disabilities are

13 offered placement in the most integrated post-release environment that is clinically

14 appropriate.

15

125. Modification of the Settlement in accordance with the Americans with

16 Disabilities Act, Section 504 of the Rehabilitation Act, and the Eighth and

17 Fourteenth Amendments of the United States Constitution.

18

126. An award of costs and attorney’s fees and expenses pursuant to 29

19 U.S.C. § 794a and any other applicable provisions of law; and

20

127. Such other relief as this Court deems just and proper.

21

22

23

24

25

26

27

28

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1 DATED: January 14, 2016

2

MUNGER, TOLLES & OLSON LLP

3

BRADLEY S. PHILLIPS

4

GRANT A. DAVIS-DENNY EMILY R.D. MURPHY

5

THOMAS P. CLANCY

6

7

By:

/s/ Grant Davis-Denny

8

GRANT A. DAVIS-DENNY

Attorneys for Plaintiff-Intervenors

9

10

11

By:

/s/ Emily Murphy

12

EMILY R.D. MURPHY

Attorneys for Plaintiff-Intervenors

13

14

15

PUBLIC COUNSEL

MARK ROSENBAUM

16

GARY BLASI

17

ANNE RICHARDSON

18

ADELAIDE ANDERSON ALISA HARTZ

19

20

21

By:

/s/ Mark Rosenbaum

22

MARK ROSENBAUM Attorneys for Plaintiff-Intervenors

23

24

25

By:

/s/ Alisa Hartz

26

ALISA HARTZ

Attorneys for Plaintiff-Intervenors

27

28
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 4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A * HB*) =>C A 85 &3*.
15-5903

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A + HB*) =>C A 85 &3*/

1

I. INTRODUCTION

2

Plaintiff, the United States of America, and Defendants, County of Los Angeles

3 ("the County") and the Los Angeles County Sheriff ("Sheriff'), in his official capacity,

4 (collectively, the "Parties") have entered into a Joint Settlement Agreement Regarding

5 the Los Angeles County Jails ("Agreement") and jointly request the Court to approve

6 and enter the attached Agreement as an Order. As set forth in Paragraph 116 of the

7 Agreement, the Parties request that the Court retain jurisdiction over the Agreement to

8 ensure that its substantive terms are properly and timely implemented.

9

The Agreement resolves litigation initiated by the United States with the

10 concurrent filing of a Complaint brought under the authority of the Civil Rights of

11 Institutionalized Persons Act, 42 U.S.C. § 1997 ("CRIPA"), and the Violent Crime

12 Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141 ("Section 14141"). The

13 United States' Complaint alleges that the County and the Los Angeles County Sheriffs

14 Department ("LASD") have engaged in a pattern or practice of conduct that deprives

15 persons confined in the Los Angeles County Jails ("the Jails") of rights, privileges, or

16 immunities secured or protected by the Constitution (including the Eighth and

17 Fourteenth Amendments) or the laws of the United States. The County and the Sheriff

18 do not admit the existence of any pattern or practice ofunconstitutional or unlawful

19 conduct.

20

The Parties agree that the Agreement is a fair, adequate, and reasonable resolution

21 ofthe United States' claims arising from its investigations of the Jails under CRIPA and

22 Section 14141. The Parties further agree that the Agreement complies in all respects

23 with the requirements for prospective relief under the Prison Litigation Reform Act

24 ("PLRA"), 18 U.S.C. § 3626. The Agreement's measures are tailored to the specific

25 needs of the Jails and are designed to protect prisoners from conditions in custody that

26 place them at unreasonable risk of harm from suicide, self-injurious behavior, or

27 unlawful injury by others, in accordance with their constitutional rights. The Agreement

28 also is expected to have collateral benefits that promote public safety, improve

HOA.ll83242.1

2

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A , HB*) =>C A 85 &3*0

1 confidence in the County's criminal justice system, and support the County's and the

2 Sheriffs collaborative efforts to expand comprehensive and effective mental health

3 diversion and re-entry programs.

4

The Parties enter into the Agreement with the goal of avoiding the costs and

5 delays of contested litigation and addressing the policies, procedures, training, and

6 oversight that the United States alleges contributed to a pattern or practice of violations.

7 The Agreement is also intended to promote the Parties' mutual interest in ensuring that

8 the Jails are operated in a manner that complies with the Constitution and laws of the

9 United States.

10

II. BACKGROUND

11

In June 1996, the Department of Justice notified the County and Sheriff that it was

12 opening an investigation under CRIPA to determine whether the conditions in the Jails

13 violate the constitutional rights of its prisoners. In September 1997, the Department of

14 Justice issued a findings letter alleging that mental health care at the Jails violated

15 prisoners' constitutional rights. The letter further alleged that systemic deficiencies

16 contributed to the violations, including inadequate: (1) intake screening and evaluation;

17 (2) diagnosis; (3) referral to mental health professionals; (4) treatment plans; (5)
administration of medications; (6) suicide prevention; (7) tracking and medical record 18
keeping; (8) staffing; (9) communication; and (1 0) quality assurance. 19
In December 2002, following extensive negotiations and additional site visits, the 20
Parties entered into a Memorandum of Agreement ("MOA") that outlined a series of 21
reforms to ensure that adequate and reasonable mental health care services are provided
22 at the Jails. The MOA also included measures to protect prisoners with mental illness

23 from abuse and mistreatment.

24

The Department of Justice monitored the Jail's implementation of the MOA with

25 the assistance of two mental health consultants. Under the MOA, the County and the

26 Sheriff made significant improvements to the delivery of mental health care at the Jails,

27 including implementing electronic medical records, increasing mental health staffing,

28 and developing roving evaluation teams composed of mental health professionals and

HOA.Il83242.1

3

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A - HB*) =>C A 85 &3*1

1 specially;.trained custody staff. Despite considerable progress, the United States alleges

2 that systemic deficiencies remain related to suicide prevention and mental health care

3 that violate prisoners' constitutional rights. The Department of Justice notified the

4 County and the Sheriff of these allegations in a letter dated June 4, 2014, following on-

5 site evaluations with expert consultants.

6

In September 2013, the Department of Justice opened a separate investigation of

7 the Jails under CRIPA and Section 14141 to address allegations of use of excessive force

8 against all prisoners at the Jails, not just prisoners with mental illness. During the course

of the investigation, the County and the Sheriff entered into a comprehensive settlement 9
agreement to resolveRosas v. McDonnell, Case No. CV 12-0428-DDP (C.D. Ca. filed 10
on Jan. 18, 2012) (hereinafter "Rosas"), a class action lawsuit alleging abuse and 1 1
excessive force by staff at certain Jails located in downtown Los Angeles. As part of the

12 Rosas settlement agreement, the County and the Sheriff have agreed to implement

13 significant measures to protect prisoners from excessive force by staff, including

14 improvements in policies, training, incident tracking and reporting, investigations,

15 resolution of prisoner grievances, prisoner and staff supervision, and accountability.

16

On August 25, 2014, the Parties commenced in-person negotiations to address the

17 Department of Justice's updated assessment on mental health care and suicide prevention

18 at the Jails. Following the Rosas settlement, the Parties also began negotiating remedial

19 measures concerning use of force by Jails staff to reach a comprehensive settlement that

20 would address all of the Department of Justice's claims under CRIPA and Section

21 14141.

22

As a result of the Parties' extensive negotiations over the course of approximately

23 eleven months, the Parties have agreed on a set of remedial measures to address

24 remaining allegations concerning suicide prevention and mental health care at the Jails

25 resulting from the partial implementation of the 2002 MOA and current conditions

26 within the Jails. The Parties have also agreed to extend the remedial measures in the

27 Implementation Plan of the Rosas settlement agreement to fully resolve the Department

28 of Justice's CRIPA findings regarding alleged mistreatment of prisoners with mental

HOA.ll83242.1

4

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A . HB*) =>C A 85 &3*2

1 illness and claims under Section 14141 regarding alleged excessive force against

2 prisoners at all of the Jails.

3

The Parties have also selected an independent monitor to assess and report on the

4 implementation of all of the substantive provisions of the comprehensive Agreement.

5 The independent monitor, in consultation with two subject matter experts selected jointly

6 by the Parties, have reviewed each detailed provision of the Agreement and have

7 developed a comprehensive monitoring plan to measure the County's and Sheriffs

8 progress and assess compliance with the Agreement.

9

III. DISCUSSION

10

The Parties request that the Court approve and enter the Agreement as an Order to

ensure that its terms are properly and timely implemented. In determining whether to
11

approve a settlement agreement as an order, courts must determine whether the 12

13 agreement is "fundamentally fair, adequate and reasonable." United States v. Oregon,

913 F.2d 576, 580 (9th Cir. 1990). Courts evaluate both the procedural and substantive 14

fairness ofthe agreement. United States v. Chevron, USA., Inc., 380 F. Supp. 2d 1104, 15

16 1110-11 (N.D. Cal. 2004). Procedural fairness centers on the negotiation process, and

substantive fairness focuses on the extent to which the agreement represents a reasonable 17

18 factual and legal determination. Id.; United States v. Cottage Bakery, Inc., No. 2:12-CV-

1697-KJM-JFM, 2013 U.S. Dist. LEXIS 117317, at *3 (B.D. Cal. Aug. 19, 2013). 19

20

Courts also consider the public policy favoring settlements when reviewing a

settlement agreement for approval. Chevron, 380 F. Supp. 2d at 1111 (internal citations 21

22 omitted). The review is deferential when a government agency acting in the public

interest has negotiated the decree. S.E.C. v. Randolph, 736 F.2d 525, 529 (9th Cir. 23

1984). This deference is particularly strong where the decree has been negotiated by the 24

25 Department of Justice on behalf of an agency that is an expert in the relevant field.

Chevron, 380 F. Supp. 2d at 1111. 26

Entry of the Agreement is appropriate because the Agreement is fundamentally 27

28 fair, adequate, and reasonable, resulted from arms-length negotiations by sophisticated

HOA.ll83242.1

5

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A / HB*) =>C A 85 &3+)

1 parties, is consistent with the purposes ofCRIPA, Section14141, and the PLRA, and is

2 the most effective way to address the allegations of unconstitutional and unlawful

3 conduct in the Complaint. See Cemex Inc. v. L.A. County, 166 Fed. App'x 306, 307 (9th

4 Cir. 2006) (finding that consent decree was negotiated in good faith and at "arm's

5 length," and was "fundamentally fair, adequate and reasonable").

6

A. The Agreement Derives from Good-Faith, Arms-Length Negotiations.

7

The process of crafting the Agreement underscores its reasonableness and

8 demonstrates that it is not the product of fraud, collusion, or overreaching. See id. The

9 Parties were each represented by experienced counsel from the Department of Justice,

10 the Los Angeles County Counsel's Office, and other County departments. The Parties

11 agreed to each of the terms of the Agreement following extensive and detailed

12 negotiations that began after the United States announced the results of its most recent

13 assessment into conditions in the Jails in June 2014. The assessment revealed alleged

14 violations ofCRIPA and Section 14141. Over the course of approximately eleven

15 months, the Parties held numerous in-person meetings to negotiate comprehensive

16 remedial measures that addressed the United States' concerns and advanced the Parties'

17 mutual interests in providing adequate mental health care and reasonable safety at the

18 Jails consistent with prisoners' federal civil rights.

19

The Agreement reflects the Parties' efforts to ensure that alleged violations of

20 CRIPA and Section 14141 do not recur. The Parties are intimately familiar with the

21 Jails' practices stemming from two pattern or practice investigations and the 2002 MOA.

22 Moreover, during this process, the Parties consulted with their respective subject matter

23 experts to ensure that each remedial measure in the Agreement is tailored to address the

24 concern and may be reasonably implemented.

25

This adversarial posture, combined with the respective duties of these government

26 agencies towards those they represent and the detailed negotiations that took place over

27 the course of several months, demonstrates that the Agreement is fair, adequate, and

28 reasonable.

I-IOA.II83242.1

6

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A 0 HB*) =>C A 85 &3+*

1

B. The Agreement Furthers the Objectives of CRIPA and Section 14141,

2 and Complies with the PLRA.

3

The Parties' Agreement in this case is meant to resolve the claims in the United

4 States' Complaint. These claims are brought under the United States' statutory authority

5 to ensure lawful and constitutional conditions of confinement and policing practices

6 under CRIPA and Section 14141. See 42 U.S.C. § 1997; 42 U.S.C. § 14141. Congress

7 enacted CRIPA to remedy conditions that deprived confined persons of rights,

8 privileges, or immunities secured or protected by the Constitution or laws of the United

9 States. 42 U.S.C. § 1997a(a). Congress enacted Section 14141 to forbid law

10 enforcement officers from engaging in a pattern or practice "that deprives persons of

11 rights, privileges, or immunities secured or protected by the Constitution or laws of the

12 United States." 42 U.S.C. § 14141(a). The United States is authorized to seek injunctive

13 reliefto remedy violations ofCRIPA and Section 14141. See 42 U.S.C. § 1997a; 42

14 U.S.C. § 14141(b).

15

The Agreement is consistent with and furthers the objectives of CRIPA and

16 Section 14141 because it embodies the County's and Sheriffs agreement to ensure that

17 no pattern or practice of unconstitutional conduct exists. The Agreement requires the

18 County and LASD to implement, or to continue to engage in, numerous reforms at the

19 Jails to ensure constitutional conditions of confinement. Specifically, the Agreement

20 requires remedial measures to: (1) recognize, assess, and treat prisoners with mental

21 illness, from intake to discharge; (2) implement significant new training on crisis

22 intervention and interacting with prisoners with mental illness for new and existing

23 custody staff; (3) improve documentation in prisoners' medical and mental health

24 records and improve communication between staff to ensure continuity of care; (4)

25 strengthen the response to suicidal and/or self-injurious behavior at the individual and

26 system levels; (5) increase supervision of mentally ill and suicidal prisoners; (6) mitigate

27 suicide risks in the physical facilities; (7) increase access to out-of-cell time for mentally

28 ill prisoners; and (8) improve investigation and critical self-analysis of suicides, suicide

I-lOA. I 183242.1

7

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A 1 HB*) =>C A 85 &3++

1 attempts and other critical events. Moreover, the Agreement provides for an

2 independent Monitor and Subject Matter Experts to assess implementation of these

3 reforms. See Agreement~~ 93-95. Finally, the Court will retain jurisdiction to enforce

4 the terms ofthis Agreement. See Agreement~ 116.

5

The Agreement is also appropriate because voluntary compliance is more likely to

6 conserve public resources and accomplish the statutory goals of CRIPA and Section

7 14141 than orders imposed at the end of protracted litigation. See Fed. R. Civ. P. 16(b)

8 advisory committee's note ("Since it obviously eases crowded court dockets and results

9 in savings to the litigants and the judicial system, settlement should be facilitated at as

10 early a stage of the litigation as possible.").

11

Here, the Agreement provides an opportunity to continue the Parties' considerable

12 efforts to ensure lawful and constitutional conditions of confinement at the Jails.

13 Settling this dispute without protracted litigation allows the Parties to achieve a shared

14 goal: ensuring constitutional conditions of confinement. This undertaking likely will

15 enjoy far broader support as part of the negotiated Agreement than as one ordered by the

16 Court after litigation.

17

Finally, the settlement negotiations ensured that the relief in the Agreement is

18 narrowly tailored to correct the particular constitutional violations alleged in the

19 Complaint. The Parties stipulate that the Agreement complies in all respects with the

20 provisions of the PLRA, 18 U.S.C. § 3626. The Parties further stipulate that the

21 prospective relief in the Agreement is narrowly drawn, extends no further than necessary

22 to correct the violations of federal rights as alleged by the United States in the

23 Complaint, is the least intrusive means necessary to correct those alleged violations, and

24 will not have an adverse impact on public safety or the operation of a criminal justice

25 system. Accordingly, the Parties agree and represent that the Agreement complies in all

26 respects with the provisions of 18 U.S.C. § 3626(a) & (c).

27

28

HOA.ll83242.1

8

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A 2 HB*) =>C A 85 &3+,

1

IV. CONCLUSION

2

The Agreement is fundamentally fair, adequate, and reasonable and should be

3 entered by this Court. The Parties negotiated the Agreement over an extended period to

4 provide a framework for ensuring that the County's and the Sheriffs operation of the

5 Jails will comply with constitutional and legal requirements. Moreover, the Agreement

6 represents a compromise forged through lengthy negotiations between experienced and

7 sophisticated litigants, aided on both sides by subject matter experts, and with an eye

8 towards their shared goals of constitutional conditions of confinement. The Agreement

9 furthers the shared goals of the Parties, as well as the intent of Congress in enacting

10 CRIPA and Section 14141. The Agreement also complies in all respects with the

11 requirements for prospective relief under the PLRA.

12

For those reasons and the others described herein, the Parties request that this

13 Court approve and enter the Agreement as an Order.

14

IT IS SO STIPULATED AND AGREED.

15 DATED: ch-Ff2ol5

16 FOR THE UNITED STATES:

17

18

19

20 EILEEN M. DECKER
United States Attorney 21 Central District of California

22 23

LEON W. WEIDMAN

AChssieisft,acn·t

.

ited States Attorney Di i .on

LORETTA E. LYNCH Attorney General
MARK J. KAPPELHOFF Deputy Assistant Attorney General Civil Rights Division
JUDITH C. PRESTON Acting Chief, Special Litigation Section Civil Rights Division

24

25

- ARIELYON MONTELEONE LAURA OON

Assistant United States Attorney

Sp~cial Counsel

26 Assistant Division Chief

LUIS E. SAUCEDO

Civil Rights Unit Chief, Civil Division

Counselor to the Chief

27

CATHLEEN S. TRAINOR

28 JOANNA HULL
Assistant United States Attorney

I-IOA.ll83242.1

9

Senior Trial Attorney U.S. Department of Justice

4 >IA +3*.'?L') .2) ,'7; <'9 6; 5H?K F AGJ- 7DEA@ ) 1() .(*. =>C A *) HB*) =>C A 85 &3+-

U.S. Attorney's Office for the Central District of California 300 N. Los An_geles Street, Suite 7516 Los Angeles, California 90012

Civil Rights Division Special Litigation Section 950 Pennsyfvania Avenue, NW, PHB 5026 Washington, D.C. 20530

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
28
HOA.ll83242.1

Is/
.R..".'.T"'Oi:"T"'D...R.<."TIG'7'"'r7'"<0 A-.'T"'C""AA.,.S.,.,..,Tcn-R"'T"O..--.-Srnl.-L-rV.,A Senior Assistant County Counsel County of Los Angeles
10

 
 Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 1 of 58 Page ID #:25

1 
 LORETTA E. LYNCH

Attorney General

2 
 MARl( J. KAPPELHOFF

Deputy Assistant Attorney General

3 
 Civil Rjghts Division

JUDITH C. PRESTON

4 
 Acting Chief, S12ecial Litigation Section LAURA L. COON, SJ>ecial Counsel, Special Litigation Section

5 
 LUIS E. SAUCEDO, Counselor to the Chief, Special Litigation Section

6 


CATHLEEN S. TRAINOR Trial Attorneys

U.S. Department of Justice 7 
 Civil Rights Division, Special Litigation Section 


8 


950 Pennsylvania Avenue, N.W., PHB 5026 
 Washington, D.C. 20530 · 


9 


TeleP,hone: (202) 514-6255 


Email: laura.coon@usdoj .gov; cathleen.trainor@usdoj .gov 


1O
 
 EILEEN M. DECKER

11 
 United States Attorney_

LEON W. WEIDMAN

12 
 Assistant United States Attorney

Chief Civil Division

13 
 ROBYN-MARIE LYON MONTELEONE (State Bar No. 130005)

Assistant United States Attorney

14 
 Assistant Division Chief+-.Civil Rights Unit Chief, Civil Division
JOANNA HULL (State oar No. 227153)

15 
 Assistant United States Attorney

16 


300 North Los AI!gele.s Street!. Suite 7516 


Los Angeles, California 9001.:

. 


Telephone: (213) 894-2458/6585; Facsimile: (213) 894-7819 


17 


E-mail: Robby.Monteleone@usdoj.gov; Joanna.Hull@usdoj.gov 


18 
 Attorneys for Plaintiff . 19 
 UNITED STATES OF AMERICA

20 


21 
 MARY C. WICKHAM

Interim County Counsel

22 
 RODRIGO A. CASTRO-SILVA (SBN 185251)

Senior Assistant Coun.ty Counsel

23 
 BRANDON NICHOLS (SBN 187188)

Assistant Countjl Counsel

. 24 
 KAREN JOYNT (SBN 206332) 


Deputy County Counsel 


25 
 648 Ke1meth Hahn Hall of Administration 


500 West Temple Street 


26 
 Los Angeles California 90012 


Tel: (213) 974-1811 Fax: (213) 626-7446 


27 
 Email: rcastro-silva@counsel.lacounty.gov 


bnichols@counsel.lacounty.gov


28 


kjoynt@counsel.lacounty.gov 


1 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 2 of 58 Page ID #:26

1 Attome_ys for Defendants COUNTY OF LOS ANGELES and LOS ANGELES
2 COUNTY SHERIFF JIM MCDONNELL, in his Official Capacity
3

4

UNITED STATES DISTRICT COURT 5

6

FOR THE CENTRAL DISTRICT OF CALIFORNIA

7

WESTERN DIVISION

8 9 UNITED STATES OF AMERICA,

CV No. 15- 5903

10

Plaintiff,

11

v.

12 COUNTY OF LOS ANGELES AND

LOS ANGELES COUNTY SHERIFF

13 JIM MCDONNELL, in his Official

Capacity,

.

14

Defendants.

15

JOINT SETTLEMENT AGREEMENT REGARDING THE LOS ANGELES COUNTY JAILS; AND STIPULATED [PROPOSED] ORDER OF RESOLDTION ·

16

17

18

1. The United States of America, acting through the United States

19 Department of Justice ("United States"), the County of Los Angeles ("County")

20 and Sheriff Jim McDonnell, in his official capacity ("Sheriff'), (collectively, the

21 "Parties") share a inutual·interest in treating all members of the community with

22 respect, promoting safe and effective custodial care, protecting public safety, and 23 upholding the constitutional rights ofprisoners. 1

24

2. The Los Angeles County Jails ("Jails") are an integral part of the

25 public safety system in Los Angeles County, California. Together, the Jails form

26

27

"Prisoners" is a defined term in Section III of this Agreement and includes

pre-trial detainees and individuals convicted of a criminal offense. 28

2 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 3 of 58 Page ID #:27

1 the largest jail system in the nation and house among the highest populations of

2 prisoners with mental illness. Maintaining these facilities is an immensely

3 complex enterprise-- approximately 15,500 to 19,500 prisoners are held in custody

4 daily, spread across multiple custody facilities, numerous patrol stations, and over

5 29 courthouses. These facilities' primary function is to incarcerate individuals

6 accused or convicted of committing a crime. In doing so, these facilities provide

7 food, shelter, and clothing, but must also address the serious medical and mental

8 health needs ofthe prisoners and ensure their reasonable safety.

9

3. The United States acknowledges that the County and the Sheriff have

10 demonstrated a renewed commitment to refonning the Jails and have begun to

11 implement improved policies and practices designed to enhance the treatment and

12 care ofprisoners with mental illness. The County and the Sheriff are also

13 exploring strategies to safely divert individuals with mental illness from the

14 criminal justice system, whenever possible. The United States further

15 aclmowledges that the number of suicides at the Jails decreased in 2014 from the

16 previous year. In.addition, the County and the Sheriffhave made significant

17 commitments to protect prisoners from abuse and excessive force by staff that

18 further the Parties' mutual interest. Finally, the United States acknowledges that

19 some of the needed changes the County and the Sheriff seek to implement through

20 this Agreement will require the allocation of additional resources to the Sheriffs

21 Department and the Los Angeles County Department of Mental Health ("DMH").

22

4. Accordingly, this Joint Settlement Agreement Regarding the Los

23 Angeles County Jails ("Agreement") is intended to build upon measures that are

24 underway and to sustain systemic improvements that are designed to protect

25 prisoners from conditions in custody that place them at unreasonable risk of harm

26 from suicide, self-injurious behavior, or unlawful injury by others, in accordance

27 with their constitutional rights. This Agreement also is expected to have collateral

28 benefits that promote public safety, improve confidence in the County's criminal

3 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 4 of 58 Page ID #:28

1 justice system, and support the County's and the Sheriffs collaborative efforts to

2 expand comprehensive and effective mental health diversion and re-entry programs

3 that are designed to lead to more positive outcomes in the care and custody of

4 individuals with serious mental illness who are also participants in the criminal

5 justice system.

6

II. BACKGROUND

7

5. The County owns and funds the operations of the Jails. The Sheriffs

8 Department is responsible for providing care, custody, and control of prisoners at

9 the Jails. The Sheriffs Department Medical Services Bureau provides medical

10 care within theJails. DMH is responsible for providing mental health care in the

11 Jails through its Jail Mental Health Services program.

12

6. The Sheriff is an elected official who is responsible for operating and

13 exercising authority over the Jails.

14

7. In June 1996, the Department ofJustice notified the County and

15 Sheriff that it was opening an investigation under the Civil Rights of

16 Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, to determine whether

17 the conditions in the Jails violate the constitutional rights of its prisoners.

18

8. In September 1997, the Department of Justice issued a findings Jetter

19 alleging that mental health care at the Jails violated prisoners' constitutional rights.

20 The letter further alleged that systemic deficiencies contributed to the violations,

21 including inadequate: (1) intake screening and evaluation; (2) diagnosis; (3)

22 referral to mental health professionals; (4) treatment plans; (5) administration of

23 medications; (6) suicide prevention; (7) tracking and medical record keeping;

24 (8) staffing; (9) communication; and (10) quality assurance.

25

9. In December 2002, following extensive negotiations and additional

26 site visits, the Parties entered into a Memorandum of Agreement (MOA) that

27 outlined a series of reforms to ensure that adequate and reasonable mental health

28

4 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 5 of 58 Page ID #:29

1 care services are provided at the Jails. The MOA also included measures to protect

2 prisoners with mental illness from abuse and mistreatment.

3

10. Under the MOA, the County and the Sheriff have made significant

4 improvements to the delivery of mental health care at the Jails, including

5 implementing electronic medical records, increasing mental health staffing, and

6 developing roving evaluation teams composed of mental health professionals and

7 specially-trained custody staff. Despite considerable progress, the United States

8 alleges that systemic deficiencies remain related to suicide prevention and mental

9 health care that violate prisoners' constitutional rights. The Department of Justice

10 notified the County and the Sheriff of these allegations in a letter dated June 4,

11 2014, following on-site evaluations with expert consultants.

12

11. In September 2013, the Department of Justice opened a separate

13 investigation of the Jails under CRIPA and 42 U.S.C. § 14141 ("Section 14141")

14 to address allegations of use of excessive force against all prisoners at the Jails, not

15 just prisoners with ment11l illness. During the course of the investigation, the

16 County and the Sheriff entered into a comprehensive settlement agreement to

17 resolve Rosas v. McDonnell, Case No. CV 12-0428-DDP (C.D. Ca. filed on Jan.

18 18, 2012) (hereinafter "Rosas"), a class action lawsuit alleging abuse and excessive

19 force by staff at certain Jails located in downtown Los Angeles. As part of the

20 Rosas settlement agreement, the County and the Sheriff have agreed to implement

21 significant measures to protect prisoners from excessive force by staff, including

22 improvements in policies, training, incident tracking and reporting, investigations,

23 resolution of prisoner grievances, prisoner and staff supervision, and

24 accountability.

25

12. This Agreement addresses remaining allegations concerning suicide

26 prevention and mental health care at the Jails resulting from the partial

27 implementation of the 2002 MOA and current conditions within the Jails. This

28 Agreement also extends the remedial measures in the Implementation Plan of the

5

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 6 of 58 Page ID #:30

1 Rosas settlement agreement to fully resolve the Department of Justice's CRIPA

2 findings regarding alleged mistreatment of prisoners with mental illness and claims

3 under Section 14141 regarding alleged excessive force against prisoners at all of

4 the Jails.

5

13. As indicated in Section VII of this Agreement, the Parties consent to a

6 finding that this Agreement complies in all respects with the provisions of the

7 Prison Litigation Reform Act, 18 U.S.C. § 3626(a).

8

14. Except to enforce, modify, or terminate this Agreement, this_

9 Agreement, and any findings made to effectuate this Agreement, will not be

10 admissible against either the County or the Sheriff in any court for any purpose.

11 Moreover, this Agreement is not an admission of any liability on the part of the

12 County or the Sheriff, and/or either of its employees, agents, and former employees

13 and agents, or any other persons, and will not constitute evidence of any pattern or

14 practice of wrongdoing.

15

III. DEFINITIONS

16

15. The following definitions will apply to terms in this Agreement:

17 ·

(a) "Sheriffs Department" refers to the Los Angeles County Sheriff's

18

Department, which is responsible for all custody, corrections, and

19

security functions within the Los Angeles County Jails system,

20

including the provision of medical care to prisoners through the

21

Sheriffs Department Medical Services Bureau.

22

(b) "Jails" refers to the Los Angeles County Jails system, and shall

23

include Men's Central Jail ("MCJ"), Twin Towers Correctional

24

Facility ("TTCF"), Inmate Reception Center ("IRC"), Century

25

Regional Detention Facility ("CRDF"), North County Correctional

26

Facility (''NCCF"), Pitchess Detention Center ("PDC"), and other

27

facilities in which prisoners are detained or held in custody by the

28

County and the Sheriff, including lockup facilities and courthouse

6

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 7 of 58 Page ID #:31

1

holding areas as well as any visiting area in the facility, and any

2

facility that is built, leased, or otherwise used, to replace or

3

supplement the current Jails or any part of the Jails.

4

(c) ~'United States'; or "DOJ" refers to the United States Department of

5

Justice, specifically the Special Litigation Section of the Civil Rights

6

Division and the United States Attorney's Office for the Central

7

District of California, which represent the United States in this matter.

8

(d) "The County" refers to the County of Los Angeles, the Los Angeles

9

County Sheriffs Department, the Los Angeles County Department of

10

Mental Health, and the agents and erp.ployees of the Sheriffs

11

Department and the Department of Mental Health. The Department

12

of Mental Health ("DMH") includes any successor County departmen

13

that assumes the duties and responsibilities ofDMH.

14

(e) "Sheriff' refers to the Los Angeles County Sheriff, currently Jim

15

McDonnell, an independently-elected constitutional officer, in his

16

official capacity, and any predecessors or successors in office,

17

including any designated acting or interim Sheriff.

18

(f) "Custody staff' means sworn deputy sheriffs and custody assistants.

19

(g) "Days" are measured in calendar days; weekend days and County

20

holidays are included.

21

(h) "Normal business work days" means all days except for weekend days

22

and County holidays.

23

(i) "Describe" means provide a clear and detailed description of

24

something done, experienced, seen, or heard.

25

"Document" when used in this Agreement as a verb means

26

completing a record of information either in hard copy or in electronic

27

format.

28

7 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 8 of 58 Page ID #:32

I

(k) "Effective Date" means the date the Court enters the signed

2

Agreement as an order of the Court, or July 1, 2015, whichever is

3

earlier.

4

(1) "Emergency maintenance needs" means a need that if left unattended

5

could result in imminent danger to the life, safety, or health of

6

prisoners.

7

(m) An "emergent" or "urgent" mental health need, as used in this

8

Agreement, is one which the Arrestee Medical Screening Form {SH­

9

R-422) or its equivalent and/or the Medical/Mental Health Screening

10

Questionnaire indicate that immediate action is required to preserve

11

life, prevent serious bodily harm, or relieve significant suffering.

12

(n) "Good cause" means fair and honest reasons, regulated by good faith

13

on the part of either party, that are not arbitrary, capricious, trivial, or

14

pretextual.

15

(o) "Implement" or "implementation" means putting a remedial measure

16

into effect, including informing, instructing, or training impacted

17

personnel as required by this Agreement, and ensuring that policies or·

18

procedures are in fact followed.

19

(p) "Include," "includes," or "including" means "include, but not be

20

limited to" or "including, but not limited to."

21

(q) "Jail Reception Centers" mean all Sheriffs Department processing

22

facilities that handle incoming bookings and arrests and that are

23

responsible for medical and mental health screenings and

24

classification, including the Inmate Reception Center and the Century

25

Regional Detention Facility. This does not include Sheriff's

26

Department station jails.

27

28

8

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 9 of 58 Page ID #:33

1

(r) "Mental Health Housing" refers to prisoner housing areas in the Jails

2

that include only the Forensic In-Patient (PIP), High Observation

3

Housing (HOH), and Moderate Observation Housing (MOH) areas.

4

(i) "Correctional Treatment Center" or "CTC" refers to the

5

licensed health facility with a specified number of beds within

6

the Jails designated to provide health care to that portion of the

7

prisoner population that does not require a general acute care

8

level of services, but which is in need of professionally

9

supervised health care beyond that normally provided in the

10

community on an outpatient basis.

11

(ii) "Forensic In-Patient" or "PIP" can be used interchangeably

12

with Mental Health Unit of the Correctional Treatment Center

13

(MHU CTC). The PIP is located in the CTC and houses

14

prisoners who present an acute danger to self or others or are

15

gravely disabled due to a mental illness and require inpatient

16

care.

17

(iii) "High Observation Housing" or "HOH" refers to designated

18

areas for prisoners with mental illness who require an intensive

19

level of observation and care and/or safety precautions.

20

(iv) "Moderate Observation Housing" or "MOH'' refers to

21

designated areas for prisoners with a broad range of mental

22

health diagnoses and functioning whose mental health needs

23

can be cared for in a less intensive and more open setting than

24

the HOH areas, but preclude general population housing.

25

(s) "Monitor" or "Independent.Monitor" means the individual selected by

26

the Parties whose duties, responsibilities, and authority are set forth in

27

SectionVI of this Agreement.

28

9

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 10 of 58 Page ID #:34

1

(t) "Subject Matter Experts" or "SMEs" means the individuals selected

2

by the Parties whose duties, responsibilities, and authority are set fort

3

in Section VI of this Agreement.

4

(u) "Prisoners" or "Prisoner" is construed broadly to refer to one or more

5

individuals detained at, or otherwise housed, held, in the custody of,

6

or confined at the Jails based on arrests, detainers, criminal charges,

7

civil contempt charges, or convictions.

8

(v) "Psychotropic medication" means any substance used to treat mental

9

health problems or mental illness and is capable of modifying mental

10

activity or behavior.

11

(w) "Qualified Medical Staff' refers to physicians, physician assistants,

12

·nurse practitioners, registered nurses, certified nursing assistants, and

13

licensed vocational nurses, each of whom is permitted by law to

14

evaluate and care for the medical needs of patients.

15

(x) "Qualified Mental Health Professional" or "QMHP" refers to

16

psychiatrists, psychologists, psychiatric social workers, psychiatric

17

nurses, and others who by virtue ortheir education, credentials, and

18

experience are permitted by law to evaluate and care for the mental

19

health needs of patients.

20

(y) "Clinical Restraints" is any device that limits a person's ability to

21

move freely and has been ordered or approved by a licensed

22

psychiatrist for the purpose of managing behavior that appears to be

23

symptomatic of a mental illness.

24

(z) "Security Restraints" is any device that limits a person's ability to

25

move freely and has not been ordered by a licensed psychiatrist or

26

Qualified Medical Staff.

27

(aa) "Serious mental illness" includes psychotic disorders, major mood

28

disorders (including major depression and bipolar disorders), and any

10 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 11 of 58 Page ID #:35

1

other condition (excluding personality disorders, substance abuse and

2

dependence disorders, dementia, and developmental disability) that is

3

associated with serious or recurrent significant self-harm, suicidal

4

ideation, imminent danger to others, current grave disability, or

5

substantially impaired ability to understand routine instructions, or

6

that prevents access to available programs. Although personality

7.

disorders alone generally do not qualify as serious mental illness,

8

personality disorders associated with serious or recurrent significant

9

self-harm do qualify as serious mental illnesses.

10

(bb) "Suicide attempt" means any serious effort to commit an act of self-

11

harm that can result in death and involving definite risk.

12

(cc) "Serious suicide attempt" means a suicide attempt that resulted in or

13

could have resulted in significant and life-threatening injury.

14

(dd) "Suicide Precautions" means any level of watch, observation, or

15

measures specifically intended to prevent suicide or self-harm and

16

includes both Suicide Watch and Risk Precautions as defined in this

17

Agreement.

18

(ee) "Suicide Watch" means the level of watch, observation, or measures

19

intended to identify and safely maintain prisoners who are imminently

20

suicidal and require admission to the Mental Health Unit ofthe

21

Correctional Treatment Center (MHU CTC or PIP) on a 72-hour hold,

22

in accordance with California Welfare and Institutions Code Section

23

5150.

24

(ff) "Risk Precautions" means a level of watch, observation, or measures

25

used to identify and safely maintain those prisoners who require

26

heightened observation and dally re-evaluation, and require admission

27

to HOH but are not considered to pose an imminent risk of suicide.

28

11 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 12 of 58 Page ID #:36

1

(gg) "Suicide resistant location" means a housing assignment in which

2

known or apparent suicide hazards do not exist or have been removed.

3

(hh) "Self-injurious behavior" means any behavior that is self-directed and

4

deliberately results in injury or the potential for injury to oneself and

5

there is no evidence of suicidal intent.

6

(ii) "Serious self-injurious behavior" means self-injurious behavior where

7

the injury is significant enough that it could lead to loss of life or limb

8

or have serious medical complications.

9

Qj) "Direct constant observation" means continuous uninterrupted

10

observation of a prisoner within a proximity that ensures the observer

11

can both see and hear the prisoner to assure the prisoner's well-being,

12

absent extraordinary circumstances.

13

(kk) "Unobstructed visual observation" means continuous but not

14

necessarilyuninterrupted observation within a reasonable physical

15

distance of the prisoner(s).

16

(ll) "Train" means to instruct in skills to a level that the trainee has the

17

demonstrated proficiency, through an assessment or evaluatwn, to

18

implement those skills as and when called for. "Trained" means

19 ·

proficient in the skills.

20

(mm) Throughout this Agreement, the following terms are used when

21

discussing compliance: substantial compliance, partial compliance,

22

and non-compliance. "Substantial Compliance" means that the

23

County and the Sheriff have achieved compliance with the material

24

components ofthe relevant provision of this Agreement in accordance

25

with the Monitor and SMEs' .monitoring plan and compliance

26

measures. "Partial Compliance" means that the County and the

27

Sheriff have achieved compliance on some, but not all, ofthe material

28

components of the relevant provision of this Agreement. "Non­

12

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 13 of 58 Page ID #:37

1

compliance" means that the County and the Sheriff have not met most

2

or all of the material components of the relevant provision of this

3

Agreement. Non-compliance with mere technicalities, or temporary

4

failure to comply coupled with prompt and appropriate corrective

5

action during a period of otherwise sustained compliance, will not

6

constitute failure to maintain Substantial Compliance. At the same

7

time, temporary compliance during a period of otherwise sustained

8

Non-compliance will not constitute Substantial Compliance.

9

(nn) "Policy" or "Policies" mean regulations, directives, or manuals,

10

regardless ofname, that have been approved by a senior executive

11

within the Sheriff's Department ("LASD") or DMH and that describe

12

the duties, functions, or obligations of LASD or DMH staff and

13

provide specific direction in how to fulfill those duties, functions, or

14

obligations. References to "existing" policies mean those policies in

15

effect on the Effective Date of this Agreement, and include any

16

subsequent revisions or changes made to those policies after the

17

Effective Date of this Agreement.

18

IV. OVERALL OBJECTIVES AND GOALS

19

16. Consistent with constitutional standards, the County and the Sheriff

20 will provide prisoners at the Jails with safe and secure conditions and ensure their

21 reasonable safety from harm, including serious risk from self-harm and excessive

22 force, and ensure adequate treatment for their serious mental health needs. In orde

23 to achieve and maintain these objectives, the County and the Sheriff agree to

24 continue, and where appropriate enhance, their current policies and practices, and

25 to implement the additional measures set forth in this Agreement.

26

17. The Parties recognize that the County and the Sheriff have made

27 considerable progress to improve conditions and the delivery of mental health care

28 at the Jails, but that additional measures are necessary to provide prisoners at the

13 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 14 of 58 Page ID #:38

1 Jails with safe and secure conditions, ensure their reasonable safety from harm,

2 including serious risk from self-harm and excessive force, and meet the serious

3 mental health needs of prisoners, in accordance with prisoners' constitutional

4 rights. The measures set forth in this Agreement address the following areas: (1)

5 training; (2) suicide hazard inspections; (3) intake; (4) medical records; (5) mental

6 health referrals; (6) mental health follow-up; (7) suicide risk procedures; (8)

7 staffing; (9) environmental conditions; (10) allowable property privileges; (11)

8 communication related to mental health; (12) safety checks; (13) quality

9 improvement plan; (14) mental health housing; (15) medication; (16) restraints;

10 (17) suicide death reviews and critical incident reviews; (18) mental health

11 treatment; and (19) use of force. The County and the Sheriff agree to maintain an

12 adequate system of mental health screening, assessment, treatment planning, and

13 record-keeping as specifically set forth in this Agreement.

14

V. SUBSTANTIVE PROVISIONS

15 A. Training

16

18. Within three months of the Effective Date, the County and the Sheriff

17 ··will develop, and within six months ofthe Effective Date will commence

18 providing: (1) a four-hour custody-specific, scenario-based, skill development

19 training on suicide prevention, which can be part ofthe eight-hour training

20 described in paragraph 4.8 of the Implementation Plan in Rosas to all new

21 Deputies as part of the Jail Operations Continuum and to all new Custody

22 Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific,

23 scenario-based, skill development training on suicide prevention to all existing

24 Deputies and Custody Assistants at their respective facilities, which can be part of

25 the eight-hour training described in paragraph 4.7 of the Implementation Plan in

26 Rosas, through in-service Intensified Formatted Training, which training will be

27 completed by December 31, 2016.

28

These trainings will include the following topics:

14

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 15 of 58 Page ID #:39

1
2
3 4 5 .
 6 7 8 9 10 11
12
13 14 15 16 17 18 19 20 21
22
23
24
25 26 27 28

(a) suicide prevention policies and procedures, including observation and supervision of prisoners at risk for suicide or self-injurious behavior;
(b) discussion of facility environments and staff interactions and why they may contribute to suicidal behavior;
(c) potential predisposing factors to suicide; (d) high-risk suicide periods and settings; (e) warning signs and symptoms of suicidal behavior; (f) case studies of recent suicides and serious suicide attempts; (g) emergency notification procedures; (h) mock demonstrations regarding the proper response to a suicide
attempt, including a hands-on simulation experience that incorporates the challenges that often accompany ajailsuicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance; (i) differentiating between suicidal and self-injurious behavior; and G) the proper use of emergency equipment. 19. Commencing July 1, 2015, the County and the Sheriff will provide: (a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men's Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams ("JMET") at North County Correctional Facility as follows: (i) 32 hours of Crisis Intervention and Conflict Resolution as
described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed Within the time frames established in that case (currently December 31, 20 16). Deputies at these
15

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 16 of 58 Page ID #:40

1

facilities will receive an eight hour refresher course consistent

2

with paragraph 4.6 of the Implementation Plan in Rosas every

3

other year until termination of court jurisdiction in that case and

4

then a four hour refresher course every other year thereafter.

5

(ii) Eighthours identifying and working with mentally ill prisoners

6

as described in paragraph 4.7 of the Implementation Plan in

7

Rosas to be completed by December 31, 2016. This training

8

requirement may be a part of the 32-hour training described in

9

the previous subsection. Deputies at these facilities will receive

10

a four hour refresher course consistent with paragraph 4.7 of the

11

Implementation Plan in Rosas every other year thereafter.

12

(b). Commencing July 1, 2015, the County and the Sheriff will ensure that

13

new Custody Assistants receive eight hours of training in the Custody

14

Assistant academy; and that all existing Custody Assistants receive

15

eight hours of training, related to identifying and working with

16

mentally ill prisoners as described in paragraph 4.7 of the

17

Implementation Plan in Rosas. This training will be completed by

18

December 31, 20 16. Custody Assistants will receive a four hour

19

refresher course consistent with.paragraph 4. 7 ofthe Implementation

20

Plan in Rosas every other year thereafter.

21

20. · Commencing no later than July 1, 2017, the County and the Sheriff

22 will provide:

23

(a) Custody-specific, scenario-based, skill development training to

24

existing Deputies assigned to North County Correctional Facility,

25

Pitchess Detention Center, and the non-Mental Health Housing Units

26

in Century Regional Detention Facility as follows:

27

(i) 32 hours of Crisis Intervention and Conflict Resolution as

28

described in paragraphs 4.6 and 4.9 ofthe Implementation Plan

16

Case 2:15-cv-05903 Document4-1 Filed 08/05/15 Page 17 of 58 Page ID #:41

1

in Rosas to be completed by December 31, 2019. Deputies at

2

these facilities will receive an eight hour refresher course

3

consistent with paragraph 4.6 of the Implementation Plan in

4

Rosas every other year until termination of court juris<;liction in

5

that case and then a four hour refresher course every other year

6

thereafter.

.7

(ii) Eight hours identifying and working with mentally ill prisoners

8

as described in paragraph 4.7 ofthe Implementation Plan in

9

Rosas to be completed by December 31, 2019. This training

10

requirement may be a part of the 32-hour training described in

11

the previous subsection. Deputies at these facilities will receive

12

a four hour refresher course consistent with paragraph 4.7 of the

13

Implementation Plan in Rosas every other year thereafter.

14

21. Consistent with existing Sheriffs Department policies regarding

15 training requirements for sworn personnel, the Cmmty and the Sheriff will ensure

16 that existing custody staff that have contact with prisoners maintain active

17 certification in cardiopulmonary resuscitation and first aid.

18

22. Within six months of the Effective Date and at least annually

19 thereafter., the County and the Sheriff will provide instructional materia~ to all

20 Sheriff station personnel, Sheriff court personnel, custody booking pers01mel, and

21 outside law enforcement agencies on the use of arresting and booking documents,

22 including the Arrestee Medical Screening Form, to ensure the sharing of known

23 relevant and available information on prisoners' mental health status and suicide

24 risk. Such instructional material will be in addition to the training provided to all

25 custody booking personnel regarding intake.

26 B. Suicide Hazard Inspections

27

23. Within three months of the Effective Date~ the County and the Sheriff

28 will commence a systematic review of all prisoner housing, beginning with the

17

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 18 of 58 Page ID #:42

1 Mental Health Unit of the Correctional Treatment Center, all High Observation

2 Housing areas, all Moderate Observation Housing areas, single-person discipline,

3 and areas in which safety precautions are implemented, to reduce the risk of self-

4 harm and to identify and address suicide hazards. The County and the Sheriff will

5 utilize a nationally-recognized audit tool for the review. From this tool, the Count

6 and the Sheriff will:

7

(a) develop short and long term plans to reasonably mitigate suicide

8

hazards identified by this review; and

9

(b) prioritize planning and mitigation in areas where suicide precautions

10

are implemented and seek reasonable mitigation efforts in those areas.

11

24. · The County and the Sheriff will review and inspect housing areas on

12 at least an annual basis to identify suicide hazards.

13 C. Intake

14

25. The County and the Sheriffwill ensure that any prisoner in a Sheriff's

15 Department station jail who verbalizes or who exhibits a clear and obvious

16 indication of current suicidal intent will be transported to IRC, CRDF, or a medical

17 facility as soon as practicable. Pending transport, such prisoners will be under

18 unobstructed visual observation, or in a suicide resistant location with safety

19 checks ev-t:ry 15 minutes.

20

26. Consistent with existing Sheriff's Department policies, the County

21 and the Sheriff will follow established screening procedures to identify prisoners

22 with emergent or urgent mental health needs based upon information contained in

23 the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the

24 Medical/Mental Health Screening Questionnaire and to expedite such prisoners for

25 mental health evaluation upon arrival at the Jail Reception Centers and prior to

26 routine screening. Prisoners who are identified as having emergent or urgent

27 mental health needs, including the need for emergent psychotropic medication, will

28

18 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 19 of 58 Page ID #:43.

1 be evaluated by a QMHP as soon as possible but no later than four hours from the

2 time of identification.

3

27. Consistent with existing Sheriff's Department policies, the County

4 and the Sheriff will ensure that all prisoners are individually and privately screened

5 by Qualified Medical Staff or trained custody personnel as soon as possible upon

6 arrival to the Jails, but no later than 12 hours, barring an extraordinary

7 circumstance, to identify a prisoner's need for mental health care and risk for

8 suicide or self-injurious behavior. The County and the Sheriff will ensure that the

9 Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening

10 Form (SH-R-422) or its equivalent, and!or the Confidential Medical Mental Health

11 Transfer Form are in the prisoner's electronic medical record or otherwise

12 available at the time the prisoner is initially assessed by a QMHP.

13

28. The County and the Sheriffwill ensure that any prisoner who has bee

14 identified during the intake process as having emergent or urgent mental health

15 needs as described in Paragraph 26 of this Agreement will be expedited through

16 the booking process. While the prisoner awaits evaluation, the County and the

17 Sheriff will maintain unobstructed visual observation of the prisoner when

18 necessary to protect his or her safety, and will conduct 15-minute safety checks if

19 the prisoner is in a cell.

20

29. The County and the Sheriff will ensure that a QMHP conducts a

21 mental health assessment ofprisoners who have non-emergent mental health needs

22 within 24 hours (or within 72 hours on weekends and legal holidays) of a

23 registered nurse conducting an intake nursing assessment at IRC or CRDF.

24

30. Consistent with existing DMH policies, the initial mental health

25 assessment will include a brief initial treatment plan. The initial treatment plan

26 will address housing recommendations and preliminary discharge information.

27 During the initial assessment, a referral will be made for a more comprehensive

28 mental health assessment if clinically indicated. The initial assessment will

19 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 20 of 58 Page ID #:44

1 identify any immediate issues and determine whether a more comprehensive

2 mental health evaluation is indicated. The Monitor arid SMEs wiii monitor

3 whether the housing recommendations in the initial treatment plan have been

4 followed.

5 D. Medical Records

6

31. Consistent with existing DMH and Sheriffs Department policies, the

7 County and the Sheriff will maintain electronic mental health alerts in prisoners'

8 electronic medical records that notify medical and mental health staff of a

9 prisoner's risk for suicide or self-injurious behavior. The alerts will be for the

10 following risk factors:

11

(a) current suicide risk;

12

(b) hoarding medications; and

13

(c) prior suicide attempts.

14

32. Infonnation regarding a serious suicide attempt wiii be entered in the

15 prisoner's electronic medical record in a timely manner.

16

33. The County wiii require mental health supervisors in the Jails to

17 ·review electronic medical records on a quarterly basis to assess their accuracy as

18 follows:

19

(a) . Supervisors wiii randomly select two prisoners from each clinician's

20

· caseload in the prior quarter;

21

(b) Supervisors will compare records for those prisoners to corroborate

22

clinician attendance, units of service, and any unusual trends,

23

including appropriate time spent with prisoners, recording more units

24

of service than hours worked, and to detennine whether contacts with

25

those prisoners are inconsistent with their clinical needs;

26

(c) Where supervisors identify discrepancies through these reviews, they

27

will conduct a more thorough review using a DMH-developed

28

20 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 21 of 58 Page ID #:45

1

standardizedtool and will consider detailed information contained in

2

the electronic medical record and progress notes;

3

(d) Serious concerns remaining after the secondary review will be

4

elevated for administrative action in consultation with DMH's

5

centralized Human Resources.

6

34. The County and the Sheriff will conduct discharge planning and

7 linkage to community mental health providers and aftercare services for all .

8 prisoners with serious mental illness as follows:

9

(a) For prisoners who are in Jail seven days or less, a preliminary

10

treatment plan, including discharge information, will be developed.

11

(b) For prisoners who are in Jail more than seven days, a QMHP will also

12

make available:

13

(i) · for prisoners who are receiving psychotropic medications, a 30­

14

day prescription for those medications will be offered either

15

through the release planning process, through referral to a re­ '

16

entry resource center, or through referral to an appropriate

17

community provider, unless clinically contraindicated;

18

(ii) in-person consultation to address housing, mental

19

health/medical/substance abuse treatment, income/benefits

20

establishment, and family/community/social supports. This

21

consultation will also identifY specific actions to be taken and

22

identifY individuals responsible for each action;

23

(iii) if the prisoner has an intense need for assistance, as described i

24

DMH policies, the prisoner will further be provided direct

25

linkage to an Institution for Mental Disease ("IMD"), IMD­

26

Step-down facility, or appropriately licensed hospital;

27

(iv) if the prisoner has a moderate need for assistance, as described

I

28

in DMH policies, and as clinically appropriate to the needs of

21 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 22 of 58 Page ID #:46

1

the prisoner, the prisoner will be offered enrollment in Full

2

Service Partnership or similar program, placement in an Adult

3

Residential Facility ("Board and Care") or other residential

4

treatment facility, and direct assistance accessing community

5

resources; and

6

(v) if the prisoner has minimal needs for assistance, as described in

7

DMH policies, the prisoner will be offered referrals to routine

8

services as appropriate, such as General Relief, Social Security,

9

community mental health clinics, substance abuse programs,

10

and/or outpatient care/support groups.

11

(c) The County will provide a re-entry resource center with QMHPs

12

available to all prisoners where they may obtain information about

13

available mental health services and other community resources.

14 E. Mental Health Referrals

15

35. Consistent with existing DMH and Sheriffs Department policies, the

16 County and the Sheriff will ensure that custody staff, before the end of shift, refer

17 prisoners in general or special populations who are demonstratmg a potenttal need ·

18 for routine mental health care to a QMHP or a Jail Mental Evaluation Team

19 ("JMET") member for evaluation, and document such referrals. Custody staff will

20 utilize the Behavior Observation and Referral Form.

21

36. Consistent with existing DMH policies, the County and the Sheriff

22 will ensure that a QMHP performs a mental health assessment after any adverse

23 triggering event, such as a suicide attempt, suicide threat, self-injurious behavior,

24 or any clear decompensation of mental health status. For those prisoners who

25 repeatedly engage in self-injurious behavior, the County will perform such a

26 mental health assessment only when clinically indicated, and will, when clinically

27 indicated; develop an individualized treatment plan to reduce, and minimize

28 reinforcement of, such behavior. The County and the Sheriff will maintain arion­

22

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 23 of 58 Page ID #:47

1 call system to ensure that mental health assessments are conducted within four

2 hours following the notification of the adverse triggering event or upon notification

3 that the prisoner has returned from a medical assessment related to the adverse

4 triggering event. The prisoner will remain under unobstructed visual observation

5 by custody staff until a QMHP has completed his or her evaluation.

6

37. Sheriffs Court Services Division staff will complete a Behavioral

7 Observation and Mental Health Referral Form and forward it to the Jail's mental

8 health and/or medical staff when the Court Services Division staff obtains

9 information that indicates a prisoner has displayed obvious suicidal ideation or

10 when the prisoner exhibits unusual behavior that clearly manifests self-injurious

11 behavior, or other clear indication of mental health crisis. Pending transport, such

12 prisoner will be under unobstructed visual observation or subject to 15-minute

13 safety checks.

14

38. Consistent with existing DMH policies and National Commission on

15 Correctional Health Care standards for jails, the County and the Sheriff will ensure

16 that mental health staff or JMET teams make weekly cell-by-cell rounds in

17 restricted non-mental health housing modules (e.g., administrative segregation,

18 disciplinary segregation) at the Jails to identifY prisoners with mental illness who

19 may have been missed during screening or who have decompensated while in the

20 Jails. In conducting the rounds, either the clinician, the JMET deputy, or the

21 prisoner may request an out-of-cell interview. This request will be granted unless

22 there is a clear and documented security concern that would prohibit such an

23 interview or the prisoner has a documented history of repeated, unjustified requests

24 for such out-of-cell interviews.

25

39. The County and the Sheriff will continue to use a confidential self-

26 referral system by which all prisoners can request mental health care without

27 revealing the substance of their request to custody staff or other prisoners.

28

23 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 24 of 58 Page ID #:48

1

40. The County and the Sheriff will ensure a QMHP will be available on-

2 site, by transportation of the prisoner, or through tele-psych 24 hours per day,

3 seven days per week (24/7) to provide clinically appropriate mental health crisis

4 intervention services.

5 F. Mental Health Follow Up

6

41. Consistent with existing DMH policies, the County and the Sheriff

7 will implement step-down protocols that provide clinically appropriate transition

8 when prisoners are discharged from PIP after being the subject of suicide watch.

9 The protocols will provide:

10

(a) intermediate steps between highly restrictive suicide measures (e.g.,

11

clinical restraints and direct constant observation) and the

12

discontinuation of suicide watch;

13

an (b)

evaluation by a QMHP before a prisoner is removed from suicide

14

watch;

15

(c) every prisoner discharged from PIP following a period of suicide

. 
16

watch will be housed upon release in the least restrictive setting

17

deemed clinically appropriate unless exceptional ctrcumstances

18

affecting the facility exist; and

19

(d) all PIP discharges following a period of suicide watch will be seen by

20

a QMHP within 72 hours of PIP release, or sooner if indicated, unless

21

exceptional circumstances affecting the facility exist.

22

42. Consistent with existing DMH policies, the County and the Sheriff

23 will implement step-down protocols to ensure that prisoners admitted to HOB and

24 placed on risk precautions are assessed by a QMHP. As part of the assessment, the

25 QMHP will determine on an individualized basis whether to implement "step­

26 down" procedures for that prisoner as follows:

27

28

24 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 25 of 58 Page ID #:49

1

(a) the prisoner will be assessed by a QMHP within three Nonnal

2

business work days, but not to exceed four Days, following

3

discontinuance of risk precautions;

4

(b) the prisoner is counseled to ameliorate the negative psychological

5

impact that any restrictions may have had and in ways of dealing with

6

this impact;

7

(c) the prisoner will remain in HOH or be transferred to MOH, as

8

determined on a case by case basis, until such assessment and

9

counseling is completed, unless exceptional circumstances affecting

10

the facility exist; and

11

(d) the prisoner is subsequently placed in a level of care/housing as

12

determined by a QMHP.

13

43. Within six months of the Effective Date, the County and the Sheriff.

14 will develop and implement written policies for formal discipline of prisoners with

15 serious mental illness incorporating the following:

16

(a) Prior to transfer, custody staff will consult with a QMHP to determine

17

whether assignment of a prisoner in mental health housing to

18

disciplinary housing is clinically contraindicated and whether

19

placement in a higher level of mental health housing is clinically

20

indicated, and will thereafter follow the QMHP's recommendation;

21

(b) If a prisoner is receiving psychotropic medication and is placed in

22

disciplinary housing from an area other than mental health housing, a

23

QMHP will meet with that prisoner within 24 hours of such placement

24

to determine whether maintenance of the prisoner in such placement i

25

clinically contraindicated and whether transfer of the prisoner to

26

mental health housing is clinically appropriate, and custody staff will

27

thereafter follow the QMHP's recommendation;

28

25

Case2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 26 of 58 Page ID #:50

1

(c) A QMHP will participate in weekly walks, as specified in Paragraph

2

38, in disciplinary housing areas to observe prisoners in those areas

3

and to identify those prisoners with mental health needs;

4

(d) Prior to a prisoner in mental health housing losing behavioral credits

5

for disciplinary reasons, the disciplinary decision-maker will receive

6

and take into consideration information from a QMHP regarding the

7

prisoner's underlying mental illness, the potential effects of the

8

discipline being considered, and whether transfer of the prisoner to a

9

higher level of mental health housing is clinically indicated.

· 10 G. Suicide Risk Procedures

11

44. Within six months of the Effective Date, the County and the Sheriff

12 will install protective barriers that do not prevent line-of-sight supervision on the

13 second floor tier of all High Observation Housing areas to prevent prisoners from

14 jumping off of the second floor tier. Within six months of the Effective Date, the

15 County and the Sheriff will also develop a plan that identifies any other areas in

16 mental health housing where such protective barriers should be installed.

17 ·

45. Consistent with existing :Sheritt's lJepartment pol!Cles, the county

18 and the Sheriff will provide both a Suicide Intervention Kit that contains an

19 emergency cut-down tool and a first-aid kit in the control booth or officer's station

20 of each housing unit. All custody staff who have contact with prisoners will know

21 the location of the Suicide Intervention Kit and first-aid kit and be trained to use

22 their contents.

23

46. The County and the Sheriff will immediately interrupt, and if

24 necessary, provide appropriate aid to, any prisoner· who threatens or exhibits self-

25 injurious behavior.

26 H. Staffing

27

47. The County and the Sheriff will ensure there are sufficient custodial,

. 28 medical, and mental health staff at the Jails to fulfill the terms of this Agreement. ·

26

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 27 of 58 Page ID #:51

1 Within six months of the Effective Date, and on a semi-annual basis thereafter, the

2 County and the Sheriff will, in conjunction with the requirements of Paragraph 92

3 of this Agreement, provide to the Monitor and DOJ a report identifying the steps

4 taken by the County and the Sheriff during the review period to implement the

5 terms of this Agreement and any barriers to implementation, such as insufficient

6 staffing levels at the Jails, if any.. The County and the Sheriffwill retain staffing

7 records for two years to ensure that for any critical incident or non-compliance

8 with this Agreement, the Monitor and DOJ can obtain those records to determine

9 whether staffing levels were a factor in that critical incident and/or non­

10 compliance.

11 I. Environmental Conditions

12

48. Within three months of the Effective Date, the County and the Sheriff

13 will have written housekeeping, sanitation, and inspection plans to ensure the

14 proper cleaning of, and trash collection and removal in, housing, shower, and

15 medical areas, in accordance with California Code of Regulations ("CCR") Title

16 15 § 1280: Facility Sanitation, Safety, and Maintenance.

17

49. Within three months of the Effective Date, the County and the Sheriff

18 will have a maintenance plan to respond to routine and emergency maintenance

19 needs, including ensuring that shower, toilet, sink, and lighting units, and heating,

20 ventilation, and cooling systems are adequately maintained and installed. The plan

21 will also include steps to treat large mold infestations.

22

50. Consistent with existing Sheriffs Department policies regarding

23 control ofvennin, the County and the Sheriff will provide pest control throughout

24 the housing units, medical units, kitchen, and food storage areas.

25

51. Consistent with existing Sheriffs Department policies regarding

26 personal care items and supplies for inmates, the County and the Sheriff will

27 ensure that all prisoners have access to basic hygiene supplies, in accordance with

28 CCR Title 15 § 1265: Issue ofPersonal Care Items.

27

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 28 of 58 Page 10 #:52

1 J. Allowable Property Privileges

2

52. The County and the Sheriff will implement policies governing

3 property restrictions in High Observation Housing that provide:

4

(a) Except when transfened directly from FIP, upon initial placement in

5

HOH:

6

(i) Suicide-resistant blankets, gowns, and mattresses will be

7

provided until the assessment set forth in section (a)(ii) below is

8

conducted, unless clinically contraindicated as determined and

9

documented by a QMHP.

10

(ii) Within 24 hours, a QMHP will make recommendations

11

regarding allowable property based upon an individual clinical

12

assessment.

13

(b) Property restrictions in H.OH beyond 24 hours will be based on

14

clinical judgment and assessment by a QMHP as necessary to ensure

15

the safety and well-being of the prisoner and documented in the

16

Electronic Medical Record.

;

17

53. If otherwise eligible tor an educatwn, worK, or similar program, a

18 prisoner's mental health diagnosis or prescription for medication alone will not

19 preclude that prisoner from participating in said programming.

20

54. Prisoners who are not in Mental Health Housing will not be denied

21 privileges and programming based solely on their mental health status or

22 prescription for psychotropic medication.

23 K. Communication Related to Mental Health

24

55. Relevant custody, medical, and mental health staff in all High

25 · Observation Housing units will meet on Normal business work days and such staff

26 in all Moderate Observation Housing units will meet at least weekly to ensure

27 coordination and communication regarding the needs of prisoners in mental health.

28 housing units as outlined in Custody Services Division Directive(s) regarding

28

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 29 of 58 Page ID #:53

1 coordination of mental health treatment and housing. When a custody staff

2 member is serving as a member of a treatment team, he or she is subject to the

3 same confidentiality rules and regulations as any other member of the treatment

4 team, and will be trained in those rules and regulations.

5

56. Consistent with existing DMH and Sheriff's Department policies, the

6 County and the Sheriff will ensure that custody, medical, and mental health staff

7 communicate regarding any change in a prisoner's housing assignment following a

8 suicide threat, gesture, or attempt, or other indication of an obvious and serious

9 chl'tllge in mental health condition.

10 L. Safety Checks

11

57. Within three months of the Effective Date, the County and the Sheriff

12 will revise and implement their policies on safety checks to ensure a range of

13 supervision for prisoners housed in Mental Health Housing. The County and the

14 Sheriff will ensure that safety checks in Mental Health Housing are completed and

15 documented in accordance with policy and regulatory requirements as set forth

16 below:

17

(a) Custody staff will conduct safety checks in a manner that allows staff

18

to view the prisoner to assure his or her well-being and security.

19

Safety checks involve visual observation and, if necessary to

20

determine the prisoner's well-being, verbal interaction with the

21

prisoner;

22

(b) Custody staff will document their checks in a format that does not

23

have pre-printed times;

24

(c) Custody staff will stagger checks to minimize prisoners' ability to

25

plan around anticipated checks;

26

(d) Video surveillance may not be used to replace rounds and supervision

27

by custodial staff unless new construction is built specifically with

28

constant video surveillance enhancements and could only be used to

29 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 30 of 58 Page ID #:54

1

replace 15 minute checks in non-FIP housing, subject to approval by

2

the Monitor;

3

(e) A QMHP, in coordination with custody (and medical staff if

4

necessary), will determine.mental health housing assigrunents.

5

(f) Supervision of prisoners in mental health housing will be conducted at

6

the following intervals:

7

(i) FIP: Custody staff will perform safety checks every 15

8

minutes. DMH staff will perform direct constant observation o

9

one-to-one observation when determined to be clinically

1 0

appropriate;

11

(ii) High Observation Housing: Every 15 minutes;

12

(iii) Moderate Observation Housing: Every 30 minutes.

13

58. Within three months of the Effective Date, the County and the Sheriff

14 will revise and implementtheir policies on safety checks. The County and the

15 Sheriff will ensure that safety checks in non-mental health housing units are

16 .completed and documented in accordance with policy and regulatory requirements

17 as set torth below:

18

(a) At least every 30 minutes in housing areas with cells;

19

(b) At least every 30 minutes in dormitory-style housing units where the

20

unit does not provide for unobstructed direct supervision of prisoners

21

from a security control room.

22

(c) Where a dormitory-style housing unit does provide for unobstructed

23

direct supervision of prisoners, safety checks must be completed

24

inside the unit at least every 60 minutes;

25

(d) At least every 60 minutes in designated minimum security dormitory

26

housing at PDC South, or other similar campus-style unlocked

27

dormitory housing;

28

30 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 31 of 58 Page ID #:55

1

(e) Custody staff will conduct safety checks in a manner that allows staff

2

to view the prisoner to assure his or her well-being and security.

3

Safety checlcs involve visual observation and, if necessary to

4

determine the prisoner's well-being, verbal interaction with the

5

prisoner;

6

(f) Custody staff will document their checks in a format that does not

7

have pre-printed times;

8

(g) Custody staff will stagger checks to minimize prisoners' ability to

9

plan around anticipated checks; and

10

(h) Video surveillance may not be used to replace rounds and supervision

11

by custodial staff.

12

59. Consistent with existing Sheriffs Department policies regarding

13 uniform daily activity logs, the County andthe Sheriff will ensure that a custodial

14 supervisor conducts unannounced daily rounds on each shift in the prisoner

15 housing units to ensure custodial staff conduct necessary safety checks and

16 document their rounds.

17 M. Quality Improvement Plan

18

60. Within six months of the Effective Date, the Department of Mental

19 Health, in cooperation with the Sheriffs Unit described in Paragraph 77 ofthis

20 Agreement, will implement a quality improvement program to identify and address

21 clinical issues that place prisoners at significant risk of suicide or self-injurious

22 behavior.

23

61. The quality improvement program will review, collect, and aggregate

24 data in the following areas and recommend corrective actions and systemic

25 improvements:

26

(a) Suicides and serious suicide attempts:

27

(i) Prior suicide attempts or other serious self-injurious behavior

28

(ii) Locations

31 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page-32 of 58 Page ID #:56

1

(iii) Method

2

(iv) Lethality

3

(v) Demographic information

4

(vi) Proximity to court date;

5

(b) Use of clinical restraints;

6

(c) Psychotropic medications;

7

(d) Access to care, timeliness of service, and utilization of the Forensic

8

In-patient Unit; and

9

(e) Elements of documentation and use of medical records.

10

62. The County and the Sheriffs Unit described in Paragraph 77 of this

11 Agreement will develop, implement, and track corrective action plans addressing

12 recommendations of the quality improvement program.

13 N. Mental Health Housing

14

63. The County and the Sheriff will maintain adequate High Observation

15 Housing and Moderate Observation Housing sufficient to meet the needs of the jail

16 population with mental illness, as assessed by the County and the Sheriff on an

17 ongoing basis. The County Will contmue 1ts practice ot placmg pnsoners with

18 · mental illness in the least restrictive setting consistent with their clinical needs.

19

64. Within six months of the Effective Date, the County and the Sheriff

20 will develop a short-term plan addressing the following 12-month period, and

21 within 12 months of the Effective Date, the County and the Sheriff will develop a

22 long-term plan addressing the following five-year period, to reasonably ensure the

23 availability of licensed inpatient mental health care for prisoners in the Jails. The

24 County and the Sheriff will begin implementation of each plan within 90 days of

25 plan completion. These plans will describe the projected capacity required,
26 strategies that w:ill be used to obtain additional capacity if it is needed, and identify

27 the resources necessary for implementation. Thereafter, the County and the Sherif

28 will review, and if necessary revise, these plans every 12 months.

32

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 33 of 58 Page ID #:57

1 0. Medication

2

65. Consistent with existing Sheriffs Department policies, the County

3 and the Sheriff will ensure that psychotropic medications are administered in a

4 clinically appropriate manner to prevent misuse, hoarding, and overdose.

5

66. Consistent with existing bMH policies, prisoners in High Observation

6 Housing and Moderate Observation Housing, and those with a serious mental

7 illness who reside in other housing areas of the Jails, will remain on an active

8 mental health caseload and receive clinically appropriate mental health treatment,

9 regardless of whether they refuse medications.

10

67. Within three months of the Effective Date, the County and the Sheriff

11 will implement policies for prisoners housed in High Observation Housing and

12 Moderate Observation Housing that require:

13

(a) documentation of a prisoner's refusal of psychotropic medication in

14

the prisoner's electronic medical record;

15

(b) discussion of a prisoner's refusal in treatment team meetings;

16

(c) the use of clinically appropriate interventions with such prisoners to

17

encourage medication compliance;

18

(d) consideration of the need to transfer non-compliant prisoners to highe

19

levels of mental health housing; and

20

(e) individualized consideration of the appropriateness of seeking court

21

orders for involuntary medication pursuant to the provisions of

22

California Welfare and Institutions Code sections 5332-5336 and/or

23

California Penal Code section 2603(a).

24

68. Within six months of the Effective Date, the County and the Sheriff

25 will develop and implement a procedure for contraband searches on a regular, but

26 staggered basis in all housing units. High Observation Housing cells will be

27 visually inspected prior to initial housing of inmates with mental health issues.

28

33 


Case 2:15-cv~05903 Document 4-1 Filed 08/05/15 Page 34 of 58 Page ID #:58

1 P. Restraints

2

69. Consistent with existing DMH policies regarding use of clinical

3 restraints, the County and the Sheriff will use clinical restraints only in the

4 Correctional Treatment Center and only with the approval of a licensed psychiatris

5 who has performed an individualized assessment and an appropriate Forensic

6 Inpatient order. Use of clinical restraints in CTC will be documented in the

7 prisoner's electronic medical record. The documentation will include the basis for

8 and duration of the use of clinical restraints and the performance and results of the

9 medical welfare checks on restrained prisoners. When applying clinical restraints,

10 custody staff will ensure a QMHP is present to document and monitor the

11 condition ·of the prisoner being placed in clinical restraints.

12

70. Within three months of the Effective Date, the County and the Sheriff

13 will have policies and procedures regarding the use of Security Restraints in HOH

14 and MOH. Such policies will provide that:

15

(a) Security Restraints in these areas will not be used as an alternative to

16

mental health treatment and will be used only when necessary to

17 ·

insure satety;

18

(b) Security Restraints will not be used to punish prisoners, but will be

19

used only when there is a threat or potential threat of physical harm,

20

destruction of property, or escape;

21

(c) Custody staff in HOH andMOH will consider a range of security

22

restraint devices and utilize the least restrictive option, for the least

23

amount of time, necessary to provide safety in these areas;

24

(d) Whenever a prisoner is recalcitrant, as defmed by Sheriffs ·

25

Department policy, and appears to be in a mental health crisis,

26

Custody staffwill request a sergeant and immediately refer the

27

prisoner to a QMHP.

28

34 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 35 of 58 Page ID #:59

1· 


71. The County and the Sheriff will ensure that any prisoner subjected to

2 clinical restraints in response to a mental health crisis receives therapeutic services

3 to remediate any effects from the episode(s) of restraint.

4 Q. Suicide Death Reviews and Critical Incident Reviews

5

72. The County and the Sheriff will develop and implement policies and

6 procedures that ensure that incidents involving suicide and serious self-injurious

7 behavior are reported and reviewed to determine: (a) whether staff engaged in any

8 violations of policies, rules, or laws; and (b) whether any improvements to policy,

9 training, operations, treatment programs, or facilities are warranted. These policies

10 and procedures will define terms clearly and consistently to ensure that incidents

11 are reported and tracked accurately by DMH and the Sheriffs Department.

12

73. Depending on the level of severity of an incident involving a prisoner

13 who threatens or exhibits self-injurious behavior, a custody staff member will

14 prepare a detailed report (Behavioral Observation and Mental Health Referral

15 Form, Inmate Injury Report, and/or Incident Report) that includes infom1ation

16 from individuals who were involved in or witnessed the incident as soon as

17 practicable, but no later than the end of shift. The report will include a description

. 1
8 of the events surrounding the incident and the steps taken in response to the

19 incident. The report will also include the date and time that the report was

20 completed and the names of any witnesses. The Sheriffs Department will

21 immediately notify the County Office of Inspector General of all apparent or

22 suspected suicides occurring at the Jails.

23

74. The Sheriffs Department will ensure that there is a timely, thorough,

24 and objective law enforcement investigation of any suicide that occurs in the Jails.

25 Investigations shall include recorded interviews of persons involved in, or who

26 witnessed, the incident, including other prisoners. Sheriffs Department personnel

27 who are investigating a prisoner suicide or suspected suicide at the Jails will ensure

28

35

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 36 of 58 Page ID #:60

1 the preservation of all evidence, including physical evidence, relevant witness 


2 statements, reports, videos, and photographs. 


3

75. Within three months of the Effective Date, the County and the Sheriff

4 will review every suicide attempt that occurs in the Jails as follows:

5

(a) Within two working days, DMH staff will review the incident, the

6

prisoner's mental health status known at the time of the incident, the ·

7

need for immediate corrective action if any, and determine the level o

8

suicide attempt pursuant to the Centers for Disease Control and

9

Prevention's Risk Rating Scale;

10

(b) · Within 30 working days, and only for those incidents determined to b

11

a serious suicide attempt by DMH staff after the review described in

12

subsection (a) above, management and command-level personnel

13

from DMH and the Sheriffs Department (including Custody Division

14

and Medical Services Bureau) will meet to review relevant

15

information known at that time, including the events preceding and

16

following the incident, the prisoner's incarceration, mental health, and

17 ·

health history, the status ot any corrective act10ns tal(en, and the nee<i

18

for additional corrective action if necessary;

19

(c) The County and the Sheriff will document the findings that result

20

from the review of serious suicide attempts described in subsection (b)

21

above; and

22

(d) The County and the Sheriff will ensure that information for all suicide

23

attempts is input into a database for tracking and statistical analysis.

24

76. The County and the Sheriff will review every apparent or suspected

25 suicide that occurs in the Jails as follows:

26

(a) Within no more than two working days, management and command-

27

level personnel from DMH and the Sheriffs Department (including

28

Custody Division and Medical Services Bureau) will meet to review

36

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 37 of 58 Page ID #:61

1

and discuss the suicide, the prisoner's mental health status known at

2

the time of the suicide, and the need for immediate corrective or

3

preventive action if any;

4

(b) Within seven working days, and again within 30 working days,

5

management and command-level personnelfrom DMH and the

6

Sheriff's Department (including Custody Division and Medical

7

Services Bureau) will meet to review relevant information known at

8

that time, including the events preceding and following the suicide,

9

the prisoner's incarceration, mental health, and health history, the

10

status of any corrective or preventive actions talcen, and the need for

11

additional corrective or preventive action if necessary;

12

(c) Within six months of the suicide, the County and the Sheriff will

13

prepare a final written report regarding the suicide. The reportwill

14

include:

15

(i) time and dated incident reports and any supplemental reports

16

with the same Uniform Reference Number (URN) from custody

17

staff who were directly involved in and/or witnessed the

18

incident;

19

(ii) a timeline regarding the discovery of the prisoner and any

20

responsive actions or medical interventions;

21

(iii) copies of a representative sample ofmateria1 video recordings

22

or photographs, to the extent that inclusion of such items does

23

not interfere with any criminal investigation;

24

(iv) a reference to, or reports if available, from the Sheriff's

25

Department Homicide Bureau;

26

(v) reference to the Internal Affairs Bureau or other personnel

27

investigations, if any, and findings, if any;

28

37 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 38 of 58 Page ID #:62

1

(vi) a Coroner's report, if it is available at the time ofthe final

2

report, and if it is not available, a summary of efforts made to

3

obtain the .report;

4

(vii) a summary of relevant information discussed at the prior review

5

meetings, or otherwise known at the time of the final report,

6

including analysis ofhousing or classification issues if relevant;

7

(viii) a clinical mortality review;

8

(ix) a Psychological Autopsy utilizing the National Commission on

9

Correctional Health Care's standards; and

10

(x) a summary of corrective actions taken and recommendations

11

regarding additional corrective actions if any are needed.

12

77. The County and the Sheriff will create a specialized unit to oversee,

13 monitor, and audit the County's jail suicide prevention program in coordination

14 with the Department of Mental Health. The Unit will be headed by a Captain, or

15 another Sheriffs Department official of appropriate rank, who reports to the

16 Assistant Sheriff for Custody Operations through the chain of command. The Unit

17 will be responsible for:

18

(a) Ensuring the timely and thorough administrative review of suicides

19

and serious suicide attempts in the Jails as described in this

20

Agreement;

21

(b) Identifying patterns and trends of suicides and serious suicide

22

attempts in the Jails, keeping centralized records and inputting data

23

· into a unit database .for statistical analysis, trends, and corrective

24

·action, if necessary;

25

(c) Ensuring that corrective actions are taken to mitigate suicide risks at

26

both the location of occurrence and throughout the concerned system

27

by providing, or obtaining where appropriate, technical assistance to

28

38 


Case 2:15-cv-05903. Document 4-1 Filed 08/05115 Page 39 of 58 Page ID #:63

1

other administrative units within the Custody Division when such

2

assistance is needed to address suicide-risk issues;

3

(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and

4

mental health service delivery issues as they relate to suicides and

5

serious suicide attempts to identify the need for corrective action

6

where appropriate; and recommend remedial measures, including

7

policy revisions, re-training, or staff discipline, to address the

8

deficiencies and ensure implementation; and

9

(e) Participating in meetings with DMH to develop, implement, and track

10

corrective action plans addressing recommendations of the quality

11

improvement program.

12

78. The County and the Sheriffwill maintain a county-level Suicide

13 Prevention Advisory Committee that will be open to representatives from the

14 Sheriffs Department Custody Division, Court Services, Custody Support Services,

15 and Medical Services Bureau; the Department of Mental Health; the Public

16 Defender's Office; County Counsel's Office; the Office of the Inspector General;

17 and the Department of Mental Health Patients' Rights Office. The Suicide

18 Prevention Advisory Committee will meet twice per year and will serve as an

19 advisory body to address system issues and recommend coordinated approaches to

20 suicide prevention in the Jails.

21 R. Mental Health Treatment

22

79. (a) Unless clinically contraindicated, the County and the Sheriff will

23 offer prisoners in mental health housing:

24

(i) therapeutically appropriate individual visits with a QMHP;

25

(ii) therapeutically appropriate group programming conducted by a

26

QMHP or other appropriate provider that does not exceed 90

27

minutes per session;

28

39 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 40 of 58 Page ID #:64

1

(b) The County and the Sheriff will provide prisoners outside of mental

2 health housing with medication support services when those prisoners are

3 receiving psychotropic medications and therapeutically appropriate individual

4 monthly visits with a QMHP when those prisoners are designated as Seriously

5 Mentally Ill.

6

(c) The date, location, topic, attendees, and provider of programming or

7 therapy sessions will be documented. A clinical supervisor will review

8 documentation of group sessions on a monthly basis.

9

80. (a) The County and the Sheriff will continue to make best efforts to

10 provide appropriate out-of-cell time to all prisoners with serious mental illness,

11 absent exceptional circumstances, and unless individually clinically

12 contraindicated and documented in the prisoner's electronic medical record. To
will 13 implement this requirement, the County and the Sheriff follow the schedule

14 below:

15

(i) By no later than six months after the Effective Date, will offer

16

25% of the prisoners in HOH ten hours of unstructured out-of­

17

cell recreational time and ten hours ot structured therapeutic or

18

programmatic time per week;

19

(ii) By no later than 12 months after the Effective Date, will offer

20

50% of the prisoners in HOH ten hours of unstructured out-of­

21

cell recreational time and ten hours of structured therapeutic or

22

programmatic time per week;

23

(iii) By no later than 18 months after the Effective Date, will offer

24

100% of the prisoners in HOH ten hours of unstructured out-of­

25

cell recreational time and ten hours of structured therapeutic or

26

programmatic time per week.

2 7

(b) No later than six months after the Effective Date, the County and the

28 Sheriff will record at the end of each day which prisoners in HOH, if any, refused

40

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 41 of 58 Page ID #:65
• 


1 to leave their cells that day. That data will be presented and discussed with DMH

2 staff at the daily meeting on the following Normal business work day. The data

3 will also be provided to the specialized unit described in Paragraph 77 and to

4 DMH's quality improvement program to analyze the data for any trends and to

5 implement any corrective action(s) deemed necessary to maximize out-of-cell time

6 opportunities and avoid unnecessary isolation.

7 S. Use of Force

8

81. Except as specifically set forth in Paragraphs 18-20 of this

9 Agreement, and except as specifically identified below, the County and the Sheriff

10 will implement the following paragraphs of the Implementation Plan in Rosas at all

11 Jails facilities, including the Pitchess Detention Center and the Century Regional

12 Detention Facility, by no later than the dates set forth in the Implementation Plan

13 or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use afforce

14 policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10 15 (use afforce on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of

16 force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner

17 supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1­

18 10.2 (management presence in housing units); 11.1 (management review of force);

19 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to

20 be completed by December 31, 2016); 13.1-13.2 (use afforce reviews and staff

21 discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7

22 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1­

23 17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning

24 system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).

25

82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the

26 County and the Sheriff will ensure that Sheriffs Department personnel responsible

27 for collecting prisoners' grievances as set forth in that paragraph are also co-

28 located in the Century Regional Detention Facility.

41

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 42 of 58 Page ID #:66

1

83. The County and the Sheriff will install closed circuit security cameras

2 throughout all Jails facilities' common areas where prisoners engage in

3 programming, treatment, recreation, visitation, and intra-facility movement

4 ("Common Areas"), including in the Common Areas at the Pitchess Detention

5 Center and the Century Regional Detention Facility. The County and the Sheriff · ·

6 will install a sufficient number of cameras in Jails facilities that do not currently

7 have cameras to ensure that all Common Areas of these facilities have security-

8 camera coverage. The installation of these cameras will be completed no later than

9 June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF

10 completed by March 1, 2016; and the remaining facilities completed by June 30,

11 2018. The County and the Sheriff will also ensure that all video recordings of

12 force incidents are adequately stored and retained for a period of at least one year

13 after the force incident occurs or until all investigations and proceedings related to

14 the use of force are concluded.

15

84. The Sheriff will continue to maintain and implement policies for the

16 timely and thorough investigation of alleged staff misconduct related to use of

17 · torce and tor ttmely dtsctplmary actton ansmg trom sucn investigations.

18 Specifically:

19

(a) Sworn custody staff subject to the provisions of California

20

Government Code section 3304 will be notified of the completion of

21

the investigation and the proposed discipline arising from force

22

incidents in accordance with the requirements of that Code section;

23

and

24

(b) All non-sworn Sheriffs Department staff will be notified of the

25

proposed discipline arising from force incidents in time to allow for

26

the imposition of that discipline.

27

28

42

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 43 of 58 Page ID #:67

1

85. The County and the Sheriffwill ensure that Internal Affairs Bureau

2 management and staff receive adequate specialized training in conducting

3 investigations ofmisconduct.

4

86. Within three months of the Effective Date, the County and the Sheriff

5 will develop and implement policies and procedures for the effective and accurate

6 maintenance, inventory, and assignment of chemical agents and other security

7 equipment. The County and the Sheriff will develop and maintain an adequate

8 inventory control system for all weapons, including OC spray.

9

VI. IMPLEMENTATION, COMPLIANCE ASSESSMENT,

10

ENFORCEMENT, AND TERMINATION

11 A. Review and Implementation of Policies, Procedures, and Programs

12

87. The County and the Sheriff are committed to continuous quality

13 . 
improvement and have taken significant steps to review and update policies and

14 procedures to protect the constitutional and federal rights of prisoners at the Jails.

15 Where necessary, the County and the Sheriff will maintain existing policies,

16 procedures, and practices to support the substantive provisions in this Agreement.

17

88. The County and the Sheriff will review all relevant policies,

18 procedures, and other written executive-approved directives within four months of

19 the Effective Date to ensure that they are consistent with the terms of this

20 Agreement, unless they were reviewed and revised for such purposes within six

21 months preceding the Effective Date.

22

89. (a) If the County or the Sheriff create or materially revise a policy

23 related to this Agreement after the Effective Date, the following process will be

24 followed before implementation:

25

(1) the County and Sheriff will provide a copy ofthe proposed policy to

26

the Monitor and DOJ prior to its implementation;

27

(2) the Monitor and DOJ will have 30 days to review the policy and

28

submit comments, if any, to the County and the Sheriff;

43

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 44 of 58 Page ID #:68

1

(3) if the Monitor and DOJ do not submit any comments within the 30­

2

day period, the County and the Sheriff will begin implementation of

3

the policy no later than 180 days after the expiration of the 30 day­

4 


review period or notice that no comments will be forthcoming;

5

(4) if the Monitor or DOJ objects to the proposed policy, the Monitor or

6

DOJ will note the objection in writing to all Parties within the 


7 


respective review period; 


8 


(5) ifthere is any objection to the proposed policy, the County and the 


9 


Sheriff will have 30 days to address the objection(s);

10

(6) if the Monitor and the Parties cannot resolve the objectlon(s), either

11

Party may ask the Court to resolve the matter;

12

(7) the Monitor may extend any time frame within this paragraph by up to

13

15 additional days. Further extensions may be granted by the Monitor

14

with the agreement of both Parties when necessary to permit amicable

15

resolution of objections.

16

(b) If after the Effective Date, the County or the Sheriff is confronted with a

1I · cnt!Cal circumstance reqmnng 1mmedmte actwn, tne county or tne S.heriii may

18 create or substantially revise, and then implement, a policy related to this

19 Agreement without the prior review of the Monitor and DOJ, so long as the

20 review, comment, and objectionprocedures set forth above in subparagraph (a) are

21 followed immediately upon implementation.

22

90. The County and the Sheriff will provide relevant staff with any policy

23 that is created or materially revised after the Effective Date if it relates to the

24 provisions of this Agreement. The County and theSheriff will further document

25 that any such policy has been received by that staff and that such staff has been

26 trained, instructed, or briefed, as appropriate, on that policy.

27

28

44

Case 2:15-cv-05903. Document 4-1 Filed 08/05/15 Page 45 of 58 Page.ID #:69

1 B. Compliance Coordination Unit·

2

91. The County and the Sheriff will establish and maintain a compliance

3 coordination unit for the duration of this Agreement. The unit will:

4

(a) serve as a liaison between the Parties and the Monitor and assume

5

primary responsibility for collecting information the Monitor requires

6

to carry out the duties assigned to the Monitor;

7

(b) maintain sufficient records to document that the requirements of this

8

Agreement are being properly implemented (e.g., census summaries,

9

policies, procedures, protocols, training materials, investigations,

10

incident reports, tier logs, use-of-force reports);

11

(c) provide written answers by electronic mail or other format when

12

necessary and any documents requested by the Monitor or DOJ

13

concerning implementation of this Agreement in a timely manner;

14

(d) coordinate and monitor compliance and implementation activities,

15

including coordination between Custody and DMH staff, and assist

16

managers in assigning compliance tasks to County or Sheriff

17

personnel; and

18

(e) ensure that the County and the Sheriff notify DOJ and the Monitor of

19

any suspected or apparent suicide within 24 hours and make related

20

reports available to the Monitor and DOJ for inspection.

21 C. Self-Assessments and Reports

22

92. (a) Fifteen days before the end of the reporting period described in

23 Paragraph 109 ofthis Agreement, the County and the Sheriff will provide the

24 Monitor and DOJ a Self-Assessment Status Report that includes:

25

(1) the actions taken by the County and the Sheriff during the review

26

period to implement this Agreement including the status of ongoing

27

and continuous improvement activities;

28

45 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 46 of 58 Page ID #:70

1

(2) responses to concerns or recommendations made in prior reports by

2

the Monitor;

3

(3) a summary of any audits related to the provisions of this Agreement

4

that were completed in the reporting period; and

5

(4) relevant trend data including the infonnation described in Paragraphs

6

61 and 77(a).

7

(b) Self-Assessment Status Reports prepared pursuant to this Paragraph will

8 be treated as confidential and not further disclosed or attached to any court

9 document, unless filed under seal with Court approval, without the consent of the

10 Coun'ty and the Sheriff or by order of the Court. The Monitor, SMEs, and other

11 monitoring staff, however, will be permitted to use the information contained in

12 the Self-Assessment Status Reports to prepare the Monitor's reports to the Court.

13 D. Independent Monitor

14

93. In order to assess and report on the implementation of this Agreement

15 and whether the implementation is having the intended beneficial impact on

16 conditions at the Jails, the Monitor, the SMEs, and their staff will:

17 ·

(a) conduct the audits, reviews, and assessments speciiieci in ri1is

18

Agreement;

19

(b) review County and Sheriff policies, procedures, training curricula, an

20

other documents related to this Agreement developed and

21

implemented pursuant to this Agreement;

22

(c) conduct such additional audits, reviews, and assessments consistent

23

with this Agreement as the Monitor and the Parties jointly agree are

24

appropriate, or in. the case of a dispute which the Parties cannot in

25

good faith resolve, as ordered by the Court; and

26

(d) evaluate the implementation of Section V.S. ofthis Agreement

27

concerning use of force consistent with the Settlement Agreement and

28

Implementation Plan-approved in Rosas.

46

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 47 of 58 Page ID #:71

1

94. The Parties have selected Richard Drooyan as the Independent

2 Monitor. The Monitor and his staff will not, and are not intended to, replace or

3 assmne the role and duties of the County or the Sheriff and will have only the

4 duties, responsibilities, and authority conferred by this Agreement.

5

To assess and report whether the provisions of this Agreement have been

6 implemented, and whether the County and the Sheriff are in compliance with the

7 substantive provisions ofthis Agreement, the Monitor will:

8

(a) evaluate the implementation of Section V ("Substantive Provisions")

9

of this Agreement and, where applicable, the Settlement Agreement

10

and Implementation Plan approved in Rosas;

11

(b) conduct specific audits, reviews, and assessments consistent with this

12

Agreement or otherwise if the Parties agree in writing; and

13

(c) prepare reports as provided in this Agreement.

14

95. The Parties have also selected Bruce C. Gage, M.D., and Manuel

15 David Romero as Subject Matter Experts ("SMEs"). The SMEs and their staff will

16 not, and are not intended to, replace or assume the role and duties of the County or

17 the Sheriff and will have only the duties, responsibilities, and authority conferred

18 · by this Agreement. The SMEs will, in conjunction with the Monitor, assess

19 compliance with the substantive provisions of this Agreement by providing

20 expertise within the scope of their subject matters.

21

96. The Monitor and/or SMEs may hire or contract with additional

22 persons with knowledge or expertise not already provided by the SMEs, or where

23 delegation to a subordinate staff member would be appropriate, as reasonably

24 necessary to perform the tasks assigned by this Agreement. The Monitor will

25 notif)rthe County, the Sheriff, and DOJ in writing when the Monitor or SMEs are

26 considering such additional persons. The Parties will have an opportunity, if

27 desired, to interview the candidate(s) and request reasonable information about the

28 candidate's background and experience. If the Parties agree to the Monitor's

47

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 48 of 58 Page ID #:72

· 1 proposal, the Monitor or SMEs will be authorized to hire or contract such

2 additional persons. If the Parties do not agree to the proposal, the Parties will have

3 ten business days to disagree with the proposal in writing. The Partieswill not

4 unreasonably withhold approval. If the Parties are unable to reach agreement

5 within ten business days of receiving notice of this disagreement, the Court will

6 resolve the dispute.

7

97. If not already developed by the Monitor and SMEs and agreed-to by

8 the Parties before the execution of this Agreement, within three months of the

9 appointment of the Monitor and SMEs by the Court, the Monitor and SMEs will

10 develop a plan for conducting the above audits, reviews, and assessments, and will

11 submit that plan to the Parties for review and approval. The plan will:

12

(a) set out a methodology for reviewing each of the substantive

13

provisions ofthis Agreement, including which provisions will be

14

assessed together, if any, and the thresholds for achieving Substantial

15

Compliance; and

16

(b) set out a schedule for conducting the assessments required by this

l/

Agreement.

18

98. The Monitor, SMEs, and any person hired or contracted to assist the

19 Monitor or SMEs will be subject to (a) the supervision and orders of the Court

20 consistent with the terms ofthis Agreement; (b) the terms of this Agreement; (c)

21 any applicable law; and (d) any security protocols while in the Jails.

22

99. The County and the Sheriffwill bear all reasonable fees and costs of

23 the Monitor, the SMEs, and their staff. Travel, lodging, and per diem expenses

24 will be reimbursed at the same rate as provided for County employees. In the

25 event that any dispute arises regarding the reasonableness or payment of the

26. Monitor's, SMEs', or their staffs fees and costs, the Parties and the Monitor will

27 attempt to resolve the dispute cooperatively before seeldng the assistance of the

28 Court.

48

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 49 of 58 Page ID #:73

1

100. At the request ofthe County and the Sheriff, and with the consent of

2 the DOJ, the Monitor, SMEs, and their staff may provide technical assistance.

3 Such assistance may not interfere with the Monitor's or SMEs' duties under this

4 Agreement, create additional duties or obligations that are enforceable under this

5 Agreement, or otherwise alter or modifY the terms of this Agreement.

6 Additionally, whenever the County or the Sheriff identifies and implements its

7 own quality improvement measures that are not related to any of the terms of this

8 Agreement, those quality improvement measures will not be monitored or enforced

9 under this Agreement.

10

101. Should all the Parties agree that the Monitor, a SME, or a member of

11 their staff has exceeded his or her authority or is not fulfilling his or her duties in

12 accordance with this Agreement, the Parties may petition the Court for the

13 immediate removal and replacement of the Monitor, SME, or staff person. After

14 good faith attempts to resolve such issues informally, any Party may petition the

15 Court for the removal of the Monitor, a SME, or any member of their staff, for

16 good cause, which may include, but is not limited to: gross neglect of duties;

17 willful misconduct; inappropriate personal relationship with a Party, any Party

18 employee, or prisoner; conflicts of interest; any criminal conduct; or any

19 significant violations of security protocols during the pendency of this Agreement.

20

l 02. The Parties recognize the Monitor and SMEs may have existing

21 clients who may now be, or in the future may be, adverse to the County or the

22 Sheriff in transactions or litigation. For the duration of this Agreement, however,

23 unless such conflict is waived by all Parties, the Monitor, the SMEs, and their staff

24 will not accept any new employment or retention for consulting services regarding

25 alleged actions or inactions by the County or the Sheriff, or any County or Sheriffs

26 employee, including any actions or inactions involving any prisoner that present a

27 conflict of interest with the Monitor's, SME's, or staff member's responsibilities

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

49 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 50 of 58 Page ID #:74

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

2 connection with a claim or suit against the County, the Sheriff, or their

3 departments, officers, agents, or employees. Similarly, the Monitor, the SMEs,

4 and their staff will not accept employment or provide consulting services (on a

5 paid or unpaid basis) by any Defendant to this matter to act as a defense witness in

6 . connection with a privateclaim or suit against the County, the Sheriff, or their

7 departments, officers, agents, or employees. This provision does not apply to any

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

9 monitoring this Agreement.

10 E. Access and Confidentiality

11

103. With the exception of documents within the attorney-client and

12 attorney-work-product privileges, and notwithstanding the confidentiality

13 restrictions ofthe Health Insurance Portability and Accountability Act("HlPAA"),

14 the California Confidentiality of Medical Information Act (Civil Code§ 56, et

15 seq.); and California Welfare and Institutions Code§ 5328 (related to

16 confidentiality of mental health records), the Monitor, SMEs, their staff, and the

. 17 · United States, its attorneys, consultants, and agents Will have tull ana compiete

18 access to the Jails and all relevant individuals, facilities, prisoner medical and

19 mental health records, documents, data, and meetings related to the provisions of

20 this Agreement.

21

104. Other than as expressly provided in this Agreement, the Monitor, the

22 SMEs, their staff, and DOJ will maintain confidential all, and will not distribute or

23 disclose any, non-public information provided by the County and the Sheriff

24 pursuant to this Agreement. This Agreement will not be deemed a waiver of any

25 privilege or right the County or the Sheriff may assert, including those recognized

26 at common law or created by statute, rule, or regulation, against any other person

27 or entity with respect to the disclosure of any document or information.

28

50 


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1 F. Pubiic Statements, Testimony, and Records

2

105. Except as required by the terms of this Agreement, an order from the

3 Court, the express written agreement of all Parties, or at meetings of the County of

4 Los Angeles Board of Supervisors, the Monitor, SMEs, and their staffwill not

5 make any public or press statements (at a conference or.otherwise), issue findings,

6 offer expert opinion, or testify in any other litigation or proceeding regarding any

7 matter or subject that he or she may have learned as a result of his or her

8 performance under this Agreement. Ifthe Monitor, SMEs, or any of their staff

9 receive a subpoena, he or she will promptly notify the Parties and thereafter advise

10 the subpoenaing court of the terms of this Agreement.

11

106. The Monitor, SMEs, and their staff will be permitted to initiate and

12 receive ex parte communications with all Parties.

13

107. The Monitor, SMEs, and their staff are not a State, County, or local

14 agency, or an agent thereof, and accordingly, the records maintained by them, or

15 any of them, will not be deemed public records subject to public inspection. If the

16 Monitor, SMEs, or any oftheir staff receive a request for inspection of their

17 records related to this Agreement, he or she will promptly notify the Parties.

18

108. This Agreement is enforceable only by the Parties. No person or

19 entity is intended to be a third-party beneficiary of the provisions ofthis

20 Agreement for purposes of any civil, criminal, or administrative action, and

21 accordingly, no person or entity may assert any claim or right as a beneficiary or

22 protected class under this Agreement.

23 G. Monitoring Reports

24

109. Every six months, the Monitor will file public written reports with the

25 Court describing the steps taken by the County and the Sheriff to implement this

26 Agreement and evaluating the extent to which the County and the Sheriff have

27 complied with this Agreement. Specifically, the Monitor and SMEs will evaluate

28 the status of compliance for each substantive provision of this Agreement using the

51

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 52 of 58 Page ID #:76

1 following standards: (1) Substantial Compliance; (2) Partial Compliance; and (3)

2 Non-compliance. In order to assess compliance, the Monitor and SMEs will 


3 
 review a sufficient number of pertinent documents to accurately assess current 


4 
 conditions, interview all relevant staff, interview a sufficient number of prisoners

5 to accurately assess current conditions, and take other reasonable actions consistent

6 with this Agreement, as needed, to fulfill their responsibilities under this

7 . Agreement. The Monitor, the SMEs, and their staff will be responsible for

8 independently verifying representations from the County or the Sheriff regarding

9 progress toward compliance, and examining supporting.documentation. Each

10 monitoring report will describe the steps taken by members of the monitoring team

11 to analyze conditions and assess compliance, including reference to the documents

12 reviewed and individuals interviewed, and the factual basis for the Monitor's and

13·· SMEs' findings. Such reports and fmdings will not be admissible by or against the

14 County or the Sheriff in any proceeding other than a proceeding related to the

15 enforcement of this Agreement initiated and handled exclusively by the County,

16 the Sheriff, or the United States.

17 ·

ll 0. At least JU days betore the antiCipate<i t!lmg oi such reports, tile

18 Monitor will provide the Parties with a draft copy and an opportunity to respond.

19 The Monitor will consider the Parties' responses and make appropriate changes, if

20 any, before filing. The Pmiies may file separate responses with the Court within

21 15 days after the filing by the Monitor although nothing in this Agreement will be

22 construed to require the filing of such responses. All public court filings by the

23 Monitor and any Paiiy will be written with due regard for the privacy interests of

24 individual prisoners and staff and the interest of the County and the Sheriff in

25 protecting against disclosure of information not permitted by this Agreement.

26

111. Except for the provisions of Section V.S. of this Agreement that have

27 different Compliance Periods under the Settlement Agreement, Implementation

28 Plan, and Monitoring Protocols approved in Rosas, upon the Monitor's and SMEs'

52

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 53 of 58 Page ID #:77

1 conclusion that the County and the Sheriff have achieved and maintained

2 Substantial Compliance with a substantive provision of this Agreement for a perio

3 of twelve (12) consecutive months, the Monitor and SMEs will no longer be

4 required to assess or report on that provision. Where the Monitor and SMEs

5 conclude that the County and the Sheriffhave achieved and maintained Substantial

6 Compliance with a substantive provision of this Agreement, as described

7 immediately above, at one Jail facility but not at other facilities, the Monitor and

8 SMEs will no longer be required to assess or report on that provision as it applies

9 to the facility found to be in sustained compliance. The Parties expect that there

10 will be multiple independent operative compliance periods under the supervision

11 of the Monitor.

12

112. If the Monitor identifies a critical and time sensitive issue that the

13 County or the Sheriff should address during a six-month reporting period and that

14 should not be delayed until the time the Monitor must provide the Parties with a

15 draft copy of the monitoring report, the Monitor will provide the Parties with a

16 verbal report on the critical issue as soon as possible, and the Monitor will provide·

17 a written report to the Parties within 30 days ofthe Monitor's identification of the

18 critical issue.

19 II. Court Jurisdiction, Modification, Enforcement, and Termination

20

113. The Court shall retain jurisdiction over the implementation of this

21 Agreement at the existing Jails or any other facility used to replace or supplement

22 the Jails for all purposes.

23

114. The County and the Sheriffwill ensure that all of the terms in this

24 Agreement are implemented. Unless otherwise provided in a specific provision of

25 this Agreement, the implementation of this Agreement will begin immediately

26 upon the Effective Date.

27

28

53 


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1

115. Unless otherwise agreed to under a specific provision of this

2 Agreement, the County and the Sheriff will implement all provisions of this

3 Agreement within six months of the Effective Date.

4

116. To ensure that the substantive provisions of this Agreement are

5 implemented in accordance with the terms of this Agreement, the Court will retain

6 jurisdiction to enforce this Agreement only until either:

7

(a) the County and the Sheriff have achieved and maintained Substantial

8

Compliance with each and every substantive provision of this

9

Agreement for a period of twelve (12) consecutive months (or other

10

time period provided in a specific provision of this Agreement or the

11

relevant Compliance Period under the Settlement Agreement,

12

Implementation Plan, and Monitoring Protocols approved in Rosas);

13

or

14

(b) the Monitor, with Court approval, detennines that the overall

15

.objectives and goals ofthis Agreement have been met even where the

16

specific requirements of substantive provisions of this Agreement may

1 I

be only m J:'artlal Compliance.

18

Either of the conditions described in sub-paragraphs (a) or (b) above will be

19 deemed to fully satisfy this Agreement. At that time, the County and the Sheriff

20 may seek to terminate this Agreement with the Court consistent with the

21 requirements ofthe Prison Litigation Reform Act, 18 U.S.C. § 3626(b).

22

117. The United States acknowledges the good faith of the County and the

23 Sheriff in committing to the reforms set forth in this Agreement. The United

24 States, however, reserves the right to seek enforcement of the provisions of this

25 Agreement with the Court if it detennines that the County or the Sheriff has failed

26 to substantially comply with any substantive provisions of this Agreement. Before

27 pursuing any remedy with the Court, the United States agrees to give written notice

28 to the County and the Sheriff in accordance with the Local Rules ofthe Central

54

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 55 of 58 Page ID #:79

1 District ofCalifomia. The County and the Sheriff will have 30 days from receipt

2 of such notice to cure the alleged failure (or such additional time as is reasonable

3 due to the nature ofthe issue and agreed upon by the Parties). During the 30-day

4 period, the Parties will meet and confer in good faith to resolve any disputes

5 regarding the alleged failure or to otherwise explore a joint resolution. The

6 Monitor and SMEs may assist the Parties in reaching a mutually agreeable

7 resolution to the alleged compliance failure, including facilitating conference

8 meetings and providing relevant factual assessments.

9

118. In case of an emergency posing an imminent and serious threat to the

10 health or safety of any prisoner or staff member at the Jails, the United States may

11 omit the notice and cure requirements set forth above and seek enforcement ofthe

12 Agreement with the Court.

13

119. The Parties may jointly stipulate to make changes, modifications, and

14 amendments to this Agreement, which will be effective absent further action from

15 the Court, 30 days after a stipulation signed by all ofthe Parties has been filed with

16 the Court. Any Party may seek to modifY this Agreement with the Court if that

17 Party establishes by a preponderance of the evidence that a significant change in

18 the law or factual conditions warrant the modification and that the proposed

19 modification is suitably tailored to the changed circumstances.

20

120. The Parties agree to defend the provisions of this Agreement. The

21 Parties will notify each other of any court or administrative challenge to this

22 Agreement. In the event any provision of this Agreement is challenged in any stat

23 court, removal to a federal court shall be sought by the Parties.

24

121. The County and the Sheriff agree to promptly notifY DOJ if any term

25 of this Agreement becomes the subject of co]lective bargaining consultation and to

26 consult with DOJ in a timely manner regarding the position the County or the

27 Sheriff takes in any collective bargaining consultation connected with this

28 Agreement.

55 


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I

will 122. This Agreement constitute the entire integrated agreement of the

'
2 Parties and will supersede the 2002 Memorandum of Agreement Between the

3 United States and Los Angeles County, Califomia, Regarding Mental Health

4 Services at the Los Angeles County Jail ("2002 MOA"). No prior or

5 contemporaneous communications, oral or written, will be relevant or admissible

6 for purposes of determining the meaning of any provisions herein, in this litigation

7 or in any other proceeding.

8

123. The Agreement will be applicable to, and binding upon, all Parties,

9 their officers, agents, employees, assigns, and their" successors in office.

10

124. Failure by any Party to enforce this entire Agreement or any provision

11 thereof with respect to any deadline or any other provision herein will not be

12 construed as a waiver of the Party's right to enforce other deadlines or provisions

13 of this Agreement.

14

VII. STIPULATION PURSUANT TO THE PRISON LITIGATION

15

REFORM ACT, 18 U.S.C. § 3626

16

125. The Parties stipulate and the Courtfinds, pursuant to 18 U.S.C. §

l7 3626(a), that although this matter was not actually litigated or resolved on tile

18 merits, the prospective relief in this Agreement is narrowly drawn, extends no

19 further than necessary to correct the violations of federal rights as alleged by the

20 United States in its Complaint, is the least intrusive means necessary to correct

21 those alleged violations, and will not have an adverse impact on public safety or

22 the operation of a criminal justice system. If the Court does not make the requisite

23 findings and the United States' Complaint is dismissed with prejudice, the Parties

24 agree that this Agreement will become a binding Memorandum of Agreement that

25 will supersede the 2002 MOA. Any admission made for purposes ofthis

26 Agreement is not admissible if presented by third parties in another proceeding.

27

28

56

Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 57 of 58 Page ID #:81

1 Respectfully submitted this_ day of_·__, 2015.

2

3

4 For the UNITED STATES OF AMERICA:

5
6
7 /}- A-.,_~
8 ~~~ECKER .
9 United States Attorney
10 LEONW. WEIDMAN
11 Assistant United States Attorney 12 Chief, vi! Division

LORETTA E. LYNCH Attorney General
VZ!i~dl 
 Acting Deputy Assistant Attorney · General

13

14

-MARlE LYON MONTELEONE JUDITH C. PRESTON 


Assistant United States Attorney 15 Assistant Division Chief

Acting Chief 


16 Civil Rights Unit Chief, Civil Division 17 18

'./~·~
·~-

19

.COON Special Counsel

20

LUIS E. SAUCEDO CATHLEEN S. TRAINOR

Trial Attorneys

.

U.S. Department of Justice

Civil Rights Division

·

Special Litigation Section

23

950 Penn~yfvania Avenue, NW

PHB 5026

24

Washington, D.C. 20530

25

26

27
28

57 


Case 2:15-cv-05903 Document 4-1 Filed 08/05/15 Page 58 of 58 Page ID #:82

1 
 For the COUNTY OF LOS ANGELES and the LO

2 
 SHERIFF, in his official capacity:

3 


4 


5

6 


7 


8 


9 


10

11 

12 


13 


14 
 15 SO ORDERED this _ _ day of _ _ _ _ _ _, 2015.

16 


ll

18 


UNITED STATES DISTRICT JUDGE 


19 


20

21 


22 


23 


24 


25

26 


27 

28 


58 


 
 Case 2:15-cv-05903-DDP-JEM Document 99 Filed 04/27/16 Page 1 of 3 Page ID #:2121

UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA

CIVIL MINUTES - GENERAL Case No. CV 15-05903-DDP (JEMx)

Title

United States of America v. County of Los Angeles, et al.

Date April 27, 2016

Present: The Honorable John E. McDermott, United States Magistrate Judge

S. Anthony
Deputy Clerk

Court Reporter / Recorder

Attorneys Present for Plaintiffs:

Attorneys Present for Defendants:

Proceedings:

(IN CHAMBERS) ORDER RE PLAINTIFF-INTERVENORS’ MOTION TO COMPEL DEPOSITION OF DR. MITCHELL KATZ (Docket No. 93)

Before the Court is Plaintiff-Intervenors’ Motion to Compel Deposition of Dr. Mitchell Katz (“Motion”), the Director of the Los Angeles County Health Agency. (Dkt. # 93.) The Motion is GRANTED in part and DENIED in part.

Background

On August 5, 2015, the U.S. Dept. of Justice filed a complaint against the County of Los Angeles and Los Angeles County Sheriff Jim McDonnell (collectively “LAC”) pursuant to the Civil Rights of Institutionalized Persons Act of 1980, 42 U.S.C. § 1997 and the Violent Crime Control and Law Enforcement Act of 1994, 42 U.S.C. § 14141. (Dkt. # 1.) The complaint alleged violations of the Eighth and Fourteenth Amendments of the U.S. Constitution regarding mental health care for inmates at County jails. Also on August 5, 2015, the parties filed a Stipulation of Settlement. (Dkt. # 4.) On September 3, 2015, the District Court approved the Settlement Agreement. (Dkt. # 13.)

On September 28, 2015, Plaintiff-Intervenors filed a Motion to Intervene, challenging Paragraph 34 of the Settlement Agreement concerning mental health services provided to inmates during the discharge planning process. (Dkt. # 17.) On December 15, 2015, the District Court granted the Motion to Intervene. (Dkt. # 75.) On January 14, 2016, Plaintiff-Intervenors filed a First Complaint in Intervention (Dkt. # 76), alleging that Paragraph 34 violates the Americans with Disabilities Act of 1990 (“ADA”), 42 U.S.C. § 12132, Section 504 of the Rehabilitation Act, 29 U.S.C. 794 and the Eighth and Fourteenth Amendments to the U.S. Constitution.

On February 23, 2016, Plaintiff-Intervenors noticed the deposition of Dr. Katz, Director of the County Health Agency, which includes the Department of Mental Health and the new Office of Diversion and Reentry. The County declined to produce Dr. Katz, asserting he is an “apex” high level

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Case 2:15-cv-05903-DDP-JEM Document 99 Filed 04/27/16 Page 2 of 3 Page ID #:2122

UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA

CIVIL MINUTES - GENERAL Case No. CV 15-05903-DDP (JEMx)

Title

United States of America v. County of Los Angeles, et al.

Date April 27, 2016

official or executive who typically need not appear, absent special circumstances. Coleman v. Schwarzenegger, 2008 WL 4300437*2 (E.D. Cal.); Affinity Labs of Texas v. Apple, Inc., 2011 WL 1753982*15 (N.D. Cal.). On April 12, 2016, the parties filed the Joint Stipulation required by Local Rule 37 (Dkt. # 94-1.) On April 19, 2016, Plaintiff-Intervenors filed a supplemental memorandum. (Dkt. # 95.) The County did not.
Analysis
Dr. Katz was appointed to his position effective November 24, 2015, according to his Declaration. This was after the Settlement Agreement was reached, filed and approved. Dr. Katz’ Declaration states that he was not employed by LAC during the negotiation of the Settlement Agreement, nor involved in the negotiation. He claims to have no direct involvement in the County’s implementation of Paragraph 34.
Were these the only facts, the Court would enforce the apex doctrine as to Dr. Katz, at least to the extent of requiring other discovery first. His comments to Plaintiff-Intervenors’ counsel Mark Rosenbaum, however, compel a different analysis and result, in part. Mr. Rosenbaum’s Declaration indicated he had a conversation with Dr. Katz on February 5, 2015 in which Dr. Katz apparently stated that certain discharge planning practices as described to him by Mr. Rosenbaum were “entirely improper.” He also expressed “great concern” about what would happen to inmates released if the practices described to him by Mr. Rosenbaum were followed.
The County asserts that Rosenbaum’s conversation was an unethical ex-parte communication in violation of California Rule of Professional Conduct 2-100. Plaintiff-Intervenors, however, note that contact with public officials is an exception to the general rule under Rule 2-100(C)(1). Mr. Rosenbaum’s conversation with Dr. Katz was not an ethical violation. Mr. Rosenbaum disclosed who he was to Dr. Katz and that he was counsel in this case. According to Rosenbaum, Dr. Katz chose to discuss the discharge planning practices at issue in this suit. There was no dishonesty, deception or coercion.
Dr. Katz’ rather conclusory statement in his Declaration that he is not involved in the implementation of Paragraph 34 misses the point. He purportedly expressed an opinion that may be inconsistent with the County’s position on Paragraph 34. His opinion is unique and personal to him and that no one else can provide. In a glaring omission, Dr. Katz’ Declaration does not mention the conversation with Mr. Rosenbaum or deny it took place or dispute Mr. Rosenbaum’s description of the conversation. Although Mr. Rosenbaum’s description of the mental health discharge planning practices that Dr. Katz said were “entirely improper” is not specific and Dr. Katz may not recall the conversation the same way, Plaintiff-Intervenors are entitled to attempt to document for the record the opinion attributed to Dr. Katz. If the opinion is as represented by Mr. Rosenbaum, then it may have some probative value that no other County employee can provide.

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Case 2:15-cv-05903-DDP-JEM Document 99 Filed 04/27/16 Page 3 of 3 Page ID #:2123

UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA

CIVIL MINUTES - GENERAL Case No. CV 15-05903-DDP (JEMx)

Title

United States of America v. County of Los Angeles, et al.

Date April 27, 2016

Thus, the Court will permit a two hour deposition of Dr. Katz limited to mental health discharge practices relevant to Paragraph 34 of the Settlement Agreement that Dr. Katz purportedly opined were “entirely improper.”
The Court, however, will enforce the apex doctrine as to all other inquiry. Dr. Katz’ Declaration abjures specific involvement in the implementation of Paragraph 34. His public comments are too general and not specific enough about Paragraph 34 to justify inquiry.

cc: Parties

:

Initials of Deputy Clerk

sa

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CIVIL MINUTES - GENERAL

Page 3 of 3

 
 1

2

3

O

4

5

6

7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

11 UNITED STATES AMERICA,

12

Plaintiff,

13

v.

14 COUNTY OF LOS ANGELES et al.,
15 Defendants.
16 ___________________________

) Case No. CV 15-05903 DDP (JEMx) ) ) ) ORDER DENYING DEFENDANTS’ MOTION ) FOR JUDGMENT ON THE PLEADINGS ) ) ) [Dkt. 84] ) )

17 Presently before the court is Defendants’ Motion for Judgment
18 on the Pleadings of Intervenors’ First Amended Complaint in
19 Intervention (“FACI”). The FACI alleges that a portion of an
20 executed settlement agreement between Plaintiff (“the government”)
21 and Defendant (“the County”) violates the Americans with
22 Disabilities Act (“ADA”), Section 504 of the Rehabilitation Act,
23 and Intervenors’ Eighth and Fourteenth Amendment rights. Having
24 considered the submissions of the parties and heard oral argument,
25 the court denies the motion and adopts the following Order.
26 I. Background
27 On August 5, 2015, the government filed a Complaint against
28 the County under the Civil Rights of Institutionalized Persons Act

1 (“CRIPA”), 42 U.S.C. §§ 1997-1997j, and the Violent Crime Control 2 and Law Enforcement Act of 1994, 42 U.S.C. § 14141.1 The Complaint

3 alleged repeated and systemic violations of prisoners’ constitional

4 rights in the Los Angeles County jail system. The alleged

5 violations included constitutionally deficient mental health care

6 and related services, such as suicide prevention, psychological and

7 pyschiatric services, and discharge planning, as well as inadequate

8 housing and sanitation practices and a pattern of excessive force

9 against prisoners. (Complaint ¶¶ 22-26.)

10

The same day the Complaint was filed, the government and the

11 County filed a stipulated settlement of this matter. The

12 stipulated Settlement Agreement (“Agreement”), which spans 125

13 paragraphs and nearly sixty pages, provides for a series of new or

14 enhanced policies and practices across nineteen subject areas

15 intended to ensure that the County will provide “prisoners at the

16 Jails with safe and secure conditions and ensure their reasonable

17 safety from harm, including serious risk from self-harm and

18 excessive force, and ensure adequate treatment for their serious

19 mental health needs.” (Agreement ¶ 16.) Among the stipulated

20 terms is a provision regarding inmate discharge planning

21 (“Paragraph 34”). That provision states:

22

34. The County and the Sheriff will conduct discharge

planning and linkage to community mental health

23

providers and aftercare services for all prisoners

with serious mental illness as follows:

24

(a) For prisoners who are in Jail seven days or

25

less, a preliminary treatment plan, including

discharge information, will be developed.

26

27

28

1 The Complaint also named Los Angeles County Sheriff Jim McDonnell as a Defendant, in his official capacity.

2

1

(b) For prisoners who are in Jail more than seven

days, a [Qualified Mental Health Professional]

2

will also make available:

3

(i)

for prisoners who are receiving

psychotropic medications, a 30-day

4

prescription for those medications

will be offered either through the

5

release planning process, through

referral to a re-entry resource

6

center, or through referral to an

appropriate community provider,

7

unless clinically contraindicated;

8

(ii)

in-person consultation to address

housing, mental

9

health/medical/substance abuse

treatment, income/benefits

10

establishment, and

family/community/social supports.

11

This consultation will also identify

specific action to be taken and

12

identify individuals responsible for

each action;

13

(iii)

if the prisoner has an intense need

14

for assistance, as described in

[County Mental Health] policies, the

15

prisoner will further be provided

direct linkage to an Institution for

16

Mental Disease (“IMD”), IMD-Step-down

facility, or appropriately licensed

17

hospital;

18

(iv)

if the prisoner has a moderate need

for assistance, as described in

19

[County Mental Health] policies, and

as clinically appropriate to the

20

needs of the prisoner, the prisoner

will be offered enrollment in Full

21

Service Partnership or similar

program, placement in an Adult

22

Residential Facility (“Board and

Care”) or other residential treatment

23

facility, and direct assistance

accessing community resources;

24

(v)

if the prisoner has minimal needs for

25

assistance, as described in [County

Mental Health] policies, the prisoner

26

will be offered referrals to routine

services as appropriate, such as

27

General Relief, Social Security,

community mental health clinics,

28

3

1

substance abuse programs, and/or

outpatient care/support groups.

2

(c) The County will provide a re-entry resource

3

center with QMHPs available to all prisoners

where they may obtain information about

4

available mental health services and other

community resources.

5

(Agreement ¶ 34.)

6

Intervenors intervened and later filed the FACI, which alleges

7

that Paragraph 34 violates the ADA, Section 504 of the

8

Rehabilitation Act, and the Eighth and Fourteenth Amendments.

9

Intervenors allege, for example, that Paragraph 34 facially

10

discriminates against disabled prisoners whose disability stems

11

from personality disorders, substance abuse and dependence

12

disorders, dementia, or developmental disabilities, as well as all

13

disabled prisoners who spend seven days or fewer in jail.2

14

(Agreement ¶ 34, 34(a); FACI ¶ 101.) The FACI also alleges that

15

Paragraph 34 discriminates against disabled inmates, fails to

16

reasonably accommodate Intervenors’ disabilities, and places

17

certain inmates in non-integrated environments in violation of the

18

ADA’s integration mandate. (FACI ¶¶ 101, 112.) Intervenors

19

further allege, in essence, that Paragraph 34's discharge

20

procedures do not allow Intervenors to access medical and

21

psychiatric services, and that Paragraph 34's failings constitute

22

deliberate indifference to Intervenors’ serious medical needs.

23

Defendants now move for judgment on the pleadings.

24

II. Legal Standard

25

26

27

2 The Agreement’s definition of “serious mental illness” expressly excludes these substantive categories, with the exception

28

of personality disorders that are “associated with serious or recurrent significant self-harm.” (Agreement ¶ 15(aa).)

4

1

A party may move for judgment on the pleadings “[a]fter the

2 pleadings are closed [] but early enough as not to delay the

3 trial.” Fed. R. Civ. P. 12(c). Judgment on the pleadings is

4 proper when the moving party clearly establishes that no material

5 issue of fact remains to be resolved and that it is entitled to

6 judgment as a matter of law. Hal Roach Studios, Inc. v. Richard

7 Feiner & Co., 896 F.2d 1542, 1550 (9th Cir. 1990); Doleman v. Meiji

8 Mut. Life Ins. Co., 727 F.2d 1480, 1482 (9th Cir. 1984). The

9 standard applied on a Rule 12(c) motion is essentially the same as

10 that applied on a Rule 12(b)(6) motion to dismiss for failure to

11 state a claim, with the court accepting all of the non-moving

12 party’s allegations as true. Lyon v. Chase Bank USA, N.A., 656

13 F.3d 877, 883 (9th Cir. 2011).

14

III. Discussion

15

A. Standing

16

Defendants contend first that Intervenors lack standing to

17 bring their claims. It is well established that the “imminent”

18 invasion of a concrete, legally protectable interest is sufficient

19 to constitute an injury for purposes of standing. See Lujan v.

20 Defenders of Wildlife, 540 U.S. 555, 560, 564 n.2 (1992).

21 Defendants argue that it is uncertain whether Intervenors will be

22 incarcerated again, and that even if they are incarcerated, it is

23 unclear whether they will be adversely affected by the policies set

24 forth in Paragraph 34. Intervenors need only show, however, a

25 credible threat of future injury. Ibrahim v. Dep’t of Homeland

26 Security, 669 F.3d 983, 992 (9th Cir. 2012).

27

As this court noted in allowing intervention in this case,

28 “Intervenors have presented evidence that they are caught up in a

5

1 tragic cycle of homelessness and incarceration perpetuated and

2 punctuated by manifestations of mental illness and unbroken by any

3 adequate treatment.” (Dkt. 75 at 8 n.4). The FACI alleges that

4 some Intervenors have been detained in Los Angeles County jail

5 facilities dozens of times, while others have been arrested

6 hundreds of times. All suffer from at least one mental illness,

7 and most have histories of substance abuse. In some cases, it

8 appears that Intervenors have entered the jail system largely as a

9 result of their mental health conditions, and that those conditions

10 have then been aggravated by incarceration and, in some cases, the

11 denial of medication. Intervenors have then been released onto the

12 streets, often in a more vulnerable, less stable state than when

13 they entered the jail system. Under these circumstances, there

14 appears to be little doubt that there is a credible threat that

15 Intervenors will again find themselves incarcerated and subject to

16 the policies set forth in Paragraph 34.

17

Defendants also argue that Intervenors lack standing as a

18 matter of law because the threat of future injury to Intervenors is

19 entirely dependent on their engaging in illegal conduct in the

20 future. The Ninth Circuit has held that “standing is inappropriate

21 where the future injury could be inflicted only in the event of

22 future illegal conduct by the plaintiff.” Armstrong v. Davis, 275

23 F.3d 849, 865 (9th Cir. 2001). In other words, standing should be

24 denied where it is “contingent upon [plaintiffs’] violating the

25 law, getting caught, and being convicted.” Hodgers-Durgin v. de la

26 Vina, 199 F.3d 1037, 1041 (9th Cir. 1999) (en banc) (quoting

27 Spencer v. Kemna, 523 U.S. 1, 15 (1983).

28

6

1

Defendants appear to assume that Intervenors are only caught

2 up in the jail system when they violate the law and are convicted

3 of a crime. Granted, some Intervenors acknowledge that they have

4 been incarcerated for drug offenses stemming from addiction

5 problems, or for shoplifting food, soap, shampoo, toothpaste, and

6 deodorant, or for other petty offenses often associated with

7 homelessness. Some have outstanding warrants for failure, or

8 inability, to pay fines incurred after riding public transportation

9 without a valid fare. It is unclear at this stage, however,

10 whether or how often Intervenors have been convicted of criminal

11 offenses. In addition, criminal activities of the type described

12 above may be closely entwined with mental health issues and

13 potential defenses related thereto. Furthermore, a person may be

14 subjected to unlawful practices by law enforcement or custodial

15 personnel without having ever engaged in illegal conduct. See,

16 e.g. Armstrong, 275 F.3d at 866; Hodgers-Durgin, 199 F.3d at 1041.

17 Some Intervenors, including veterans, appear to have been

18 incarcerated after exhibiting symptoms of mental illness, including

19 schizophrenic episodes, periods of confusion related to post-

20 traumatic stress disorder, hearing voices, and talking to trees,

21 without any facially apparent tie to any illegal activity. (Dkt.

22 27.)

23

Nor is the court persuaded that the standing principle

24 articulated in Armstrong is applicable to the mental health-focused

25 circumstances here. The Hodgers-Durgin court, citing the same

26 Supreme Court cases as did the Armstrong court, explained that the

27 Supreme Court’s approach to the denial of standing was “based on

28 the plaintiff’s ability to avoid engaging in illegal conduct.”

7

1 Hodgers-Durgin, 199 F.3d at 1041 (discussing City of Los Angeles v.

2 Lyons, 461 U.S. 95, 105 (1983) and Spencer v. Kemna, 523 U.S. 1, 15

3 (1998)) (emphasis added). This court has serious questions whether

4 mentally ill, homeless, and possibly addicted or chemically

5 dependent individuals can realistically be said to have the ability

6 to avoid engaging in the type of minor infractions that appear to

7 result in repeated incarcerations, particularly where the very fact

8 of incarceration may disrupt ongoing care, exacerbate the effects

9 of disabilities, and impede future treatment.

10

At this stage, it appears to the court that the threat of

11 future harm to Intervenors is not dependent on their conscious

12 decisions to purposefully engage in unlawful activity in the

13 future. Rather, the very nature of Intervenors’ disabilities and

14 concomitant symptoms and behaviors, which may be aggravated by the

15 types of practices challenged here, are likely to lead to repeated

16 incarcerations and exposure to the harms alleged. Intervenors,

17 therefore, have standing.

18

B. ADA and Rehabilitation Act Claims

19

A plaintiff bringing a discrimination claim under Title II of

20 the ADA or Section 504 of the Rehabilitation Act must allege “(1)

21 the plaintiff is an individual with a disability; (2) the plaintiff

22 is otherwise qualified to participate in or receive the benefit of

23 some public entity’s services, programs, or activities; (3) the

24 plaintiff was either excluded from participation in or denied the

25 benefits of the public entity’s services, programs, or activities,

26 or was otherwise discriminated against by the public entity; and

27 (4) such exclusion, denial of benefits, or discrimination was by

28 reason of the plaintiff’s disability.” Thompson v. Davis, 295 F.3d

8

1 890, 895 (9th Cir. 2002); Melton v. Dallas Area-Rapid Transit, 391

2 F.3d 669, 676 (9th Cir. 2004).

3

Much of the parties’ argument here is colored by differences

4 in the characterization of the FACI’s claims. Defendants seek to

5 cast the claims in terms of discrimination between groups of

6 disabled inmates; namely, those who qualify for extra discharge

7 planning under Paragraph 34 and those who do not. Although

8 acknowledging that they did take this position earlier, Intervenors

9 appear to concede that benefits extended to one group of disabled

10 individuals need not necessarily be provided to all disabled

11 people. See Traynor v. Turnage, 485 U.S. 535, 548-49 (1988) ( . .

12 . [T]he central purpose of [the Rehabilitation Act] . . . is to

13 assure that handicapped individuals receive ‘evenhanded treatment’

14 in relation to nonhandicapped individuals. . . . There is nothing

15 in the Rehabilitation Act that requires that any benefit extended

16 to one category of handicapped persons also be extended to all

17 other categories of handicapped persons.”).

18

Intervenors’ main contention, however, is different.

19 Intervenors argue that Paragraph 34 results in a denial of

20 meaningful, state-provided discharge planning services with respect

21 to Intervenors. (Opposition at 16.) That denial, in turn, “bars

22 [Intervenors] from meaningful access to County and other services

23 based on their disability.” (Opp. at 18:14-15.)

24

Hewing closely to Traynor, Defendants argue that Intervenors

25 cannot possibly be discriminated against because non-disabled

26 inmates do not receive any discharge planning services that are not

27 available to disabled inmates, including Intervenors. (Reply at 13

28 (“Although Intervenors argue that non-disabled persons receive

9

1 discharge planning in the form of being ‘processed, released, and

2 walked out the door,’ they do not allege that disabled persons are

3 not processed and released.”).) In other words, even if discharge

4 planning is considered a “service,” all inmates are processed and

5 released in the same, evenhanded way. Thus, the argument goes, the

6 fact that Paragraph 34 provides some additional benefits to some,

7 but not all, disabled people is immaterial, as the provision of

8 those extra benefits to a select disabled few does not deny any

9 disabled person a service available to a nondisabled person.

10 (Reply at 13 (“Non-disabled persons do not need or receive any of

11 the services set forth in paragraph 34.”).) This argument is not

12 persuasive.

13

The ADA and Rehabilitation Act cover both intentional

14 discrimination and facially neutral practices that

15 disproportionately impact disabled people. Crowder v. Kitagawa, 81

16 F.3d 1480, 1484 (9th Cir. 1996). The Ninth Circuit has counseled

17 that courts should not dwell on distinctions between intentionally

18 discriminatory practices and those that are merely “thoughtless,”

19 but should instead “assess whether disabled persons were denied

20 ‘meaningful access’ to state-provided services.” Id. (discussing

21 Alexander v. Choate, 469 U.S. 287, 302 (1985).) A policy that

22 denies disabled persons meaningful access to state services by

23 reason of their disability discriminates against disabled

24 individuals in violation of the ADA. Crowder, 81 F.3d at 1485.

25

It is somewhat unclear whether the parties consider discharge

26 planning itself to be a state-provided service. Defendants

27 implicitly suggest that it is, albeit a very basic one that is

28 provided in the same way to every inmate. At this stage of the

10

1 proceedings, the nature and scope of Defendants’ “processing and

2 release” procedures are not yet factually developed. Any

3 characterization, however, of discharge policy as mere, and

4 uniformly-applied, guidance toward the jailhouse door strikes the

5 court as an oversimplification. Defendants’ discharge policies are

6 designed to achieve certain goals, which may or may not be limited 7 to constitutional or other floors.3 Defendants presumably do not,

8 and could not, for example, simply show a severely ill inmate to an

9 exit without any concern for what might befall that inmate on the

10 other side of the door. See, e.g. Wakefield v. Thompson, 177 F.3d

11 1160, 1164 (9th Cir. 1999) (“A state’s failure to provide

12 medication sufficient to cover [a post-incarceration] transitional

13 period amounts to an abdication of its responsibility to provide

14 medical care to those, who by reason of incarceration, are unable

15 to provide for their own medical needs.”). Indeed, Defendants

16 acknowledged at argument that the discharge process does account

17 for disabilities to some extent. Defendants do not dispute, for

18 example, that a jail cannot discharge a wheelchair-bound inmate by

19 simply wheeling her out the door onto an elevated, ramp-less

20 entryway without running afoul of the ADA.

21

Although factual questions abound, it appears to the court

22 that inmates may receive some form of discharge planning services.4

23 For a non-disabled person, the procedure necessary to satisfy

24 Defendants’ goals may not entail anything more than directing the

25

26

3 The court recognizes that further factual development may be required before these goals can be delineated.

27

4 It is unclear, for example, whether Paragraph 34 represents

28

the entirety of Defendants’ discharge policy even regarding those disabled persons to whom it applies.

11

1 inmate to the exit stairs. That does not mean, however, that no

2 service is provided, or that the same discharge service would prove

3 meaningful to a person in a wheelchair, or to mentally ill persons

4 such as Intervenors. Intervenors argue that Defendants discharge

5 non-disabled people and, as a result of Paragraph 34, some disabled

6 people, in a manner and condition that enables those persons to

7 perform life activities such as arranging transportation, obtaining

8 medical care, accessing food and shelter, and seeking other public

9 services. Intervenors, in contrast, are not discharged in that

10 same manner or condition. At this stage, Intervenors have

11 adequately alleged that, as a result of their particular

12 disabilities, they are denied meaningful access to discharge

13 planning services. Whether that is the case, and if so, whether

14 any or all of the modifications to Paragraph 34 Intervenors seek

15 are reasonable or necessary to afford them meaningful access to

16 such services, are questions for another day.

17

Even if discharge planning is not itself a service, Defendants

18 are not entitled to judgment as a matter of law. Defendants’

19 position is premised upon “the assumption that no violation of the

20 ADA occurs unless a service or benefit of the state is provided in

21 a manner that discriminates against disabled individuals.”

22 Crowder, 81 F.3d at 1483. As the Ninth Circuit stated in Crowder,

23 however, “[t]his simply is not so.” Crowder, 81 F.3d at 1483. In

24 addition to “outright discrimination” of the type upon which

25 Defendants focus, the ADA also prohibits “those forms of

26 discrimination which deny disabled persons public services

27 disproportionately due to their disability.” Id.

28

12

1

In Crowder, disabled plaintiffs brought an ADA challenge to

2 the State of Hawaii’s policy of quarantining all carnivorous

3 animals entering the state. Crowder, 81 F.3d at 1482-83. The same

4 120-day quarantine procedures were imposed on all dogs, including

5 guide dogs for the visually impaired. Id. In finding against the

6 visually-imparied plaintiffs on summary judgment, the district

7 court concluded that even though Hawaii’s quarantine policy did not

8 allow plaintiffs to make meaningful use of state-provided services,

9 plaintiffs could not show an ADA violation because they had not

10 been denied any state services on the basis of a disability. Id.

11 at 1483-84.

12

The Ninth Circuit, focusing on “meaningful access” to public

13 services rather than intentional denial of them, reversed.

14 Crowder, 81 F.3d at 1484-85. The court held that, notwithstanding

15 the fact that the state applied the quarantine evenhandedly, the

16 policy disproportionately burdened the visually disabled,

17 effectively denying them access to public services such as

18 transportation, parks, and government facilities. Id. Such

19 denials of meaningful access, the court held, constitute

20 discrimination on the basis of disability in violation of the ADA.

21 Id. at 1485.

22

Intervenors here allege discrimination similar to that in

23 Crowder. Certain inmates are released, whether under Paragraph 34

24 or not, in a manner that allows them to access state services,

25 programs, and activities. Intervenors, whose manner of release is

26 allegedly determined by their particular disabilities, are not

27 afforded that same access. See Crowder, 81 F.3d at 1484 (“Hawaii’s

28 quarantine effectively denies . . . the plaintiffs in this case[]

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1 meaningful access to state services . . . while such services . . .

2 remain open and easily accessible by others.”).

3

Defendants argue in a footnote that Crowder is inapt because

4 it involved taking something away from a disabled person. (Reply

5 at 13 n. 3.) That distinction is not persuasive. The Crowder

6 court’s reasoning had nothing to do with the state’s active taking

7 of disabled individuals’ guide dogs. To the contrary, the court’s

8 “meaningful access” approach moved away from an emphasis on

9 intentional acts in an attempt to better capture instances of 10 discriminatory “benign neglect, apathy, and indifference.”5

11 Crowder, 81 F.3d at 1484 (internal quotation marks and citation

12 omitted). The court analogized Hawaii’s quarantine not to any form

13 of active deprivation, but to other facially neutral barriers, such

14 as stairs or a refusal to communicate by spoken word. Id. at 1483-

15 84. To the extent Defendants contend that “meaningful access”

16 cannot, as a matter of law, require Defendants to provide

17 Intervenors with “extra” accommodations, that argument is no more

18 persuasive than asserting that wheelchair-bound people need not be

19 provided “extra” ramps or elevators to access government buildings

20 accessible by staircase. See Crowder, 81 F.3d at 1483-84.

21

Intervenors have adequately alleged that they are denied

22 meaningful access to public services on the basis of their

23

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5 Even if some sort of active intrusion were required, Defendants provide no explanation why the deprivation of

26

Intervenors’ liberty, which denies them the ability to seek out or continue mental health treatment of their choosing, and may

27

disproportionately exacerbate the deleterious effects of certain disabilities, in part as a result of the loss of the ability to

28

access community resources, would not constitute an affirmative deprivation on par with the quarantining of a guide dog.

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1 disabilities. Accordingly, judgment on the pleadings is not

2 warranted.

3

1. Integration Mandate

4

Paragraph 34(b)(iii) provides that certain prisoners with an

5 “intense need for assistance” will be provided a “direct linkage to

6 an Institution for Mental Disease (“IMD”), IMD-Step-down facility,

7 or appropriately licensed hospital.” Intervenors allege that this

8 provision does not adequately define “intense need,” and thus

9 violates the ADA’s integration mandate, which requires public

10 entities to “administer services, programs, and activities in the

11 most integrated setting appropriate to the needs of qualified 12 individuals with disabilities.”6 28 C.F.R. § 35.130(d).

13

In Olmstead v. L.C. ex rel. Zimring, the Supreme Court

14 concluded that the integration mandate requires community-based, as

15 opposed to hospital or institutional, treatment when “[1] the

16 State’s treatment professionals determine that such placement is

17 appropriate, [2] the affected persons do not oppose such treatment,

18 and [3] the placement can be reasonably accommodated, taking into

19 account the resources available to the State and the needs of

20 others with mental disabilities.” Olmstead v. L.C. ex rel.

21 Zimring, 527 U.S. 581, 607 (1999). The Ninth Circuit subsequently

22 addressed an integration mandate claim in Townshend v. Quasim, 328

23 F.3d 511 (9th Cir. 2003). There, although citing to both the

24 integration mandate regulation and Olmstead, the court nevertheless

25 applied the traditional ADA pleading standard. Townshend v.

26

27

6 This mandate is patterned on one set forth in the

28

Rehabilitation Act’s implementing regulations. 41.51(d).

See 28 C.F.R. §

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1 Quasim, 328 F.3d at 516 (“To prove that a public service or program

2 violates Title II of the ADA, a plaintiff must show (1) he is a

3 qualified individual with a disability; (2) he was either excluded

4 from participation in or denied the benefits of a public entity’s

5 services, programs, or activities or was otherwise discriminated

6 against by the public entity; (3) such exclusion, denial of

7 benefits, or discrimination was by reason of his disability.”)

8 (internal quotation and citation omitted).

9

Here, the arguments regarding the integration mandate claims

10 are focused primarily on the parties’ conflicting views of the

11 appropriate pleading standard, and are otherwise not fully

12 developed. At this juncture, Intervenors’ integration mandate

13 claim appears sufficiently pleaded under Townshend. Defendants’

14 motion is therefore denied with respect to the integration mandate

15 claim, without prejudice.

16

B. Constitutional Claims

17

The FACI alleges that Intervenors “have a known and obvious

18 need for medical care after release from custody,” that inadequate

19 discharge planning under Paragraph 34 threatens to deny them that

20 medical care as a matter of policy, and that adoption of Paragraph

21 34 constitutes deliberate indifference to Intervenors’ medical

22 needs in violation of the Eighth and Fourteenth Amendments.

23 Defendants argue that Intervenors’ constitutional claims fail as a

24 matter of law.

25

Defendants, citing to the Supreme Court of Massachusetts,

26 argue that homeless, mentally ill people have no constitutional

27 rights to follow-up medical care after incarceration. (Motion at

28 21, citing Williams v. Sec’y of the Exec. Office of Human Servs.,

16

1 414 Mass. 551, 566 (1993). The court disagrees. In the Ninth

2 Circuit, “the state must provide an outgoing prisoner who is

3 receiving and continues to require medication with a supply

4 sufficient to ensure that he has that medication available during

5 the period of time reasonably necessary to permit him to consult a

6 doctor and obtain a new supply. A state’s failure to . . . cover

7 this transitional period amounts to an abdication of its

8 responsibility to provide medical care to those, who by reason of

9 incarceration, are unable to provide for their own medical needs.”

10 Wakefield, 177 F.3d at 1164. The court sees no reason why this 11 principle should not apply to mental illness.7

12

Next, Defendants contend that Intervenors fail to allege

13 deliberate indifference. Defendants are correct that the FACI

14 inartfully makes reference to the deliberate indifference standard

15 with respect to both the Fourteenth and Eighth Amendment claims. A

16 pre-trial detainee need not show deliberate indifference to prevail

17 on a Fourteenth Amendment claim. See, e.g. Jones v. Blanas, 393

18 F.3d 918, 934 (9th Cir. 2004). In any event, however, the FACI

19 does allege deliberate indifference. Intervenors allege that their

20 disabilities and serious medical needs are apparent and known to

21 Defendants, and that Defendants not only ignore those needs, but do

22 so as an explicit matter of policy, i.e. Paragraph 34.

23

As with the integration mandate claim, the constitutional

24 claims are not the focus of either party’s briefing. As presented

25 thus far, Intervenors’ constitutional claims are adequately

26

27

7 If anything, a public entity may be more responsible for

28

mental health treatment where the incarceration itself has aggravated or exacerbated the harmful symptoms of mental illness.

17

1 alleged. Defendants’ motion is therefore denied with respect to

2 the constitutional claims, without prejudice.

3 IV. Conclusion

4

For the reasons stated above, Defendants’ motion is DENIED.

5

6 IT IS SO ORDERED.

7

8

9 Dated: May 17, 2016 10

DEAN D. PREGERSON United States District Judge

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UNITED STATES DISTRICT COURT

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CENTRAL DISTRICT OF CALIFORNIA

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11 UNITED STATES AMERICA,

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Plaintiff,

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v.

14 COUNTY OF LOS ANGELES et al.,
15 Defendants.
16 ___________________________

) Case No. CV 15-05903 DDP (JEMx) ) ) ORDER DENYING DEFENDANT’S MOTIONS ) FOR (1) REVIEW OF MAGISTRATE ) JUDGE’S ORDER AND (2) ) DISQUALIFICATION ) ) ) [Dkt. Nos. 101, 102] )

17 Presently before the court are two motions filed by Defendant.
18 First, Defendant seeks to disqualify Plaintiff-Intervenors’
19 counsel, Mark Rosenbaum, for alleged violations of rules of
20 professional conduct related to Mr. Rosenbaum’s discussion with Dr.
21 Mitchell Katz, Director of the Los Angeles County Health Agency.
22 Defendant also moves for review of Magistrate Judge McDermott’s
23 Minute Order allowing Plaintiff-Intervenors to depose Dr. Katz.
24 Having considered the submissions of the parties and heard oral
25 argument, the court denies both motions and adopts the following
26 Order.
27 I. Background
28

Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 2 of 12 Page ID #:2444

1

Plaintiff and Defendant entered into a settlement agreement

2 regarding various policies and practices in the Los Angeles County

3 Jail system. Plaintiff-Intervenors (“Intervenors”) allege that a

4 portion of that agreement concerning inmate discharge procedures,

5 Paragraph 34, violates the Americans with Disabilities Act, the

6 Rehabilitation Act, and the constitutional rights of certain

7 disabled, mentally ill inmates.

8

Intervenors’ counsel, Mark Rosenbaum, attended a small social

9 gathering at the home of Dr. Mitchell Katz, the Director of the Los

10 Angeles County Health Agency. (Declaration of Mark Rosenbaum ¶ 3.)

11 Mr. Rosenbaum informed Dr. Katz that he, Mr. Rosenbaum, is an

12 attorney and is involved in a case against the County regarding the

13 County’s jail discharge planning practices. (Id. ¶ 4.) Mr.

14 Rosenbaum stated that Dr. Katz was under no obligation to discuss

15 the matter, and was free to consult an attorney. (Id.) Dr. Katz

16 nevertheless engaged in conversation on the subject and, in

17 response to Mr. Rosenbaum’s description of certain practices,

18 opined as to the propriety of those practices. (Id. ¶ 5.) Dr.

19 Katz stated that he was not aware of or familiar with Paragraph 34,

20 but “felt he could take care of putting into place proper

21 protocols.” (Id. ¶¶ 6, 8, 9.)

22

A few weeks later, Intervenors noticed Dr. Katz’s deposition.

23 Defendant declined to produce him, and Intervenors moved to compel.

24 The Magistrate Judge granted Intervenors’ motion, concluding that

25 Mr. Rosenbaum did not engage in any unethical behavior and that, in

26 light of Dr. Katz’s conversation with Mr. Rosenbaum, the “apex

27 doctrine” is not applicable to a deposition of Dr. Katz regarding

28 Defendant’s mental health-related discharge practices. Defendant

2

Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 3 of 12 Page ID #:2445

1 now moves for review of the Magistrate Judge’s decision allowing

2 the deposition, and moves separately to disqualify Mr. Rosenbaum

3 for an alleged violation of California Rule of Professional Conduct

4 2-100.

5 II. Legal Standard

6

This court reviews non-dispositive discovery orders under a

7 clearly erroneous or contrary to law standard. Rivera v. NIBCO,

8 Inc., 364 F.3d 1057, 1063 (9th Cir. 2004); Fed. R. Civ. P. 72.

9 “The ‘clearly erroneous’ standard applies to factual determinations

10 and discretionary decisions.” McAdam v. State Nat. Ins. Co., 15 F.

11 Supp. 3d 1009, 1013 (S.D. Cal. 2014). “[L]egal conclusions are

12 reviewed de novo to determine whether they are contrary to law.”

13 Perry v. Schwarzenegger, 268 F.R.D. 344, 348 (N.D. Cal. 2010).

14 “When the court reviews the magistrate’s determination of relevance

15 in a discovery order . . . the standard of review in most instances

16 is . . . abuse of discretion. The court should not disturb the

17 magistrate’s relevance determination except where it is based on an

18 erroneous conclusion of law or where the record contains no

19 evidence on which [the magistrate] rationally could have based that

20 decision.” Perry v. Schwarzenegger, 268 F.R.D. 344, 348 (N.D. Cal.

21 2010) (citations omitted). Discovery motions regarding depositions

22 are subject to the clearly erroneous or contrary to law standard.

23 Rockwell Int’l, Inc. v. Pos-A-Traction Indus., Inc. 712 F.2d 1324,

24 1325 (9th Cir. 1983) (per curiam).

25

In the Ninth Circuit, courts “apply state law in determining

26 matters of disqualification.” In re Cnty. of Los Angeles, 223 F.3d

27 990, 995 (9th Cir. 2000). This district has adopted “the standards

28 of professional conduct required of members of the State Bar of

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 4 of 12 Page ID #:2446

1 California and contained in the State Bar Act, the Rules of

2 Professional Conduct of the State Bar of California, and the

3 decisions of any court applicable thereto.” C.D. Cal. L.R. 83-

4 3.1.2. This Court must also bear in mind that its “authority to

5 disqualify an attorney or craft appropriate relief to punish or

6 deter attorney misconduct derives from the court’s equitable

7 powers,” and that, therefore, equitable considerations such as

8 waiver, unclean hands, and estoppel apply. UMG Recordings, Inc. v.

9 MySpace, Inc., 526 F. Supp. 2d 1046, 1062 (C.D. Cal. 2007).

10 III. Discussion

11

A. Motion to Disqualify

12

Defendant contends that, by discussing discharge practices

13 with Dr. Katz, Mr. Rosenbaum violated California Rule of

14 Professional Conduct 2-100, and should therefore be disqualified

15 from this matter. Rule 2-100 provides that :

16

(A) While representing a client, a member shall not

17

communicate directly or indirectly about the subject of the

representation with a party the member knows to be

18

represented by another lawyer in the matter, unless the

member has the consent of the other lawyer.

19

. . .

20

(C) This rule shall not prohibit:

21

(1) Communications with a public officer, board,

committee, or body; or

22

(2) Communications initiated by a party seeking advice

or representation from an independent lawyer of the party's

23

choice; or

(3) Communications otherwise authorized by law.

24

25 (emphasis added). The question this Court must resolve is whether

26 Rule 2-100(C)(1)’s public officer exception applies to Mr.

27 Rosenbaum’s conversation with Dr. Katz, Director of the county

28 health agency.

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 5 of 12 Page ID #:2447

1

In 1977, the California State Bar Standing Committee on

2 Professional Responsibility and Conduct (“the Committee”) issued a

3 Formal Opinion analogous to the facts here. CA Eth. Op. 1977-43,

4 1977 WL 15961. Addressing a rule essentially identical to that at

5 issue here, the Committee opined that it would be acceptable for an

6 attorney bringing suit against a city to meet with a city council

7 member or city manager, even in private, to discuss the action.

8 1977 WL 15961 at *1-2 (“Public officers are vested with authority

9 to exercise some sovereign power. To the extent they have that

10 authority, they remain public officers off the job. For that

11 reason, it makes no difference whether the attorney approaches the

12 official publicly or privately. The subject of conversation (here,

13 apparently, an attempt to influence the response to an action

14 against the city) determines the capacity in which the individual

15 acts. In either case, the restraints of rule 7-103 of the Rules of

16 Professional Conduct do not apply.”) (parenthetical in original).

17

Thus, pursuant to the Committee’s formal opinion, Mr.

18 Rosenbaum’s discussion was proper. Defendant asserts, however,

19 that the public officer exception is narrower than stated by the

20 Committee, pointing instead to a discovery order in United States

21 v. Sierra Pacific Industries, 759 F.Supp.2d 1206 (E.D. Cal. 2010)

22 (“Sierra Pacific”) (reconsideration denied by United States v.

23 Sierra Pacific Indus., 759 F.Supp.2d 1215 (E.D. Cal. 2011). In

24 Sierra Pacific, the defendant’s attorney attended a public tour

25 sponsored by the Forest Service. Sierra Pacific, 759 F.Supp.2d at

26 1208. While on the tour, the attorney questioned Forest Service

27 employees about facts relevant to a pending case. Id. The

28

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 6 of 12 Page ID #:2448

1 attorney never disclosed his status as opposing counsel, even when

2 asked whether he was representing anyone. Id.

3

In analyzing whether the attorney’s conduct fell within the

4 public officer exception to Rule 2-100, the Sierra Pacific court

5 relied heavily upon a proposed, but never adopted, state bar

6 opinion regarding “line police officers.” Id. at 1210. Under the

7 proposed opinion, the public officer exception would apply to

8 communications with “a person whom a communication would be

9 constitutionally protected by the First Amendment right to petition

10 the government. Such a person would be one who, for example, has

11 the authority to address, clarify or alter governmental policy; to

12 correct a particular grievance; or to address or grant an exemption

13 from regulation.” Id. at 1209 (quoting Proposed Formal Opinion

14 Interim No. 98-0002 (internal quotation marks omitted)). Because

15 the Forest Service employees were not “policy-making official[s] or

16 persons with authority to change a policy or grant some specific

17 request for redress,” the Sierra Pacific court concluded that the

18 public officer exception did not apply, and that the attorney

19 therefore violated Rule 2-100. Id. at 1213-14; See also Guthrey v.

20 California Dep’t of Corrections and Rehabilitation, No. 10-cv-

21 02177-AWI-BAM, 2012 WL 3249554 at *4-5 (E.D. Cal. Aug. 7, 2012)

22 (adopting Sierra Pacific’s reasoning and concluding that

23 correctional employees are not public officers for Rule 2-100

24 purposes).

25

Defendant here argues that Mr. Rosenbaum’s discussion with Dr.

26 Katz is analogous to Sierra Pacific and falls outside the public

27 officer exception because (1) Katz does not have the authority to

28 alter Paragraph 34, and therefore does not qualify as a “public

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 7 of 12 Page ID #:2449

1 officer” and (2) Rosenbaum was not “exercising his or his clients’

2 First Amendment rights.” (Motion to Disqualify at 8.) These

3 arguments are not persuasive. As an initial matter, this Court is

4 not bound by Sierra Pacific’s interpretation of the public officer

5 exception. Although the Sierra Pacific court cited to American Bar

6 Association rules and the state bar’s proposed interim order, the

7 court made no mention of the 1977 Formal Opinion and its broad

8 reading of the exception.

9

In any event, even under Sierra Pacific’s narrower, First

10 Amendment-focused framework, Mr. Rosenbaum’s conduct is within the

11 public officer exception. First, there is no dispute that Mr.

12 Rosenbaum disclosed that he is an attorney and represents a party

13 adverse to Defendant in an active case. The attorney in Sierra

14 Pacific, in contrast, affirmatively concealed his role. Second,

15 Defendant’s contention that Dr. Katz does not have the requisite

16 authority to qualify as a “public officer” is incorrect. Although

17 Dr. Katz cannot unilaterally change Paragraph 34, Defendant appears

18 to have conceded, as it must, that policymaking power extends well

19 beyond the Board of Supervisors, and that, as the Director of the

20 Los Angeles County Health Agency, Dr. Katz has extensive “authority

21 to address, clarify or alter governmental policy [and] to correct a

22 particular grievance.” Sierra Pacific, 759 F.Supp.2d at 1209. See

23 Declaration of Dr. Mitchell Katz in Support of Motion to Disqualify

24 ¶ 1 (“The Health Agency is comprised of the Department of Health

25 Services (“DHS”), the Department of Mental Health (“DMH”), and the

26 Department of Public Health (“DPH”) . . . . As head of the Health

27 Agency, my duties include planning, organizing and directing the

28 activities of the Agency.”).

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 8 of 12 Page ID #:2450

1

Furthermore, Defendant’s assertion that Mr. Rosenbaum was

2 gathering evidence for litigation purposes, and therefore could not

3 have been exercising a First Amendment right, presents a false

4 dichotomy. As suggested in Sierra Pacific and Guthrey, whether a

5 public employee qualifies as a “public official” under Rule 2-100

6 depends upon that employee’s particular duties. Those duties fall

7 somewhere along a continuum of roles, ranging from line officers

8 and ministerial workers at one end and legislators, senior

9 executives, and other individuals who have meaningful input into

10 matters of policy and public concern closer to the other.

11 Although the conversation between Mr. Rosenbaum and Dr. Katz may

12 have been relevant to this particular case, that is of secondary

13 importance. The public’s fundamental right to discuss any matter

14 with a senior government official is paramount. Mr. Rosenbaum’s

15 conduct falls within the public officer exception of Rule 2-

16 100(C)(1), and was entirely ethical. Accordingly, Defendant’s

17 Motion to Disqualify is DENIED.

18

B. Motion for Review of Order Granting Motion to Compel

19

Defendant refused to produce Dr. Katz for deposition under the

20 “apex doctrine.” In light of the conversation between Dr. Katz and

21 Mr. Rosenbaum, the Magistrate Judge found the apex doctrine

22 inapplicable, and allowed Intervenors to conduct a limited

23 deposition of Dr. Katz. Defendant now seeks review of the

24 Magistrate Judge’s decision.

25

Under the apex doctrine, “[h]eads of government agencies are

26 not normally subject to deposition.” Kyle Engineering Co. v.

27 Kleppe, 600 F.2d 226, 231 (9th Cir. 1979). “[T]he settled rule

28 across the circuits is that absent extraordinary circumstances,

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 9 of 12 Page ID #:2451

1 high-ranking officials may not be subjected to depositions or

2 called to testify regarding their official actions.” Coleman v.

3 Schwarzenegger, No. CIV W-90-0520 LKK JFM P, 2008 WL 4300437 at *2

4 (E.D. Cal. Sept. 15, 2008). When a party seeks to depose “a

5 high-level executive (a so-called ‘apex’ deposition),” the court

6 can limit the discovery after considering “(1) whether the deponent

7 has unique firsthand, non-repetitive knowledge of the facts at

8 issue in the case and (2) whether the party seeking the deposition

9 has exhausted other less intrusive discovery methods.” In re

10 Google Litigation, No. C 08-03172 RMW(PSG), 2011 WL 4985279 at *2

11 (N.D. Cal. Oct. 19, 2011). “A party seeking to prevent a

12 deposition carries a heavy burden to show why discovery should be

13 denied . . . .” Celerity, Inc. v. Ultra Clean Holding, Inc., No. C

14 05-4374 MMC(JL), 2007 WL 205067 at *4 n.3 (N.D. Cal. Jan. 25,

15 2007); See also Blankenship v. Hearst Corp., 519 F.2d 418, 429 (9th

16 Cir. 1975).

17

Much of Defendant’s argument is premised on the assumption

18 that the conversation between Dr. Katz and Mr. Rosenbaum violated

19 California Rule of Professional Conduct 2-100, and therefore cannot

20 serve as the basis for granting Intervenors’ Motion to Compel. As

21 discussed above, Mr. Rosenbaum’s conduct was not unethical, and the

22 Magistrate Judge did not err in so concluding.

23

Defendant also argues that the Magistrate Judge erred in

24 finding that Dr. Katz opined about Paragraph 34 because Rosenbaum

25 himself acknowledged that Dr. Katz stated that he had never heard

26 of Paragraph 34, let alone seen its contents. (Reply at 2;

27 Rosenbaum Decl. ¶ 7.) This argument is not persuasive. First,

28 Rosenbaum stated that he described “some of the practices that we

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 10 of 12 Page ID #:2452

1 had documented in our investigation,” and that Dr. Katz opined on

2 those practices. (Rosenbaum Decl. ¶ 5.) The practices Intervenors

3 are investigating, of course, are related to Paragraph 34.

4 Furthermore, although Dr. Katz has stated that “[n]o portion of

5 [the] discussion with Mr. Rosenbaum concerned current jail

6 discharge planning policies pursuant to Paragraph 34” (Supplemental

7 Declaration of Dr. Mitchell Katz ¶ 2), he also declared that “Mr.

8 Rosenbaum spoke to me about this lawsuit, . . . Paragraph 34 of the

9 Settlement Agreement in particular, jail discharge planning

10 policies, and jail discharge practices . . . .” (Katz Decl. ¶ 2.)

11 Notably, and contrary to Defendant’s characterization, the

12 Magistrate Judge did not conclude that Dr. Katz opined about

13 Paragraph 34 in particular. Rather, the Magistrate Judge stated

14 that Dr. Katz opined about “certain discharge planning practices as

15 described to him by Mr. Rosenbaum [,] . . . chose to discuss the

16 discharge planning practices at issue in this suit[, and] . . .

17 purportedly expressed an opinion that may be inconsistent with the

18 County’s position on Paragraph 34.” (Dkt. 99 at 2.) Those

19 conclusions are well-supported by the record.

20

Defendant’s final, and chief, contention is that the

21 Magistrate Judge erred in his analysis of the apex doctrine and

22 application of the relevant factors. This Court, however,

23 concludes that the Magistrate Judge did not err in finding the apex

24 doctrine inapplicable because Dr. Katz effectively waived any apex

25 doctrine objection.

26

Dr. Katz, as Director of the Los Angeles County Health Agency,

27 is a sophisticated, senior public official with significant

28 responsibilities, decision-making power, and policy-making

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Case 2:15-cv-05903-DDP-JEM Document 120 Filed 07/27/16 Page 11 of 12 Page ID #:2453

1 influence. There is no dispute that Mr. Rosenbaum, who had never

2 met Dr. Katz before, disclosed his own role as an attorney adverse

3 to Defendant in an active case regarding mental health policies and

4 jail discharge practices. Dr. Katz does not dispute that he was

5 aware that he was free to consult with counsel if he so wished, and

6 was under no obligation to discuss this matter of public import

7 with Mr. Rosenbaum at all. Dr. Katz does not dispute that he

8 represented himself as being capable of “putting into place proper

9 protocols” and interested in doing so. (Rosenbaum Dec. ¶ 8.)

10 Defendant now argues that it would be unduly disruptive to allow

11 the deposition of a policymaker, even where that official has

12 knowingly and voluntarily undertaken to discuss matters of public

13 significance with an attorney known to be adverse to the County.

14

The primary purpose of the apex doctrine is not to gain a

15 litigation advantage or to insulate officials from providing

16 evidence in cases, but rather to “protect [] officials from

17 discovery that will burden the performance of their duties,

18 particularly given the frequency with which such officials are

19 likely to be named in lawsuits.” Coleman, 2008 WL 4300437 at *2.

20 Under the circumstances here, application of the doctrine would in

21 no way serve that goal. To the extent that questioning about Dr.

22 Katz’s opinions about jail discharge policies can be considered a

23 burden, it is one that he has already volunteered to bear.

24 Furthermore, rather than regard Dr. Katz’s decision as a mistake,

25 this Court views his willingness to receive input and discuss

26 matters of public concern as entirely admirable and consistent with

27 his responsibilities as a senior government official.

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1

The Magistrate Judge’s conclusion that the apex doctrine does

2 not bar Dr. Katz’s deposition was not erroneous. Defendant’s

3 Motion for Review is, therefore, DENIED.

4

IV. Conclusion

5

For the reasons stated above, Defendant’s Motion to Disqualify

6 and Motion for Review are DENIED. In light of the waiver of the

7 apex doctrine objection, this Court declines to adopt the portion

8 of the Magistrate Judge’s decision limiting the scope and duration

9 of the deposition. The court expects, however, that the parties

10 will work collaboratively to ensure that the deposition is as brief

11 and efficient as possible.

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16 IT IS SO ORDERED.

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19 Dated: July 27, 2016 20

DEAN D. PREGERSON United States District Judge

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 Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 1 of 87 Page ID #:1791

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) 601 West Fifth Street, 12th Floor

3 Los Angeles, CA 90071-2025

4

Telephone: (213) 613-4655 Facsimile: (213) 613-4656

5 Email: rdrooyan@scheperkim.com

6 Monitor 7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

WESTERN DIVISION

11

12 UNITED STATES OF AMERICA,

13

Plaintiff,

14

15

v.

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR’S FIRST REPORT

16 COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF
17 JIM MCDONNELL, in his Official Capacity,
18 Defendants.
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MONITOR'S FIRST REPORT

CASE NO. 15-cv-05903 DDP (JEMx)

Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 2 of 87 Page ID #:1792

1

Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and the

4 Los Angeles County Sheriff during the six-month period from July 1, 2015, to

5 December 31, 2015, “to implement the Agreement and evaluating the extent to

6 which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

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13 DATED: March 1, 2016

Respectfully submitted,

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SCHEPER KIM & HARRIS LLP

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RICHARD E. DROOYAN

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By: /s/ Richard E. Drooyan Richard E. Drooyan

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Monitor

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- 1 -

CASE NO. 15-cv-05903 DDP (JEMx)

MONITOR’S FIRST REPORT

Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 3 of 87 Page ID #:1793
MONITOR’S REPORT
The Settlement Agreement (the "Agreement") between the County of Los Angeles (the “County”) and the United States Department of Justice (“DOJ”) requires the Monitor, with the advice of the Subject Matter Experts, “to assess and report on the implementation of the Agreement by the Los Angeles Sheriff’s Department (the “Department”) and Los Angeles County’s Department of Mental Health (“DMH”), and whether the implementation is having the intended beneficial impact on conditions at the [County] Jails.” This Report sets forth the status, and assesses, the implementation of each of the Substantive Provisions in Section V of the Agreement by Department and/or DMH as measured by the agreed-upon Compliance Measures for assessing Substantial Compliance during the initial reporting period from the Effective Date of July 1, 2015, through December 31, 2015 (the “Initial Reporting Period”).
As used herein, “Substantial Compliance” means that the County has achieved Substantial Compliance as that term is used in the Agreement, which it must maintain for twelve-consecutive months; and “Partial Compliance” means that the County has made significant progress towards meeting the requirements of the Compliance Measures. In some cases, this Report summarizes what the County needs to do to achieve Substantial Compliance; these summaries do not, however, set forth all of the specific requirements or the percentages that the County must meet, which are governed by terms of the agreedupon Compliance Measures.
The Agreement sets forth implementation dates for specific provisions (e.g., Paragraph 48 requires “written housekeeping, sanitation, and inspection plans” within three months of the Effective Date). Paragraph 115 further provides that “[u]nless otherwise agreed to under a specific provision of this Agreement, the County and Sheriff will implement all provisions of this Agreement within six months of the Effective Date.” The County and DOJ have advised the Monitor that provisions subject to this "default" implementation date were not subject to monitoring during the Initial Reporting Period, unless specifically implemented by the County. This Report uses the term “Not Currently Subject to Monitoring” for those provisions that are subject to the default provision and were not implemented by the County during the Initial Reporting Period.
This Report is based upon a review of the policies, procedures and directives proposed and/or implemented by the Department and DMH, the assessments of the Subject Matter Experts, multiple tours of the jails by the Monitor and the Subject Matter Experts, and the Department’s Self-Assessment Status Report (the “Self-Assessment”), which was received timely on December 14, 2015. It also takes into consideration additional results for the Initial Reporting Period reported to the Monitor by the County through February 26, 2016, along with comments received from the parties in accordance with Paragraph 110 of the Agreement.
Beginning in September 2015, the Department and DMH submitted proposed revisions of various policies to the Monitor and DOJ for review and comments pursuant to Paragraph 89 of the Agreement. The Monitor and the DOJ provided comments
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 4 of 87 Page ID #:1794
regarding the proposed revisions of these policies. In most cases, the proposed revisions had not been finalized by the Department or DMH as of December 14, 2015, and the Department and DMH have continued to submit revised policies since that date, which the Monitor has taken into consideration in determining whether the County is in Substantial Compliance with the terms of the Agreement. Where the Monitor has deemed the County to be in Substantial Compliance as a result of required revised policies that were issued after the Initial Reporting Period, the Monitor will use the date of this Report for purposes of determining the twelve-month period of Substantial Compliance that the County must maintain under Paragraph 111 of the Agreement.
Many of the Compliance Measures require the County to report, either quarterly or semi-annually, the results of reviews of randomly selected Department and DMH records. Those results (and any conclusions regarding the County's compliance based on those results) are subject verification by the Monitor though inspections or audits by the Monitor’s auditors during the next reporting period and cannot be considered final until verified. If the results of particular provisions are not verified by the Monitor, the County will not deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the twelve-month compliance period for those provisions under Paragraph 111.
Attached to this Report is an Appendix showing the status of each of the 69 provisions of the Agreement that are subject to monitoring and reporting by the Monitor under the Agreement and the triggering dates under Paragraph 111 for those provisions where the County is deemed to be in Substantial Compliance.
Richard Drooyan, Monitor March 1, 2016
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 5 of 87 Page ID #:1795
EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the Department is in Substantial Compliance with five of the provisions and in Partial Compliance with 16 provisions. There are an additional 43 provisions that were Not Currently Subject to Monitoring during the Initial Reporting Period. In addition, there are five provisions in which some facilities are in Substantial Compliance and others are either in Partial Compliance or Not Currently Subject to Monitoring. Under Paragraph 11 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis.
As of the date of this Report and subject to verification by the Monitor and continuing monitoring, the Department is in Substantial Compliance with the following provisions of the Settlement Agreement:
The Department has provided documentation reflecting that it is in Substantial Compliance with Paragraph 21, which requires active certifications in cardiopulmonary resuscitation and first aid, at the North County Correctional Facility (“NCCF”) and the North, South, and East facilities in the Pitchess Detention Center. The underlying records upon which the results reported by the Department are based will be subject to verification by the Monitor through an audit by the Monitor’s auditors.
The Department has provided documentation reflecting that it is in Substantial Compliance with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules. The Department’s results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
The Department is in Substantial Compliance with Paragraph 44, which requires the installation of protective barriers in High Observation Housing (“HOH”) and the development of a plan for the installation of such barriers in Moderate Observation Housing (“MOH”). As of the date of this Report, the Department has installed the protective barriers in all HOH units and all MOH units except one, which it anticipates it will install on or about March 1, 2016. The Monitor and Subject Matter Experts have toured these housing units and verified the installation of the barriers.
The Department has provided documentation showing that is in Substantial Compliance with Paragraph 45, which requires Suicide Intervention Kits and First Aid Kits in control booths and officer stations, at all facilities, except Men’s Central Jail (“MCJ”), for which it is in Partial Compliance. The Monitor and Subject Matter Experts have toured all of the facilities and verified, on random basis, that control booths and officer stations have the required kits. The Department’s results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 6 of 87 Page ID #:1796
The Department is in Substantial Compliance with Paragraphs 48 and 49, which require it to have written housekeeping, sanitation, and inspection plans and maintenance plans to respond to routine and emergency maintenance needs. The Monitor and Subject Matter Experts inspected each of the facilities during the Initial Reporting Period, and reviewed Unit Orders, Local Detention Health Reports and Corrective Actions Plans for each facility.
The Department is in Substantial Compliance with Paragraph 51, which requires it to ensure that all prisoners have access to basic housekeeping supplies. The Department has provided the Monitor with a photograph of an Admission Kit and a copy of the form allowing prisoners to order Admission Kits. The Department has reported that it has inspected each facility and confirmed that the kits are readily available and that contract vendors have consistently provided the kits in response to prisoners orders. This report is subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
The Department has provided documentation reflecting that it is in Substantial Compliance with Paragraph 55, which requires daily and weekly custody, medical, and mental health staff meetings in HOH and MOH units, at Century Regional Detention Facility (“CRDF”), but not at the Twin Towers Correctional Facility (“TTCF”). The Department reports that it achieved Partial Compliance at TTCF. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
The Department has provided documentation reflecting that it is in Substantial Compliance with Paragraph 59, which requires unannounced daily rounds by custodial supervisors, at the South facility only. The other facilities are not currently subject to monitoring. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
The Department is in Substantial Compliance with Paragraph 83, which requires the installation of closed circuit cameras in Common Areas, at MCJ, TTCF, and the Inmate Reception Center (“IRC”). The other facilities were not subject to monitoring during the Initial Reporting Period. The Monitor and Subject Matter Experts toured MCJ, TTCF, and IRC and confirmed that the cameras have been installed and are operational in the Common Areas. The Department has provided documentation pertaining to the installation of the cameras, which will be audited by the Monitor’s auditors, and an inventory of force incidents and video recordings, which the Monitor will review to verify that force incidents in the Common Areas are being recorded.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 7 of 87 Page ID #:1797
18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016.
These trainings will include the following topics: (a) suicide prevention policies and procedures, including observation and
supervision of prisoners at risk for suicide or self-injurious behavior; (b) discussion of facility environments and staff interactions and why they
may contribute to suicidal behavior; (c) potential predisposing factors to suicide; (d) high-risk suicide periods and settings; (e) warning signs and symptoms of suicidal behavior; (f) case studies of recent suicides and serious suicide attempts; (g) emergency notification procedures; (h) mock demonstrations regarding the proper response to a suicide attempt,
including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance; (i) differentiating between suicidal and self-injurious behavior; and (j) the proper use of emergency equipment.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 8 of 87 Page ID #:1798

STATUS (18):

PARTIAL COMPLIANCE

The Monitor, in consultation with the Mental Health Subject Matter Expert, has concluded that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015.

The County's Self-Assessment Status Report (the "Self-Assessment") delivered on December 14, 2015, reports that the Department commenced its suicide prevention training on July 1, 2015 for new Deputy Sheriffs and Custody Assistants and before July 1, 2015 for existing Deputy Sheriffs and Custody Assistants, and that this provision is "[r]eady for monitoring as of October 1, 2015.” Substantial Compliance with respect to new deputies and Custody Assistants in Custody Operations will require that new personnel receive the required training for 12 consecutive months. The Monitor has not received the Department's training records for new deputies and Custody Assistants to determine whether the Department achieved (and since maintained) Substantial Compliance as of October 1, 2015, which is the date that the Department reports this provision was "[r]eady for monitoring."

Substantial Compliance with respect to existing deputies and Custody Assistants in Custody Operations as of July 1, 2015 will be determined when the percentage of those members still in Custody Operations who have received the training reaches 85% on or before the Completion Date of December 31, 2016. At that time the Monitor will need the Department's training records to confirm that the Department is in Substantial Compliance.

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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 9 of 87 Page ID #:1799
19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams (“JMET”) at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 10 of 87 Page ID #:1800

STATUS (19):

PARTIAL COMPLIANCE

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and paragraphs 4.6, 4.7 and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert has reviewed and approved the training materials developed by the Department for the DeVRT, which materials are still being reviewed by the Rosas Monitors.

The Department Self-Assessment reports that new Deputies and Custody Assistants have attended DeVRT classes beginning on August 3, 2015, and some existing Deputies and Custody Assistants have attended the classes beginning on August 24, 2015. Although the classes covered much of the curriculum that was subsequently approved as of November 4, 2015, these Department members will need to attend some additional training in order to satisfy the requirements of this Substantive Provision. Substantial Compliance with respect to new deputies and Custody Assistants in Custody Operations will require that the new personnel receive the required training for 12 consecutive months.1 The Monitor has not received the Department's training records for new deputies and Custody Assistants to determine whether the Department achieved (and since maintained) Substantial Compliance as of October 1, 2015, which is the date that the Department reports this provision was "[r]eady for monitoring."

Substantial Compliance with respect to existing deputies and Custody Assistants in Custody Operations as of July 1, 2015 will be determined when the percentage of those members still in Custody Operations reaches 85% on or before the Completion Date of December 31, 2016. At that time the Monitor will need the Department's training records to confirm that the Department is in Substantial Compliance.

1 The Monitor acknowledges the Department’s concerns regarding the “enormous cost of retraining [] a large number of staff,” but the Rosas Monitors concluded that the Department’s DeVRT training prior to November 4, 2015 did not meet all of the requirements of 4.6 and 4.9 of the Implementation Plan in Rosas. The Monitor believes that there are a limited number of essential topics that need to be covered, and it may be possible for the Department to provide the additional training in connection with the eight-hour refresher course.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 11 of 87 Page ID #:1801

20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

NOT CURRENTLY SUBJECT TO MONITORING

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the DeVRT curriculum for the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), which provides for 32 hours of Crisis Intervention and Conflict Resolution that meets the requirements of Paragraph 20 of the Settlement Agreement. This training of Deputies assigned to the North County Correctional Facility (“NCCF”), the Pitchess Detention Center (“PDC”), and the nonMental Health Housing Units in Century Regional Detention Facility (“CRDF”) is not required before July 1, 2017.

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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.

STATUS:

SUBSTANTIAL COMPLIANCE (NCCF AND PDC ONLY)2 NOT CURRENTLY SUBJECT TO MONITORING (REMAINING FACILITIES)

The Compliance Measures provide that “[t]he Department will provide semiannual Self Assessment reports to the Monitor and Subject Matter Experts regarding the active certification of custody staff in cardiopulmonary resuscitation and first aid. The Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required certification for 12 consecutive months.”

The Self-Assessment indicates that the Department was “[r]eady for monitoring at PDC North, PDC South, and PDC East facilities as of July 1, 2015” and “at NCCF as of October 1, 2015.” The Department has provided documents reflecting that it is in Substantial Compliance at NCCF as of October 1, 2015 and at the three other facilities as of July 1, 2015. It has not provided any documents for Men’s Central Jail (“MCJ”), Twin Towers Correctional Facility (“TTCF”), Inmate Reception Center (“IRC”), or CRDF. The underlying records upon which the results documented by the Department are based will be subject to verification by the Monitor through audits by the Monitor's auditors.

2 Compliance with this provision will be assessed on a facility-by-facility basis under Paragraph 111 of the Settlement Agreement. Subject to verification by the Monitor, the periods for determining whether the Department has “achieved and maintained” Substantial Compliance will begin on the “as of” dates upon which the Department reports that it achieved Substantial Compliance for each facility.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 14 of 87 Page ID #:1804
22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: PARTIAL COMPLIANCE
The Proposed Revision of Volume 6 of the Department’s Station Jail Manual provides an overview for “the use of arresting and booking documents, including instructions to Department personnel and outside law enforcement agencies on the use of the Arrestee Medical Screening Form." It also requires a Behavioral Observation and Mental Health Referral (“BOMHR”) form to be completed for inmates with symptoms of mental illness or who exhibit self-injurious behavior, but it does not provide any instructional material on filling out the form "to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.”
Substantial Compliance requires the Monitor, after consultations with the Subject Matter Experts, to “approve the required instructional material,” and the Department to provide on a quarterly basis the Justice Data Interface Controller (“JDIC”) instructional message reflecting the approved instructional material. The Monitor, after consulting the Subject Matter Experts, believes that the policies and procedures reflected in the Manual are not sufficient to provide the necessary instructional materials to the various personnel responsible for arresting and booking inmates.
The Monitor also believes that the JDIC messages that the Department provided to the Monitor for IRC did not provide sufficient information on the “use of arresting and booking documents,” including what information is required in the Arrestee Medical Screening Form and the use of the “BOMHR form or the Electronic Special Handling system for inmates who are at risk for suicide or have a history of mental illness,” who have symptoms of mental illness, or who exhibit self-injurious behavior. The Department has advised the Monitor that it “has augmented the JDIC message” and “will submit a revised version to the Monitor[.]”
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 15 of 87 Page ID #:1805
23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: PARTIAL COMPLIANCE The Monitor has verified with the Subject Matter Expert that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department has provided a status report showing which housing units have been inspected at each facility and completed checklists for the inspections. It has also submitted proposed short and long term mitigation plans for CRDF. The proposed plans for this facility are set forth in a spreadsheet that lists what needs to be done to reasonably mitigate suicide hazards, but it does not include timelines for starting and completing the work, or who is responsible for the work (e.g., outside vendor or the Department’s internal facilities services). As expressed by one of the Subject Matter Experts, “this is not a plan but a list of what needs to be done, albeit a reasonable list.”
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 16 of 87 Page ID #:1806 24. The County and the Sheriff will review and inspect housing areas on at
least an annual basis to identify suicide hazards. STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revision of CDM 3-06/020.00 FACILITIES INSPECTIONS
provides that each “facility shall conduct an annual inspection of all inmate housing areas identifying potential suicide hazards.” Monitoring will commence in the next Reporting Period after the Department issues a revised policy reflecting the Monitor’s comments.
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revision of Volume 6 of the Station Jail Manual requires that any arrestee who “displays obvious suicidal ideation or exhibits unusual behavior that clearly manifests self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, Suicidal inmates. . .shall be under unobstructed visual observation or in a suicidal restraint location with 15 minute safety checks.” A similar provision in the Proposed Revision to CDM 503/030.00 PRE-SCREENING also provides that an inmate who "verbalizes or exhibits self-injurious behavior or suicidal intent shall be under unobstructed visual observation, or in a suicide resistant location with safety checks conducted every 15 minutes.” None of these provisions, however, provide guidance on which form of monitoring (unobstructed visual observation or a suicide resistant location) should be used under what circumstances. The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent for analysis to determine compliance with Paragraph 25 of the Agreement. Monitoring will commence in the next Reporting Period after the Department issues the revised Manual and policy, and the results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING
The Proposed Revision of Volume 6 of the Station Jail Manual requires the arresting deputy/officer to complete the Arrestee Medical Screening Form (SH-R-422) “for every person who is arrested by Sheriff’s Department personnel or booked into a Sheriff’s Department station/facility by an outside law enforcement agency.” It provides that “[a]n affirmative answer to any question on the SH-R-422 form shall be brought to the attention of the watch sergeant who must sign the form in the indicated space.”
The Proposed Revision of Medical Service Bureau (“MSB”) 201.01 RECEPTION CENTERS HEALTH SCREENING provides that prisoners “with urgent or emergent medical/mental health needs will be expedited to mental health for an evaluation,” and it requires the Registered Nurse to determine whether inmates with mental health conditions need to be expedited to the clinic for treatment and to review and expedite to the clinic those inmates who report suicidal thoughts.
Section 2.2 of the Proposed Revision of DMH 20.2 RECEPTION CENTER INITIAL ASSESSMENT provides that inmates “who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a clinician as soon as possible but no later than 4 hours from the time of identification.” Similar provisions are reflected in Section 4.1.1.2 of the Proposed Revised DMH 70.7 SUICIDE PREVENTION.
Taken together, the policies and procedures reflected in these proposed revisions address the requirements of Paragraph 26 of the Agreement. Substantial Compliance under the Compliance Measures requires the Department to “review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC to confirm that Department personnel are completing the form with the required mental health information.” Monitoring will commence in the next Reporting Period after the proposed revised policies have been issued and the County begins to report the results of its random reviews, which will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING
The Proposed Revision of MSB 201.01 provides that “[e]ach newly booked inmate into the Los Angeles County jail shall receive a medical/mental health screening prior to housing” and that prisoners “with urgent or emergent medical/mental health needs will be expedited to mental health for an evaluation.” This needs to be revised since prisoners with “urgent or emergent medical needs” should not be sent to “mental health for an evaluation.”
The revision also provides that “[e]ach inmate at the entry into booking front will be asked questions listed on the Medical/Mental Health Screening Questionnaire by trained custody or medical personnel” and that the Medical/Mental Health transfer summary or Arrestee Medical Screening form are supposed to “be reviewed during the intake screening.” A nurse is also supposed to “[p]rovide a hard copy of the arrestee screening form or transfer summary to the mental health clinician if the records have not been scanned into the patient’s medical record.” The policy does not, however, specifically require that the initial screening be competed within 12 hours of an inmate's arrival. The Department has advised the Monitor that it will re-publish the policy to address these remaining issues.
The Compliance Measures require the Department to review the records of "randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC” to determine compliance with this provision. Monitoring will commence in the next Reporting Period after the Bureau issues this proposed revised policy reflecting the Monitor’s comments, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 20 of 87 Page ID #:1810
28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revision of Volume 6 of the Department’s Station Jail Manual requires any “arrestee who displays obvious suicidal ideation or exhibits unusual behavior that clearly manifest self-injurious behavior or other clear indication of mental health crisis” to be “transported” as soon as practical to IRC, CRDF or a medical facility, but it does not specifically provide for expedited “booking.” Similarly, the Proposed Revision of CDM 5-03/030 PRE-SCREENING does not provide for expedited booking for such arrestees, but it does require the Department to maintain “unobstructed visual observation of the prisoner when necessary to protect his or her safety,” and to “conduct 15-minute safety checks if the prisoner is in a cell.” The Department has advised the Monitor that it will re-publish the policy to address these remaining issues. The Compliance Measures require the Department to review for one randomly selected week each quarter the records of randomly selected prisoners at CRDF and at IRC who have been identified as having urgent or emergent mental health needs to determine whether they were expedited through the booking process. The Department is also supposed to conduct quarterly unannounced visits to CRDF and IRC (with the Monitor and at least one of the Subject Matter Experts on a least two occasions) to observe where prisoners with urgent or emergent mental health needs are housed pending a QMHP evaluation and whether required safety checks are being conducted. Monitoring will commence in the next Reporting Period after the Department issues proposed revised policies reflecting the Monitor’s comments and addressing the booking process, and the reported results will be subject to verification by the Monitor.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 21 of 87 Page ID #:1811
29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 2.1 of the Proposed Revision of DMH 20.2 RECEPTION CENTER INITIAL ASSESSMENT requires that “[w]ithin 24 hours on weekdays (or within 72 hours on weekends and legal holidays) of an intake nursing assessment in the [Reception Centers], a mental health clinician (Qualified Mental Health Professional) shall provide an initial assessment of all inmates referred for mental health evaluation who have nonemergent-urgent mental health needs.” This proposed revision addresses the requirements of Paragraph 29 of the Settlement Agreement. The Compliance Measures require the Department to review randomly selected records of the prisoners who are identified in the intake nursing assessment as having non-emergent mental health needs to determine compliance with this requirement. Monitoring will commence in the next Reporting Period after the DMH issues this proposed revision of revised DMH 20.2, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 22 of 87 Page ID #:1812
30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 2.3 of the Proposed Revision of DMH 20.2 requires that, “[t]he initial assessment” of inmates with non-emergent-urgent mental health needs “shall include a brief initial treatment plan that addresses housing recommendations and preliminary release information.” Section 3.1.5 provides that “[t]he initial assessment shall identify any emergent issues and determine whether a referral for a more comprehensive mental health evaluation is clinically indicated." These proposed revisions address the requirements of Paragraph 30 of the Settlement Agreement The Compliance Measures require the Department to review randomly selected initial mental health assessments and report to the Monitor and the Subject Matter Experts on the percentage of the assessments reviewed by the Department that meet this requirement. The Monitor is also supposed to determine whether the housing requirements have been followed. Monitoring will commence in the next Reporting Period after DMH issues a proposed revised DMH 20.2, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 23 of 87 Page ID #:1813
31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk; (b) hoarding medications; and (c) prior suicide attempts. STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 3.1 of Proposed Revision of DMH 80.1 MENTAL HEALTH ALERTS provides that electronic medical records (“EMR”) alerts shall “apply” to the “client circumstances” that include the risk factors identified above. Section 3.5.1 requires that “EMR alerts shall be initiated whenever a JMHS psychiatrist or clinician become[s] aware of one or more of the client circumstances[.]” The Compliance Measures require the Department to review randomly selected records for prisoners in certain at-risk groups to determine if the required mental health alerts are in the electronic records. Monitoring will commence in the next Reporting Period after DMH issues proposed revised DMH 80.1, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 24 of 87 Page ID #:1814
32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 3.5.1 of the Proposed Revision of DMH 80.1 requires that electronic medical records (“EMR”) “alerts” shall be “initiated” whenever a JMHS psychiatrist or clinician becomes aware of certain prisoner circumstances, including “Suicide Risk” and “Prior Suicide Attempts.” Although it does not specifically require an alert when there is “a serious suicide attempt,” such an attempt would presumably fall within the categories that are covered. Section 4.4.5 of the Proposed Revision of DMH 70.7 requires clinicians to “summarize the [Suicide Risk] assessment including the level of risk” in the prisoners EMR, but does not specify a timeline for the entry of the information in the EMR. The Compliance Measures require the Department to review the electronic medical records of all prisoners who had a serious suicide attempt in the prior quarter and provide the Monitor and Subject Matter Experts with a random sample of the records reviewed by the Department. Monitoring will commence in the next Reporting Period after DMH issues proposed revised DMH 80.1, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 25 of 87 Page ID #:1815
33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:
(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;
(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;
(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and
(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.
STATUS : NOT CURRENTLY SUBJECT TO MONITORING The Department of Mental Health issued DMH 50.1 CONTINUOUS QUALITY IMPROVEMENT, effective December 31, 2015, to “provide Jail Mental Health Services (JMHS) staff policy and procedures for a Continuous Quality Improvement Program." The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected two prisoners from each clinician’s caseload. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 26 of 87 Page ID #:1816
34. The County and the Sheriff will conduct discharge planning and linkage to community mental health providers and aftercare services for all prisoners with serious mental illness as follows:
(a) For prisoners who are in Jail seven days or less, a preliminary treatment plan, including discharge information, will be developed.
(b) For prisoners who are in Jail more than seven days, a QMHP will also make available:
(i) for prisoners who are receiving psychotropic medications, a 30-day prescription for those medications will be offered either through the release planning process, through referral to a re-entry resource center, or through referral to an appropriate community provider, unless clinically contraindicated;
(ii) in-person consultation to address housing, mental health/medical/substance abuse treatment, income/benefits establishment, and family/community/social supports. This consultation will also identify specific actions to be taken and identify individuals responsible for each action;
(iii) if the prisoner has an intense need for assistance, as described in DMH policies, the prisoner will further be provided direct linkage to an Institution for Mental Disease ("IMD"), IMD-Step-down facility, or appropriately licensed hospital;
(iv) if the prisoner has a moderate need for assistance, as described in DMH policies, and as clinically appropriate to the needs of the prisoner, the prisoner will be offered enrollment in Full Service Partnership or similar program, placement in an Adult Residential Facility (“Board and Care”) or other residential treatment facility, and direct assistance accessing community resources; and
(v) if the prisoner has minimal needs for assistance, as described in DMH policies, the prisoner will be offered referrals to routine services as appropriate, such as General Relief, Social Security, community mental health clinics, substance abuse programs, and/or outpatient care/support groups.
(c) The County will provide a re-entry resource center with QMHPs available to all prisoners where they may obtain information about available mental health services and other community resources.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 27 of 87 Page ID #:1817

STATUS (34):

NOT CURRENTLY SUBJECT TO MONITORING

The Proposed Revisions of DMH 20.2 (to provide “initial assessment policy and procedures for mental health evaluation while in the Reception Centers”) and DMH Policy 70.9 RELEASE PLANNING (to provide “policy and procedures for Release Planning”) are intended to address Paragraph 34 (and other paragraphs) of the Settlement Agreement. When issued, these proposed policies together will satisfy Paragraph 34. Section 4.7 of the Proposed Revision of DMH Policy 70.3.7 MEDICATION EVALUATION AND MANAGEMENT also covers Paragraph 34(b)(i).

The Compliance Measures require the Department to review randomly selected records of prisoners with serious mental illnesses to determine whether the required preliminary treatment plan was developed and whether the prisoners received the assistance required by the corresponding subparts of this provision, and to report the results to the Monitor on a semi-annual basis. Monitoring will commence in the next Reporting Period after DMH issues these revised policies, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.

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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 28 of 87 Page ID #:1818 35. Consistent with existing DMH and Sheriff’s Department policies, the
County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team ("JMET") member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral (“BOMHR”) records for prisoners newly referred by custody staff for evaluation to a QMHP or JMET member to determine the timeliness of the referrals. Monitoring will commence in the next Reporting Period, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 29 of 87 Page ID #:1819
36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revisions of DMH 70.7 SUICIDE PREVENTION (to “identify, screen, assess, and treat incarcerated individuals who may be at risk for suicide”) and DMH 70.2.1 MENTAL HEALTH TREATMENT PROGRAMS (to provide policy and procedures for “mental health treatment programs”) are intended to address Paragraph 36 (and other paragraphs) of the Settlement Agreement. When implemented, DMH Policy 70.7, sections 4.1.2. and 4.1.2.1, and DMH Policy 70.2.1, sections 2.2, 3.2.5.1, and 3.2.5.2 (with additions suggested by the Monitor and DOJ) will address the first and third sentences of Paragraph 36. The Compliance Measures for Paragraph 36 require the Department to review randomly selected records of all prisoners who are newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; conduct quarterly unannounced visits and provide the Monitor with a staffing schedule for on-call services. Monitoring will commence in the next Reporting Period after the Department issues proposed revised policies reflecting the comments of the Monitor and DOJ, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 30 of 87 Page ID #:1820
37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter and review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner; incident reports for self-injurious behavior by prisoners appearing in the selected courts; and BOMHR forms completed by the Court Services Division staff in the selected courts to determine compliance with this provision. It is anticipated that monitoring of this provision will commence in the next Reporting Period, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 31 of 87 Page ID #:1821
38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE Section 3.1.7 of DMH 70.2.3 DISCIPLINARY SEGREGATION, effective December 31, 2015, addresses the requirements of Paragraph 38. The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision. Substantial Compliance requires that (a) 90% of the required weekly cell-by-cell checks were completed; and (b) 85% of the out-of-cell interviews requested were granted, absent documented justification for denial of the request. The Monitor randomly selected the week of August 2, 2015 for this review. As supported by the documentation provided to the Monitor, the Department's Self-Assessment reports 100% success for the third and fourth quarters in 2015, and that it has achieved Substantial Compliance with both subparts. The Department's reported results will be subject to verification by the Monitor based upon an audit by the Monitor's auditors. In addition to the audit, the Monitor will include direct observations and interviews in assessing whether the Department has “maintained” Substantial Compliance with this provision for purposes of Paragraph 111 of the Agreement.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 32 of 87 Page ID #:1822
39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their request to custody staff or other prisoners.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revision of CDM 8-03/020.00 MEDICAL AND MENTAL HEALTH GRIEVANCES is part of the new inmate grievance system the Department is creating to address Section 6 of the Implementation Plan in the Rosas case, but it does not adequately address prisoner requests for mental health care as distinct from grievances about the care (or lack of care), and it does not provide for confidentiality of the selfreferral as required by the requirements of Paragraph 39. The Proposed Revision of DMH 70.10 SELF-REFERRAL/REQUESTS that was submitted to the Monitor and DOJ on December 30, 2016, sets forth policy and procedures for handling “selfreferrals/requests for mental health services.” Substantial Compliance requires the Department to inspect housing areas in each facility each quarter, and document that these areas have the required referral forms and envelopes and that electronic kiosks are functional. The Department is also required to review randomly selected self-referrals for mental health care received by the Department from prisoners during one week per quarter and report the handling of the self-referrals by the Department and DMH. Monitoring will commence in the next Reporting Period after the Department issues revised policies addressing the requirements of Paragraph 39, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 33 of 87 Page ID #:1823 40. The County and the Sheriff will ensure a QMHP will be available on-site,
by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 2.2 of the Proposed Revision of DMH 70.2.1 MENTAL HEALTH TREATMENT PROGRAMS addresses the requirements of Paragraph 40 of the Agreement. Substantial Compliance requires DMH to provide to the Monitor with on-call schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week and randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify compliance with Paragraph 40. Monitoring will commence in the next Reporting Period, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 34 of 87 Page ID #:1824
41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Sections 4.8 and 4.9 of revised DMH 70.7, effective February 4, 2016, address Paragraph 41 of the Agreement. Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. Monitoring will commence in the next Reporting Period, and the reported results will be subject to verification by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 35 of 87 Page ID #:1825
42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement “step-down” procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 4.10 of revised DMH 70.7 addresses the requirements of Paragraph 42 of the Agreement. Substantial Compliance will require the Department to review the medical records of all prisoners in HOH and placed on risk precautions for one randomly selected month each quarter, and submit a report on the implementation of the step-down protocols and the results of the medical records review. Monitoring will commence in the next Reporting Period , and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 36 of 87 Page ID #:1826
43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING
Sections 3.1.1, 3.1.2 and 3.1.7 of DMH 70.2.3 DISCIPLINARY SEGREGATION, effective December 31, 2015, address the requirements of Paragraph 43.
Substantial Compliance requires the Department to maintain a log documenting weekly walks by a QMHP in each disciplinary housing area, review the medical records of prisoners who were in mental health housing units or were receiving psychotropic medication before being assigned to disciplinary housing, and report the results of its reviews. Monitoring will commence in the next Reporting Period, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 37 of 87 Page ID #:1827
44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE The Monitor and Subject Matter Experts have observed that the Department has installed protective barriers on the second floor tier of High Observation Housing areas and most Moderate Observation Housing areas at TTCF and the CRDF. The Department has provided the Monitor and Subject Matter Experts with an updated plan for the installation of protective barriers in the remaining Moderate Observation Housing modules at TTCF and a timetable for the installation of these barriers within the first quarter of 2016. Further, the Department reports that as of February 12, 2016, there is only one MOH module awaiting a barrier, which the Department anticipates will be installed around March 1, 2016. The Monitor will verify the installation of the remaining barriers.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 38 of 87 Page ID #:1828
45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.
STATUS: SUBSTANTIAL COMPLIANCE (EXCEPT MCJ); PARTIAL COMPLIANCE (MCJ)
Substantial Compliance requires the Department to verify once each quarter that each control booth or officer’s station in each housing unit has both a first-aid kit and a Suicide Intervention Kit that contains an emergency cut-down tool, and to include training in the use of both the Suicide Intervention Kit and the first-aid kit in the curricula for Custody Assistants in the Academy, for new Deputy Sheriffs in the Jail Operations Continuum, and for existing deputies in the two-hours of Suicide Prevention Training. The Department has reported 100% compliance at all jail facilities except for Men’s Central Jail. These results are subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
During visits to the jail facilities, including Men’s Central Jail, the Monitor and Subject Matter Experts inspected control booths on a random basis and verified that each inspected control booth had both a first-aid kit and a Suicide Intervention Kit.
Training in the use of the Suicide Intervention Kit is included in the Department’s Suicide Prevention Training and in comprehensive training in the Department’s mandated First Aid Training.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 39 of 87 Page ID #:1829 46. The County and the Sheriff will immediately interrupt, and if necessary,
provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior. STATUS: NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance requires the Department to review the documentation
from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment. Monitoring will commence in the next Reporting Period, and the reported results will be subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 40 of 87 Page ID #:1830
47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: PARTIAL COMPLIANCE
The County’s semi-annual Self Assessment sets forth what the County has done to implement specific paragraphs of the Settlement Agreement that it reports were “ready for monitoring” in the Reporting Period. It does not, however, describe the steps it has taken to implement the remaining terms of the Agreement. Since the remaining terms of the Agreement should be ready for monitoring in the next Reporting Period, the Monitor anticipates the future Self Assessments will address this comment by reporting on the steps to implement those terms.
Looking to the future, the Monitor notes that the County's criteria for determining what is a Critical Incident is both too broad and too restrictive. As expressed in the SelfAssessment, situations such as a water main break and an inmate escape “do not fall within the subject matter of the Agreement,” and therefore are not Critical Incidents that must be included in the Department’s future Self-Assessments. At the same time, among the Critical Incidents that should be included, in addition to inmate deaths and suicides, are serious suicide attempts, inmate assaults on staff resulting in criminal referrals, riots, multiple-cell extractions, and incidents resulting in Category 3 uses of force (or a statement that no such incidents occurred). The term “Critical Incident” is not defined in either the Settlement Agreement or the Compliance Measures, but the Self-Assessments should include a broader range of incidents in reporting on Critical Incidents in the future.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 41 of 87 Page ID #:1831
48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations ("CCR") Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE The Department’s revised CDM 5-11/020.00 SANITATION issued on July 6, 2015, requires each facility to “have a written housekeeping, sanitation and inspection plan.” The Department has provided Unit Orders for each facility that, for example, “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility." As required by the Compliance Measures, the Department has provided the most recent Local Detention Health Inspection Report pursuant to California Health & Safety Code Section 101045 and Corrective Action Plans for each facility. During this monitoring period, the Monitor and a Subject Matter Expert inspected each of the facilities to assess the Department’s compliance with Paragraph 48 of the Agreement. During the inspections, we interviewed facility staff and inmates; reviewed housekeeping, sanitation, and inspection plans and forms; and inspected the food service departments, medical departments, intake areas and random housing units. We found that there was “an acceptable level of cleanliness, sanitation, repair and safety” in each facility.3 Following the on-site inspections, the Monitor and Subject Matter Expert reviewed each facility’s written housekeeping, sanitation and inspection plans, Unit Orders, the Health Inspection Reports and the Corrective Action Plans. The Monitor, after consultation with the Subject Matter Expert, certifies that the Department’s plans satisfy the requirements of CCR Title 15, § 1280 and have been implemented.
3 Notwithstanding the finding of “Substantial Compliance,” the Monitor and Subject Matter Expert encourage the Department and DMH to further assess how to address those limited instances where severely mentally ill inmates refuse to clean their cells or to bathe.
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49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE
CDM 4-07/020, effective January 26, 2016, requires Unit Commanders to establish plans for their facilities that address the requirements of Paragraph 49 of the Agreement. The Department has provided Unit Orders for each facility that, for example, “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility.” The Unit Orders indicate that the Facilities Services Bureau (“FSB”) is to be notified when there is mold, and it will be responsible for treating the problems. The Department has submitted a memorandum from FSB, dated February 3, 2016, indicating what steps FSB takes to treat the problem.
During this monitoring period, the Monitor and a Subject Matter Expert inspected each of the facilities for the purpose of assessing the Department’s compliance with Paragraph 49. During the inspections we interviewed facility staff and inmates; reviewed maintenance plans for responding to routine and emergency needs; inspected shower areas, toilets, sinks and urinals (in housing units and medical areas); and inspected lighting systems, heating, ventilation and cooling systems for functionality and upkeep.
Following the on-site inspections, the Monitor and Subject Matter Expert reviewed each facility’s written maintenance plan for responding to routine and emergency needs and for addressing small and large mold infestations (minor mold infestations are handled by facility staff and inmate work crews and large mold infestations are reported to FSB for handling). We also reviewed Unit Orders that address procedures for handling maintenance requests and examined the eUDAL and Maximo automated systems that are used to track such requests while on-site. Each facility has a maintenance coordinator that serves as the point person between the facility, maintenance contractors and the Internal Services Departments, as well as serving as coordinator for inmate work crews. We also reviewed Local Detention Health Inspection Reports for each facility and Corrective Action Plans in response to those Reports.
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50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING
CDM 5-11/030.00 CONTROL OF VERMIN, revised December 14, 2015, addresses the requirements of Paragraph 50 of the Settlement Agreement. The Monitor and Subject Matter Expert inspected each of the facilities found that there was “an acceptable level of cleanliness, sanitation, repair and safety” in each facility.
Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with a copy of a contract with an outside vendor for regular pest control services at each jail facility and, on a quarterly basis, a schedule of the pest control activities at each facility in the previous quarter; a pest control compliance checklist of the pest control activities taken at each facility in the previous quarter; documentation from the outside vendor reflecting visits to each jail facility and the work performed during the visits; and a copy of the most recent report by the County Department of Public Health concerning pest control in the jail facilities. The SelfAssessment reports that "[a]ll facilities are in the process of ensuring pest control documentation is completed properly to reflect the pest control activities taken at each facility once implementation begins."
During this monitoring period, the Monitor and a Subject Matter Expert inspected each of the facilities for the purpose of assessing the Department’s compliance with Paragraph 50. During the inspections we interviewed facility staff and inmates; reviewed housekeeping, sanitation, and inspection plans and forms; and inspected the food service departments, medical departments, intake areas and random housing units. Following the inspections, we reviewed copies of the Department’s contracts with outside vendors for regular pest control services for the jail facilities; the pest control compliance checklists of the pest control activities taken at each facility in the previous quarter; documentation from the outside vendor reflecting visits to each jail facility and the work performed during the visits; and a copy of the most recent report by the County Department of Public Health concerning pest control in the jail facilities.
The food service areas are serviced frequently for pest, rodent and insect control, but medical areas and housing units are not serviced as often. At TTCF, it appears that the modules are included for pest control services, but it is unclear what areas of the modules were actually serviced. We also noted an entry in the IRC documents for August 17, 2015, that, “Technician did not spray indicated area…he only filled out forms.” Hopefully this is an isolated occurrence, but nevertheless, due diligence is required when carrying out pest control services.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 44 of 87 Page ID #:1834
51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.
STATUS: SUBSTANTIAL COMPLIANCE The Department provided the Monitor with a photograph of an Admission Kit and a copy of the form allowing existing prisoners to order admission kits. The Department also issued revised CDM 5-13/090.00 PERSONAL CARE ITEMS AND SUPPLIES FOR INMATES, effective February 24, 2016, which requires that Admission Kits be provided to new prisoners and to existing prisoners upon request in accordance as required by CCR Title 15 § 1265. The Department reported on February 12, 2016, that it has, as required by the Compliance Measures, inspected each facility and confirmed that kits are present in intake areas and readily available to all housing areas; provided documents confirming that contracted vendors have consistently provided kits in response to prisoner orders and the number of admission kits provided to prisoners; and reviewed randomly selected order forms to confirm that admission kits were provided to the inmates who submitted the forms. The Department’s report is subject to verification by the Monitor based upon the audit by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 45 of 87 Page ID #:1835
52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING
The Department has provided the Monitor with its Proposed Revisions of the Department's ALLOWABLE INMATE PROPERTY policies – CDM 5/06.010.05 for male inmates and CDM 5/06.010.10 for female inmates that require property restrictions for inmates in mental health housing to be determined by ”a mental health professional after a clinical assessment has been conducted." Sections 4.7.2.1 and 4.7.2.2 of the Proposed Revision of DMH 70.7 set forth property restrictions that address the requirements of Paragraph 52, except that they do not require the same level of property restrictions where two inmates in mental health housing are co-housed in a single cell.
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 46 of 87 Page ID #:1836
53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revisions of CDM 5-13/100.00 RELIGIOUS PROGRAMS, CDM 5-13/130.00 INMATE EDUCATION (which is subject to a revision required by the Monitor), and CDM 5-01/020.00 INMATE WORKER ASSIGNMENTS address the requirements of Paragraph 53 of the Settlement Agreement. The Monitor and Subject Matter Expert are concerned, however, that inmates with mental health needs may not be able to participate in programs that may only be available at the Pitchess Detention Center because the Department is not able to house and provide mental health care for such inmates at the Pitchess facilities. Substantial Compliance requires the Department to audit the records of prisoners who were eligible and rejected or disqualified for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 47 of 87 Page ID #:1837
54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revisions of CDM 5-13/100.00 RELIGIOUS PROGRAMS, CDM 5-13/130.00 INMATE EDUCATION (which is subject to a revision required by the Monitor), and CDM 5-01/020.00 INMATE WORKER ASSIGNMENTS address the requirements of Paragraph 54 of the Settlement Agreement. See Implementation Status of Paragraph 53, supra. Substantial Compliance requires the Department to audit the records of prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 48 of 87 Page ID #:1838
55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.
STATUS: SUBSTANTIAL COMPLIANCE (CRDF) PARTIAL COMPLIANCE (TTCF)
Sections 3.5.2.3 and 3.5.3.2 of the Proposed Revision of DMH Policy 70.2.1 require "relevant custody, medical and mental health staff" to meet in accordance with the requirements of Paragraph 55. The Monitor and a Subject Matter Expert attended a weekly HOH meeting at CRDF on November 18, 2015, and we were impressed with the level of communications among custody, medical, and mental health personnel. We understand that there are daily HOH meetings at CRDF with fewer participants, which we did not attend.
The Self-Assessment states that the "meetings are being conducted for all HOH and MOH units at [TTCF and CRDF] as required by the Agreement," and that the Department and DMH have gone beyond the requirements of Paragraph 55 by holding "additional interdisciplinary meetings. . .to facilitate conversations about inmates who may not be the most urgently in need, but who still benefit from a more thorough discussion about their needs." On February 9, 2016, the County reported that it had reviewed records of staff meetings in HOH and MOH units and confirmed that the Department and DMH have met the percentages required by the Compliance Measures at CRDF, but not at TTCF. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing. The Department's reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 50 of 87 Page ID #:1840
57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57): PARTIAL COMPLIANCE The Proposed Revisions of CDM 4-11/030.00 INMATE SAFETY CHECKS and CDM 4-11/030.05 TITLE 15 SCANNER, address the requirements of Paragraph 57,4 except for 57(e). Pending approval of CDM 4-11/030.00, the Department issued a directive to implement this paragraph. Substantial Compliance will require the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit to determine if the safety checks were staggered and conducted as required by paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit to determine if a QMHP approved the new mental health housing assignments. The Department’s reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
4 The Monitor has advised the Department County and DOJ that the definition of "Unobstructed Visual Observation" in this policy, which is based upon the definition in the Agreement, is internally inconsistent. The parties have taken the Monitor’s comments under consideration.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 52 of 87 Page ID #:1842
58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells;
(b) At least every 30 minutes in dormitory-style housing units where the unit does not provide for unobstructed direct supervision of prisoners from a security control room;
(c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes;
(d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing;
(e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(f) Custody staff will document their checks in a format that does not have pre-printed times;
(g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and
(h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
STATUS: PARTIAL COMPLIANCE
The Proposed Revisions of CDM 4-11/030.00 and CDM 4-11/030.05 address the requirements of Paragraph 58. Pending approval of CDM 4-11/030.00, the Department issued a directive to implement this paragraph.
Substantial Compliance will require the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by paragraph 58 of the Agreement. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.

STATUS:

SUBSTANTIAL COMPLIANCE (SOUTH) NOT CURRENTLY SUBJECT TO MONITORING (REMAINING FACILITIES)

The revision of CDM 4/11-020.00 UDAL, published January 22, 2016, requires shift floor sergeants to visit housing areas under their supervision once per shift to review the UDAL "for accuracy, and to ensure all inmate safety checks and other required officer activities are conducted and documented properly." The revision of CDM 4/11.030.00, also published January 22, 2016, requires the sergeants to "conduct an unannounced check of each housing area under their supervision, not less than once per shift, to ensure all inmate safety checks are conducted and properly documented." These provisions address the requirements of Paragraph 59 of the Agreement.

Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if the supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. The Department reports that the South Facility is in Substantial Compliance with this provision. The report results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.

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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Effective December 31, 2015, DMH adopted revised Policy 50.1 CONTINUOUS QUALITY IMPROVEMENT "to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program" that focuses on "identifying and addressing clinical issues that place inmates at significant risk of suicide or self injurious behavior[.]" Although not subject to monitoring in this Reporting Period, the County has provided a description of DMH's quality improvement program under Provision 61 in the Self-Assessment, including a summary of what DMH is doing to review, collect and aggregate data and recommend Corrective Action Plans in each of the areas set forth in Paragraph 61 of the Agreement. Substantial Compliance will require future Self-Assessments to set forth any (a) identified clinical issues in the areas in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods.
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts: (i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints; (c) Psychotropic medications; (d) Access to care, timeliness of service, and utilization of the Forensic In-
patient Unit; and (e) Elements of documentation and use of medical records.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Effective December 31, 2015, the Department of Mental Health adopted revised DMH Policy 50.1 CONTINUOUS QUALITY IMPROVEMENT "to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program." See the report of the Status of Paragraph 60, supra. Substantial Compliance will require future Self-Assessments to set forth any (a) any identified clinical issues in the areas set forth in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods.
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Effective December 31, 2015, the Department of Mental Health adopted revised DMH 50.1 CONTINUOUS QUALITY IMPROVEMENT "to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program." The Proposed Revision of CDM 2-00/070.00 provides that “[p]ersonnel from CCSB will conduct follow up assessments upon the completion of corrective action reports to verify that any identified deficiencies have been addressed" and "will participate in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program." The Proposed Revision addresses the requirements of Paragraph 62. Upon approval of CDM 2-00/070.00, Substantial Compliance will require future Self-Assessments to set forth any (a) identified clinical issues in the areas set forth in paragraph 61 of the Agreement that place prisoners at significant risk of suicide or selfinjurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 57 of 87 Page ID #:1847
63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance will require that future Self-Assessments set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period: (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. The Department must also review the count sheets for available beds in two random weeks and report on the availability of HOH and MOH beds at TTCF and CRDF. The Department’s reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 58 of 87 Page ID #:1848
64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in the following 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed.
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revision of CDM 5-03/050.00 STANDARDS OF MEDICAL CARE provides that "[i]t is the responsibility of the licensed nurse to ensure that medication has been ingested," but does not otherwise set forth what the nurse is required to do to ensure the medication has been ingested. It adds that “Custody personnel shall assist the pill call nurse" and refers to MSB policy M205.01. It does not, however, by itself address the requirements of Paragraph 65. Substantial Compliance requires the Self-Assessments to set forth the (1) the results of weekly medication Administration Audits documenting the visual observation of the administration of medication during the quarter; (2) unauthorized medications found as a result of cell searches during the reporting period; and (3) incidents involving confirmed prescription drug overdoses. The reported results will be subject to the Monitor’s conclusions, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 60 of 87 Page ID #:1850
66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 2.3 of DMH policy 70.3.7 provides that prisoners in HOH units, and any prisoners in MOH units "who are refusing medications and are having significant symptomatology due to refusing, and clients with Serious Mental Illness (SMI) housed in other areas of the jails shall remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications. . . . " and "shall be managed in such a way as to increase the likelihood of psychotropic medication compliance." The policy needs to be further revised so to make it clear that it applies to all HOH and all MOH prisoners who refuse medications, not just those "having significant symptomatology due to refusing." The Department has advised the Monitor that it will re-publish the policy to address this remaining issues. Substantial Compliance will require the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with SMI to assess whether they remain on an active mental health caseload, have been offered structured mental health treatment, and have been seen by a QMHP at least monthly, regardless of whether they refuse medications. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings; (c) the use of clinically appropriate interventions with such prisoners to
encourage medication compliance; (d) consideration of the need to transfer non-compliant prisoners to higher
levels of mental health housing; and (e) individualized consideration of the appropriateness of seeking court orders
for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a). STATUS: NOT CURRENTLY SUBJECT TO MONITORING Section 4.5 of DMH 70.3.7 addresses the requirements of Paragraph 67(a) through (e) for prisoners in HOH or MOH units (and others) who refuse psychotropic medications for specified periods. Substantial Compliance will require the County Department to review the electronic medical records of prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records reflect the documentation and consideration of the matters required by the terms of paragraph 67. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.
STATUS: PARTIAL COMPLIANCE The Proposed Revision of CDM 5-08/010.00 SEARCHES, which requires contraband searches on a regular, but staggered basis in all housing units, and visual inspection of HOH housing units prior to housing prisoners with mental health issues in HOH units, addresses the requirements of Paragraph 68. Pending approval of this policy, the Department has issued a Directive "to establish additional procedures for conducting inmate contraband searches with respect to the hoarding of medication." Upon issuance of the revised policy, Substantial Compliance will require SelfAssessments to include a summary of searches conducted in the previous quarter and to randomly select and review 25 Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revision of CDM 7-03/030.00 MEDICALLY ORDERED RESTRAINT DEVICES sets forth the Department's policies regarding use of clinical restraints. Although it was approved by the Rosas Monitors to address Paragraph 17.7 of the Implementation Plan in that case, it does not satisfy Paragraph 69 of the Settlement Agreement, which requires the approval of a “licensed psychiatrist” who has performed an individualized assessment and an appropriate Forensic Inpatient order.5 The Proposed Revision of DMH 100.8 CLINICAL RESTRAINTS, together with CTC MHU Policy 21f, provides "policy and procedures for the use of clinical restraints by JMHS staff." Subject to a further revision of CDM 7-03/030.00, Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved, and documented, and that the results of medical welfare checks on restrained prisoners were also documented, as required by Paragraph 69 of the Agreement. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
5 The Subject Matter Expert believes that it is, however, reasonable for a medical physician to order restraints in some circumstances.
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: PARTIAL COMPLIANCE CDM 7-03/000.00 SECURITY RESTRAINTS AND HANDCUFFING INMATES, which was approved by the Rosas Monitors, sets forth the Department's policies regarding use of security restraints generally, and as required by Paragraph 70(a), (b), and, in part, (d). It does not, however, specifically address the requirements of Paragraph 70(c) or require referrals to a QMHP as required by Paragraph 70(d). Proposed revision of CDM 7-03/010.00 WAIST-CHAIN PROCEDURES provides that "[p]ersonnel assigned to HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas," which addresses the requirements of Paragraph 70(c), but does not address referrals to a QMHP as required by Paragraph 70(d). Substantial Compliance requires the Department to implement the policies and procedures required by Paragraph 70.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 65 of 87 Page ID #:1855 71. The County and the Sheriff will ensure that any prisoner subjected to
clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance will require the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71. The reported results will be subject to verification by the Monitor based upon the audits by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 66 of 87 Page ID #:1856
72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.
STATUS: PARTIAL COMPLIANCE
There are gaps in the revised policies proposed by the Department and DMH. Proposed Revision of CDM 4-10/05.00 INMATE DEATH – REPORTING AND REVIEW PROCESS requires certain notifications in the event of an inmate death, along with corrective action plans as necessary. It does not, however, encompass incidents involving "serious self-injurious behavior" or specifically require the Department to determine "whether staff engaged in any violations of policies, rules, or laws."
Proposed Revision of CDM 4-10/060.00 CRITICAL INCIDENT REVIEW COMMITTEE – SUICIDAL INMATES covers attempted suicides as "serious suicidal behavior" by DMH, but not actual or suspected suicides or "serious self-injurious behavior."6 It requires the Critical Incident Review Committee to consider, within 30 days of the incident "whether violations of policy or laws by department personnel were a factor. If so, the review will consider improvements to policy, training, programs or the facility are warranted." Further, it provides that "Correction action plans (CAP) which identify areas in need of improvement and propose solutions will be developed and documented."
The revision of DMH 50.2 CRITICAL INCIDENT REVIEW, effective February 4, 2016, encompasses “actual or suspected suicides” as well as “serious self-injurious behavior” in the review process that includes “determining whether staff engaged in any violations of policies, rules or laws and whether improvements to policy, training, operations or treatment programs are warranted.”
In addition to approval of written policies and procedures that address the requirements of Paragraph 72, Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings reviewing incidents that involve serious self-injurious behavior in the reporting period. The Department's SelfAssessment for the Initial Reporting Period reports that five CIRC meetings reviewed "a total of 43 serious suicide attempts in the jails" for which "the Department created a total of 50 [Correction Action Plans] were created. Future Self-Assessments will need to indicate and describe "whether staff engaged in any violations of policies, rules, or laws" and "whether any improvements to policy, training, operations, treatment, programs, or facilities are warranted."
6 The Self-Assessment does, however, indicate that the CRIC, "in collaboration with CCSB, ensures that incidents involving suicide and serious suicide attempts (including serious self-injurious behavior) in the jails are reported and reviewed.”
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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING The Proposed Revision of CDM 4-05/000 BEHAVIORAL OBSERVATION AND MENTAL HEALTH REFERRAL REPORTS requires "[a]ll custody personnel who identify an inmate, either through observation, information received from another person (i.e. relative, clergy, etc.), intake screening, or exhibited behavior indicative of possible mental illness, or who threatens or exhibits self-injurious behavior" to complete a BOMHR "no later than the end of shift." Proposed revision of CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU requires the Custody Compliance and Sustainability Bureau ("CCSB") to promptly notify the County Office of Inspector General (OIG) of all apparent or suspected suicides occurring at the Jails. These propose revisions address the requirements of Paragraph 73. Substantial Compliance will require the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; to report the results of its review to the Monitor; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicides during the reporting period. The reported results will be subject to verification by the Monitor based upon the audit by Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 68 of 87 Page ID #:1858
74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS : NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance requires the Department to provide the Monitor with a report of any Executive Suicide Death Review during a quarter reflecting the results of the Department’s investigation of any suicide in the Jails, which must be completed within six months of the suicide; reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded. The reported results will be subject to verification by the Monitor.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 69 of 87 Page ID #:1859
75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
STATUS: PARTIAL COMPLIANCE
Sections 4.2, 4.7.2 and 4.8 of the Proposed Revision of DMH 50.2 address each of the requirements of Paragraph 75 of the Settlement Agreement. Proposed Revision of CDM 4-10/060.00 CRITICAL INCIDENT REVIEW COMMITTEE—SUICIDAL INMATES addresses the requirement of Paragraph 75(b). The County's Self-Assessment indicates that "[d]uring the reporting period, there were 5 CIRC meeting during which a total of 43 incidents were reviewed" and "a total of 50 CAPs were created."
Substantial Compliance will require (1) DMH to randomly select and review documentation of suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (2) the Department and DMH to review the documentation of CIRC meetings to confirm that CIRC reviewed the relevant information known at that time, the status of any corrective actions taken, and that it considered the need for additional corrective action if necessary; and (3) that the information is reflected in the Department's database for tracking and statistical analysis. The reported results will be subject to verification by the Monitor.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 70 of 87 Page ID #:1860

76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

NOT CURRENTLY SUBJECT TO MONITORING

The Proposed Revision of CDM 4-10/050.00 DEATH REPORTING REVIEW PROCESS addresses each of the requirements of Paragraph 76. It provides that, within two working days, personnel from DMH, the Custody Division and Medical Services Bureau will meet "to review the circumstances surround[ing] all in-custody deaths," including in the case of an apparent or suspected suicide "a discussion of the inmate's mental health status known at the time of the suicide." It also provides for CCSB "to conduct a death review within seven (7) working days and again within thirty (30) working days," which "will include a discussion of relevant information known at that time, including the events preceding and following the suicide[.]" It also provides for a final report within six months. Section 4.7 of the Proposed Revised of DMH policy 50.2 CRITICAL INCIDENT REVIEW is consistent with these provisions. CDM 4-10/050.00 also refers to Executive Inmate Death Reviews, but does not indicate when those reviews are supposed to take place.

Paragraph 76 is not subject to monitoring because, as the County's SelfAssessment Status notes, "there have been no suicides since the Effective Date of the Agreement."

Substantial Compliance requires, in the event of an apparent or suspected suicide, that the Department and/or DMH will review the documentation of each initial management and command-level personnel meeting and any subsequent management and command-level personnel meetings to confirm that they took place timely, and all of the required information was discussed, and the status of a corrective or preventive action was reported. In addition, within six months of each suicide in the Jails, the Department will provide the Monitor and Subject Matter Experts with a completed Executive Suicide Death Report that complies with the requirements of Paragraph 76(c).

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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
Proposed Revision of CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU provides for the creation of a bureau "to oversee, monitor, and audit the Department's jail suicide prevention program" in coordination with DMH. Upon issuance, this policy will address each of the requirements of Paragraph 77 of the Settlement Agreement. The Department has also provided the Monitor and Subject Matter Experts with an organizational chart for CCSB.
The Self-Assessment is divided into sections that track the requirements of the Compliance Measures, but subsections (b), (e) and (f) do not address any trends, staff/personnel issues, or remedial measures as a result of serious suicide attempts. While it is fortunate that there have not been any suicides, there were 43 serious suicide attempts, which need to be discussed in these subsections. In addition, future SelfAssessment Status Reports will need to provide more detail with respect to subsections (c) and (g), and not simply refer the Monitor to the underlying documents.
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: PARTIAL COMPLIANCE The Self-Assessment indicates the Suicide Prevention Advisory Committee met on November 12, 2015, and the Department has provided the sign-in sheet, agenda, slide presentation and minutes for the meeting. Substantial Compliance requires (1) the Committee to meet twice per year and (2) “recommend coordinated approaches to suicide prevention in the Jails.” Although the materials provided reflect that the initial meeting was a comprehensive review of the year 2015 in review, none of the materials reflect any recommendations of “coordinated approaches to suicide prevention” as required by Paragraph 78 and by the Compliance Measures for this provision.
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING
Proposed revision of DMH 70.2.1 sets forth “policy and procedures for mental health treatment programs” in the Jails. Sections 3.2.7 and 3.5 provide for individual visits and group programming as required by Paragraph 79(a) and (c), although it is not clear that these provisions are intended to cover only those inmates who are in “mental health housing.” Section 3.5.4 addresses the requirements of Paragraph 79(b).
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; to provide a description of the medication support services available for prisoners who are not in mental health housing and who are receiving psychotropic medications; and to randomly select and review electronic medical records of prisoners who reside outside of mental health housing and receive psychotropic medications to confirm that medication support services were provided to these prisoners. The reported results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business work day. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

PARTIAL COMPLIANCE

Section 3.5.2 of the Proposed Revision of DMH 70.2.1 requires inmates in HOH areas to “be offered ten hours per week structured therapeutic or programmatic time unless individually clinically contraindicated[.]” The Department has not provided a similar provision requiring “unstructured out-of-cell recreational time” for HOH inmates.

The Department has provided an “Out of Cell Offered Tracker” for the week of 12/13/15 to 12/19/15 that lists the names of the inmates in HOH at CRDF and TTCF; the amount of unstructured out-of-cell recreation time and structured therapeutic or programming time offered to these inmates; if the inmates have refused the time offered; and (in many cases) the reasons for the refusals. Based on the Average Daily Population in HOH during the prior two weeks and the tracker, CCSB reports that 28.9% of the inmates in HOH units at CRDF and TTCF were offered 10 hours of unstructured out of cell time during that week, but it does not report on the percentage of inmates who received 10 hours of structured therapeutic or programmatic time.

Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with records of daily staff meetings reflecting that prisoners in HOH who refused to leave their cells on any days in the prior two weeks were discussed; and documentation reflecting that their refusals were analyzed by CCSB and DMH.

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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 77 of 87 Page ID #:1867
81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development);7 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.17.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
Policies have been approved by the Rosas Monitors and adopted by the Department to implement the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.116.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture). The Department’s implementation of these policies at CRDF and the Pitchess Detention Center will be assessed by the Monitor and the Use of Force Subject Matter Expert.
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 reflect training requirements that are supposed to be completed by December 31, 2016. Paragraphs 4.10 and 9.1 are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Paragraph 8.2 (combining “Complaints of Retaliation”) will be included in a new system for handling prisoner grievances and complaints that will be adopted by the Department to implement Paragraphs 6.1-6.20. It is anticipated that these provisions along with policies to implement Paragraphs 13.1-13.2 will be adopted on or before June 1, 2016, and that the Early Warning System to implement Paragraphs 19.1-19.3 will be completed sometime thereafter.
7 As requested by the Department of Justice, these provisions were reviewed and approved by the Monitor’s Use of Force Subject Matter Expert.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING. The Department has provided a proposed organizational chart for personnel assigned to handle prisoner grievances in the Jails, dated April 29, 2015, that provides for a sergeant, a bonus deputy, and a Custody Assistant to be assigned to handle grievances at CRDF. The draft procedures and policies provided by the Department to the Rosas Monitors in December are consistent with the proposed organizational chart. It is anticipated that a new system for handling inmate grievances and requests will be implemented on or before June 1, 2016, through Custody Operations, and it will include the assignment of personnel to CRDF.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 79 of 87 Page ID #:1869

83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement (“Common Areas”), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.

STATUS:

SUBSTANTIAL COMPLIANCE (MCJ, TTCF, AND IRC)8
NOT CURRENTLY SUBJECT TO MONITORING (REMAINING FACILITIES)9

On September 2, 2015, the Monitor and Subject Matter Experts toured TTCF, MCJ and IRC and confirmed that closed circuit security cameras have been installed and are operational in the Common Areas. On October 13, 2015, the Department provided the Monitor and Subject Matter Experts with summaries showing the number of cameras needed and installed at these facilities as of November 27, 2012, and the number of additional cameras needed and installed at MCJ as of May 12, 2014 and at TTCF as of August 11, 2014. The Department also provided a spreadsheet listing the completed work orders for the installation of the cameras installed in the Common Areas in TTCF, MCJ and IRC. The Monitor’s auditors will need to review the actual work orders to verify the list.

The Department has provided the Monitor and Subject Matter Experts with lists of force incidents in Common Areas of the facilities where cameras have been installed, an inventory of the video recordings of those force incidents stored and retained by the Department, and descriptions of the video recordings, which confirm that the force incidents were recorded. The Monitor will review randomly selected recordings to verify that force incidents in the Common Areas are being recorded.

8 Notwithstanding this finding, the Monitor and Subject Matter expert encourage the Department to continue to improve the camera surveillance in the identified areas where there are potential blind spots or where camera surveillance could be improved by installing additional cameras. 9 The Department has substantially completed the installation of the cameras in the Common Areas at CRDF, which was not required in the Initial Reporting Period. The Department’s further compliance with the requirements of Paragraph 83 will be included in the Monitor’s next report.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:
(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and
(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance will require the Department to demonstrate that investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 81 of 87 Page ID #:1871 85. The County and the Sheriff will ensure that Internal Affairs Bureau
management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: NOT CURRENTLY SUBJECT TO MONITORING Substantial Compliance will require the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 82 of 87 Page ID #:1872
86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: PARTIAL COMPLIANCE The Proposed Revision of CDM 7-08/100 ACCOUNTABILITY OF WEAPONS requires each facility to “establish procedures for the storage, issuance, reissuance, accountability, and periodic inventory of all weapons. . . stored at, or issued from the facility,” which includes detailed requirements for the “Inventory, Control, and Accountability of Aerosol Chemical Agents.” Pending adoption of the proposed revision, the Department issued Custody Directive 15-008, dated December 10, 2015, “to establish additional procedures for the accurate inventory and adequate control of personally assigned aerosol chemical agents[.]” Substantial Compliance requires the Department to provide to the Monitor and Subject Matter Experts with written policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment, a written description of the Department’s inventory control system for all weapons, including OC spray (which may be included in the policies and procedures responsive to paragraph 1 above), up-to-date Unit Orders for each Jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons. The Monitor and Subject Matter Expert inspected the armory of each jail facility. Although the controls of most authorized weapons were adequate, there were a few instances in which discrepancies were noted in the control and accountability regarding OC canisters and security equipment. Further, although some of the facilities have up-todate unit orders, others have orders that were issued as long as eight years ago and have not been updated.
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Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 83 of 87 Page ID #:1873 APPENDIX

NO. PROVISION

STATUS

18 Suicide Prevention Training Partial Compliance

COMPLIANCE DATE

19 Crisis Intervention & Conflict Partial Compliance Resolution Training

20 Training at NCCF, PDC and Not Currently Subject to Monitoring CRDF

21 CPR Certification

Substantial Compliance (PDC and NCCF) Not Currently Subject to Monitoring (Remaining Facilities)

7/1/15 (PDC) 10/1/15 (NCCF)

22 Use of Arresting and Booking Partial Compliance Documents

23 Suicide Hazard Mitigation Plans

Partial Compliance

24 Suicide Hazard Inspection Not Currently Subject to Monitoring

25 Transportation of Suicidal Inmates

Not Currently Subject to Monitoring

26 Identification and Evaluation Not Currently Subject to Monitoring of Suicidal Inmates

27 Screening for Mental Health Not Currently Subject to Monitoring Care and Suicide Risk

28 Expedited Booking of Suicidal Inmates

Not Currently Subject to Monitoring

29 Mental Health Assessments Not Currently Subject to Monitoring

30 Initial Treatment Plans

Not Currently Subject to Monitoring

31 Electronic Medial Records Alerts

Not Currently Subject to Monitoring

32 Electronic Medical Records – Not Currently Subject to Monitoring Suicide Attempts

Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 84 of 87 Page ID #:1874 APPENDIX

33 Supervisor Reviews of

Not Currently Subject to Monitoring

Electronic Medical Records

34 Discharge Planning

Not Currently Subject to Monitoring

35 Referral for Mental Health Care

Not Currently Subject to Monitoring

36 Assessments After Triggering Not Currently Subject to Monitoring Events

37 Court Services Division Referrals

Not Currently Subject to Monitoring

38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

7/1/15

39 Confidential Self-Referral Not Currently Subject to Monitoring

40 Availability of QMHPs

Not Currently Subject to Monitoring

41 FIP Step-Down Protocols

Not Currently Subject to Monitoring

42 HOH Step-Down Protocols Not Currently Subject to Monitoring

43 Disciplinary Policies

Not Currently Subject to Monitoring

44 Protective Barriers

Substantial Compliance

1/1/16

45 Suicide Intervention and First Substantial Compliance

Aid Kits

Partial Compliance (MCJ)

10/1/15

46 Interruption of Self-Injurious Not Currently Subject to Monitoring Behavior

47 Staffing Requirements

Partial Compliance

48 Housekeeping and Sanitation Substantial Compliance

1/1/16

49 Maintenance Plans

Substantial Compliance

3/1/16

50 Pest Control

Not Currently Subject to Monitoring

51 Personal Care & Supplies

Substantial Compliance

3/1/16

52 HOH Property Restrictions Not Currently Subject to Monitoring

Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 85 of 87 Page ID #:1875 APPENDIX

53 Eligibility for Education, Work and Programs
54 Privileges and Programs
55 Staff Meetings
56 Changes in Housing Assignments
57 Inmate Safety Checks in Mental Housing
58 Inmate Safety Checks in Non-Mental Housing
59 Supervisor Rounds
60 Implementation of Quality Improvement Program
61 Requirements of Quality Improvement Program
62 Tracking of Corrective Action Plans
63 Sufficient HOH and MOH Housing
64 Plans for Availability of Inpatient Health Care
65 Administration of Psychotropic Medication
66 Active Mental Health Caseloads
67 Prisoner Refusals of Medication

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Substantial Compliance (CRDF) Partial Compliance (TTCF)

3/1/16

Not Currently Subject to Monitoring

Partial Compliance

Partial Compliance

Substantial Compliance (South)

3/1/16

Not Currently Subject to Monitoring

(Remaining Facilities)

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Not Currently Subject to Monitoring

Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 86 of 87 Page ID #:1876 APPENDIX

68 Contraband Searches

Partial Compliance

69 Clinical Restraints in CTC Not Currently Subject to Monitoring

70 Security Restraints in HOH Partial Compliance and MOH

71 Therapeutic Services for

Not Currently Subject to Monitoring

Inmates in Clinical Restraints

72 Administrative Reviews

Partial Compliance

73 Reporting of Self-Injurious Behavior and Threats

Not Currently Subject to Monitoring

74 Law Enforcement Investigations of Suicides

Not Currently Subject to Monitoring

75 Management Reviews of Suicide Attempts

Partial Compliance

76 Management Reviews of Suicides

Not Currently Subject to Monitoring

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Partial Compliance Committee

79 Therapeutic Services in Mental Health Housing

Not Currently Subject to Monitoring

80 Out-of-Cell Time in HOH Partial Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

82 Collection of Grievances at Not Currently Subject to Monitoring CRDF

83 Closed Circuit Cameras

Substantial Compliance (MCJ, TTCF, and IRC) Not Currently Subject to Monitoring (Remaining Facilities)

10/1/15

Case 2:15-cv-05903-DDP-JEM Document 81 Filed 03/01/16 Page 87 of 87 Page ID #:1877 APPENDIX

84 Investigation of Staff Misconduct

Not Currently Subject to Monitoring

85 Internal Affairs Bureau Training

Not Currently Subject to Monitoring

86 Maintenance and Inventory of Partial Compliance Security Equipment

 
 Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 1 of 102 Page ID #:2455

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) 601 West Fifth Street, 12th Floor

3 Los Angeles, CA 90071-2025

4

Telephone: (213) 613-4655 Facsimile: (213) 613-4656

5 Email: rdrooyan@scheperkim.com

6 Monitor 7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

WESTERN DIVISION

11

12 UNITED STATES OF AMERICA,

13

Plaintiff,

14

15

v.

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR’S SECOND REPORT

16 COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF
17 JIM MCDONNELL, in his Official Capacity,
18 Defendants.
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CASE NO. 15-cv-05903 DDP (JEMx) MONITOR'S SECOND REPORT

Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 2 of 102 Page ID #:2456

1

Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and the

4 Los Angeles County Sheriff during the six-month period from January 1, 2016,

5 through June 30, 2016, “to implement the Agreement and evaluating the extent to

6 which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

12

13 DATED: September 1, 2016 Respectfully submitted,

14

SCHEPER KIM & HARRIS LLP

15

RICHARD E. DROOYAN

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By: /s/ Richard E. Drooyan Richard E. Drooyan

19

Monitor

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21

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24

25

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- 1 -

CASE NO. 15-cv-05903 DDP (JEMx)

MONITOR’S SECOND REPORT

Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 3 of 102 Page ID #:2457
MONITOR’S SECOND REPORT
This Second Report sets forth the Monitor’s assessments of the implementation of the Settlement Agreement (the “Agreement”) between the County of Los Angeles (the “County”) and the United States Department of Justice (“DOJ”) by the Los Angeles Sheriff’s Department (the “Department”) and the County's Department of Mental Health (“DMH”). It covers the County's reported results for the period from January 1, 2016, through June 30, 2016 (the “Second Reporting Period”), and reflects the observations and comments of the Subject Matter Experts regarding the County's compliance during that period.
As used herein, “Substantial Compliance” means that the County has “achieved compliance with the material components of the relevant provisions of this Agreement in accordance with the [agreed-upon Compliance Measures for assessing Substantial Compliance],” which it must maintain for twelve-consecutive months; “Partial Compliance” means that the County has achieved “compliance on some, but not all, of the material components of the relevant provision of this Agreement;” and “NonCompliance” means that the County has not met “most or all of the material components of the relevant provisions of this Agreement.”
This Second Report is based upon the Monitor's review of the policies, procedures and directives proposed and/or implemented by the Department and DMH, assessments of the Subject Matter Experts, multiple tours of the jails by the Monitor and the Subject Matter Experts, the County’s Second Self-Assessment Status Report (the “Second SelfAssessment”), which was received on June 15, 2016, and augmented on June 30, 2016, and results reported by the County after the close of the Second Reporting Period. It also takes into consideration the comments that the Monitor received from the County and DOJ on the draft of this Report submitted to the parties on August 1, 2016.
As noted in the Monitor’s Initial Report, many of the Compliance Measures require the County to report, either quarterly or semi-annually, the results of reviews of randomly selected Department and DMH records. which are subject to verification by the Monitor's auditors. This Second Report reflects the results of audits by the Monitor's auditors to verify results reported by the County in the Initial Reporting Period ending December 31, 2015, and in the first quarter of 2016 in the Second Reporting Period. The Monitor has deemed the County to be in Substantial Compliance as of the date reported by the County if the auditors verified that the County met the thresholds in the Compliance Measures. If the auditors were not able to verify the results reported by the County, the twelve-month period for maintaining Substantial Compliance will commence when the County's reported results in a future period are verified by the auditors.
Some of the Substantial Compliance results reported by the County in the Second Reporting Period have not been audited by the Monitor’s auditors and cannot be considered final until verified by the auditors. The County will not be deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 4 of 102 Page ID #:2458
twelve-month compliance period in the Monitor's future reports if the results are not verified by the Monitor’s auditors.
The County has made progress in implementing provisions of the Agreement during the Second Reporting Period, which is the first period in which most of the provisions are subject to monitoring. As the County notes in its augmented Second SelfAssessment, it has encountered a number of challenges in gathering the necessary documentation or changing its processes and procedures to establish Substantial Compliance for a significant number of the provisions. This has resulted in findings of Partial Compliance or Non-Compliance for those provisions. The County’s augmented Second Self-Assessment reports that it anticipates substantial progress during the next reporting period.
The Monitor has had discussions with the parties about having the Mental Health Subject Matter Expert perform qualitative assessments of the County's compliance with Substantive Provisions of the Settlement Agreement. The parties have deferred to the Monitor to determine, with the advice of the Mental Health Subject Matter Expert, what qualitative assessments should be performed beginning in the next Reporting Period.
Attached to this Second Report is an Appendix showing the status of each of the 69 provisions of the Agreement that are subject to monitoring under the Agreement and the twelve-month compliance triggering dates where the County is deemed to be in Substantial Compliance.
As was the case during the First Reporting Period, the County cooperated completely with the Monitor and the Subject Matter Experts during the Second Reporting Period. The Department, DMH, and County Counsel facilitated our visits and inmate interviews, answered our questions, and responded to our requests for documents and information. We appreciate their responsiveness, professionalism, and courtesy in handling our monitoring requests.
Richard Drooyan, Monitor September 1, 2016
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 5 of 102 Page ID #:2459
EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the County and the Department are in Substantial Compliance with 14 provisions, in Partial Compliance with 30 provisions, and in Non-Compliance with 13 provisions. In addition, there are ten other provisions in which the Department is in Substantial Compliance at some facilities and in Partial Compliance or Non-Compliance at other facilities. Thus, there are 24 provisions for which the County and the Department are in Substantial Compliance at some or all of the facilities.1 There is also one provision, Paragraph 20, that is Not Currently Subject to Monitoring and one provision, Paragraph 34, that has been stayed pending litigation initiated by third party intervenors.
As of the date of this Report and subject to verification by the Monitor and continuing monitoring, the County and the Department are in Substantial Compliance at some or all of the facilities with the following provisions of the Settlement Agreement:
The County has provided documentation reflecting that, as of October 1, 2016, it achieved Substantial Compliance with Paragraph 21, which requires active certifications in cardiopulmonary resuscitation and first aid, at the East and South facilities in the Pitchess Detention Center ("PDC"). The reported results have been verified by the auditors. The County also reported the Department had achieved Substantial Compliance at North County Correctional Facility (“NCCF”), the PDC North facility, and the Inmate Reception Center ("IRC") as of January 1, 2016, which has been verified by the auditors for NCCF and North, but not IRC.
The County has achieved Substantial Compliance as of July 1, 2016 with Paragraph 21, which requires the County and the Sheriff to provide instructional material on the use of arresting and booking documents to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance at IRC with Paragraph 28, which requires the Department to ensure that prisoners with emergent or urgent mental health needs are expedited through the booking process. The Monitor and Subject Matter Expert toured IRC and confirmed that there is an expedited booking process for inmates with these mental health needs.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance with Paragraph 29, which requires that a Qualified Mental Health Professional (“QMHP”) conducts a mental health assessment of prisoners with non-emergent mental health needs within 24 hours (72 hours on weekends) of the nursing intake assessment. The reported results for the first quarter 2016 have been
1 Under Paragraph 111 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 6 of 102 Page ID #:2460
verified by the Monitor’s auditors.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance with Paragraph 32, which requires that a serious suicide attempt be entered in the prisoner’s electronic medical record in a timely manner. The records reviewed by the Subject Matter Expert are consistent with the County's reported results, which have been verified by the Monitor’s auditors.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules to identify prisoners with mental illnesses and grant prisoner requests for out-of-cell interviews. The auditors have verified the reported results, which are consistent with the observations of the Monitor and the Mental Health Subject Matter Expert during tours of MCJ, TTCF, and CRDF.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance with Paragraph 41, which requires the Department and the DMH to implement step-down protocols when prisoners are discharged from FIP after being on a suicide watch. The source documents indicate that the step-down protocols required by Paragraph 41 were followed for the two prisoners who were transferred to mental health housing at TTCF.
The County has achieved Substantial Compliance as of January 1, 2016, with Paragraph 44, which requires the Department to install protective barriers in High Observation Housing and other mental health housing areas. The Monitor and Subject Matter Experts have observed that these barriers have been installed as required in TTCF and CRDF.
The County has achieved Substantial Compliance with Paragraph 45, which requires Suicide Prevention Kits and first-aid kits in control booths, as of October 1, 2015 for all facilities other than MCJ, IRC and PDC North, and as of January 1, 2016 for MCJ, IRC and PDC North. During visits to the jails in the Second Reporting Period, the Monitor and Subject Matter Experts randomly inspected control booths and staff stations, and opened Suicide Intervention Kits to verify that the Department has maintained Substantial Compliance during this period.
The County has achieved Substantial Compliance as of January 1, 2016, with Paragraph 48, which requires the Department to have written housekeeping, sanitation, and inspection plans to ensure proper cleaning in accordance with California regulations. During visits to the jails in the Second Reporting Period, the Monitor and Subject Matter Expert verified that the Department has maintained Substantial Compliance during this period.
The County has achieved Substantial Compliance as of March 1, 2016, with Paragraph 49, which requires the Department to have maintenance plans to respond to
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 7 of 102 Page ID #:2461
routine and emergency maintenance needs. During subsequent visits to the jails in the Second Reporting Period, the Monitor and Subject Matter Expert verified that the Department has maintained Substantial Compliance during this period.
The County has achieved Substantial Compliance as of January 1, 2016, at all facilities other than PDC South and PDC East with Paragraph 50, which requires the Department to provide pest control in the jails. The monitors have reviewed the Department’s documentation and verified the Department’s reported results. During visits to the jails in the Second Reporting Period, the Monitor and Subject Matter Expert verified that the Department maintained Substantial Compliance during this period.
The County has provided documentation reflecting that, as of October 1, 2015, it achieved Substantial Compliance at all facilities other than CRDF with Paragraph 51, which requires the Department to ensure that all prisoners have access to basic hygiene supplies in accordance with state regulations. Although the Monitor and Subject Matter Experts verified that the kits were regularly available and provided to prisoners at all facilities, including CRDF, the Department did not have the required documentation for CRDF. The auditors have verified the reported results.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance at MCJ and NCCF with Paragraph 54, which requires the Department to ensure that prisoners in mental health housing are "not denied privileges and programming based solely on their mental health status or prescription for psychotropic medication." The reported results are subject to verification by the Monitor based upon the audit by the Monitor's auditors.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance with Paragraph 56, which requires custody, medical, and mental health staff to communicate regarding any change in a housing assignment following a suicide attempt or serious change in mental health condition. The auditors have verified the reported results.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance at MCJ with Paragraph 57, which requires the Department to ensure that safety checks in mental health housing are completed and documented and that QMHPs approve new housing assignments. The auditors have verified the reported results.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance at PDC South, North and East with Paragraph 58, which requires the Department to ensure that safety checks in non-mental health housing are completed and documented.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance at all facilities other than TTCF and CRDF with Paragraph 68, which requires the Department to conduct staggered contraband searches
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 8 of 102 Page ID #:2462
and visible inspection of HOH cells. The reported results have been verified by the auditors.
The County has achieved Substantial Compliance as of September 1, 2016 with Paragraph 70, which requires the Department to have "policies and procedures regarding the use of Security Restraints in HOH and MOH."
The County has achieved Substantial Compliance as of September 1, 2016, with Paragraph 74, which requires the Department to have an objective law enforcement investigation of every suicide that occurs in the jails.
The County has achieved Substantial Compliance as of June 1, 2016, with Paragraph 78, which requires it to maintain a Suicide Prevention Advisory Committee.
The County has achieved Substantial Compliance with Paragraph 83, which requires it to install closed circuit security cameras throughout all of the common areas in the jails, as of July 1, 2015, at MCJ and IRC; as of October 1, 2015, at TTCF, and as of April 1, 2016, at CRDF. The Monitor and Subject Matter Expert have verified the installation and operation of the cameras during visits to the jails, and the Monitor verified that the cameras are capturing force incidents in the common areas.
The County has provided documentation reflecting that, as of January 1, 2016, it has achieved Substantial Compliance with Paragraph 84, which requires the Department's investigations of force incidents and administrative actions to be completed timely. The auditors have verified the reported results.
The County achieved Substantial Compliance with Paragraph 86, which requires inventory policies and control of all weapons, as of April 1, 2016 at MCJ and CRDF. The Monitor and Subject Matter Expert inspected the armory for each jail facility and reviewed a Custody Division directive, inventory logs, and unit orders.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 9 of 102 Page ID #:2463
18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016.
These trainings will include the following topics: (a) suicide prevention policies and procedures, including observation and
supervision of prisoners at risk for suicide or self-injurious behavior; (b) discussion of facility environments and staff interactions and why they
may contribute to suicidal behavior; (c) potential predisposing factors to suicide; (d) high-risk suicide periods and settings; (e) warning signs and symptoms of suicidal behavior; (f) case studies of recent suicides and serious suicide attempts; (g) emergency notification procedures; (h) mock demonstrations regarding the proper response to a suicide attempt,
including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance; (i) differentiating between suicidal and self-injurious behavior; and (j) the proper use of emergency equipment.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 10 of 102 Page ID #:2464

STATUS (18):

PARTIAL COMPLIANCE

The Monitor, in consultation with the Mental Health Subject Matter Expert, has concluded that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015.

The County's Initial Self-Assessment Status Report delivered on December 14, 2015, reported that the Department commenced its suicide prevention training for new Deputy Sheriffs and Custody Assistants on July 1, 2015 and for existing Deputy Sheriffs and Custody Assistants before the Effective Date of the Settlement Agreement.

The Monitor’s auditors have received training records for new deputies and new Custody Assistants sufficient to verify that the Department achieved Substantial Compliance for new personnel as of July 1, 2015, which it has maintained through December 31, 2015.

Assuming that the Department continues to maintain Substantial Compliance for new personnel, Substantial Compliance under Paragraph 18 will be achieved when 85% of the existing deputies and Custody Assistants in Custody as of July 1, 2015, have received the required training on or before the Completion Date of December 31, 2016.

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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 11 of 102 Page ID #:2465
19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams (“JMET”) at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 12 of 102 Page ID #:2466

STATUS (19):

PARTIAL COMPLIANCE

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution training and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and paragraphs 4.6, 4.7 and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert and the Rosas Monitors approved the training materials developed by the Department for the DeVRT on March 4, 2016.

The Department’s Initial Self-Assessment reported that new Deputies and Custody Assistants attended DeVRT classes beginning on August 3, 2015, and some existing Deputies and Custody Assistants attended the classes beginning on August 24, 2015. Although the classes covered much of the curriculum that was subsequently approved as of November 4, 2015, some additional training is required for Deputy Sheriffs to satisfy the requirements of this Substantive Provision. The Monitor, with the advice of the Subject Matter Expert, and the Rosas Monitors have agreed that this additional training can be included in the first refresher course required under the Rosas Implementation Plan.

The Monitor’s auditors have not received the Department's training records for new deputies and Custody Assistants to determine whether the Department achieved (and has since maintained) Substantial Compliance as of October 1, 2015, which is the date that the Department’s Initial Self-Assessment reported that this provision was "[r]eady for monitoring." The Department’s Second Self-Assessment reports that its “compliance reporting with this provision is in progress.”

The Second Self-Assessment reports that 360 existing deputies have attended 11 DeVRT classes and 140 new deputies attended the DeVRT classes in the post-Academy Jail Operations, but it does not indicate how many Custody Assistants have received the eight-hours of training in identifying and working with mentally ill prisoners as required by Paragraph 19(b).

Substantial Compliance will be achieved when 85% of the existing deputies and Custody Assistants in Custody Operations as of July 1, 2015, have received the required training, and 95% of the new deputies and Custody Assistants have received the training for twelve consecutive months.

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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 13 of 102 Page ID #:2467

20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

NOT CURRENTLY SUBJECT TO MONITORING

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the DeVRT curriculum for the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), which provides for 32 hours of Crisis Intervention and Conflict Resolution training that meets the requirements of Paragraph 20 of the Settlement Agreement. This training of Deputies assigned to the North County Correctional Facility (“NCCF”), the Pitchess Detention Center (“PDC”), and the non-Mental Health Housing Units in Century Regional Detention Facility (“CRDF”) is not required before July 1, 2017.

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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.

STATUS:

SUBSTANTIAL COMPLIANCE (at PDC East and South (verified) as of October 1, 2015; NCCF and North (verified) and IRC (unverified) as of January 1, 2016)

NON-COMPLIANCE (Remaining facilities)

The Compliance Measures provide that “[t]he Department will provide semiannual Self-Assessment reports to the Monitor and Subject Matter Experts regarding the active certification of custody staff in cardiopulmonary resuscitation and first aid. The Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required certification for 12 consecutive months.”

The County’s Initial Self-Assessment indicated that the Department was “[r]eady for monitoring at PDC North, PDC South, and PDC East facilities as of July 1, 2015” and “at NCCF as of October 1, 2015.” The Monitor’s auditors have been unable to verify these results as of these dates, but have now verified that PDC South and PDC East were in Substantial Compliance as of October 1, 2015 through the first quarter of 2016, and that PDC North and NCCF were in Substantial Compliance as of January 1, 2016. The Department has also reported that it is in Substantial Compliance at IRC as of January 1, 2016, but these results have not been verified by the auditors.

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22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016)
The revised Justice Data Interface Controller ("JDIC") message that the Department provided to the Monitor on May 11, 2016, explained what information is required in the Arrestee Medical Screening Form (SH-R-422) “to ensure the sharing of known relevant medical information on inmates’ mental health status and suicide risk,” and also that the BOMHR form (SH-J-407) is required for “all arrestees who display obvious suicidal ideation or exhibits unusual behavior that clearly manifest self-injurious behavior or other clear indication of mental health crisis[.]” In response to comments by the Monitor and Mental Health Subject Matter Expert, the Department submitted a new version of the JDIC that includes links to instructions on how to fill out both forms. The Monitor has determined, with the advice of the Subject Matter Expert, that this version is sufficient to establish Substantial Compliance, and has verified that the Department began to use the new version on June 29, 2016.
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23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: PARTIAL COMPLIANCE The Monitor has verified with the Subject Matter Expert that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department reports that it inspected all of the housing units by January 14, 2016, and it has provided the Monitor with completed checklists documenting the inspections. The County has submitted spreadsheets that list proposed work at CRDF, MCJ, and TTCF, which includes the CTC. These lists do not include times for starting and completing the work. The County also has submitted a Suicide Hazard Mitigation Plan with time-lines that reflects its responses to the observations and recommendations of the Mental Health Subject Matter Expert. The Monitor and Subject Matter Expert believe that the Department needs to create a more concrete plan specifying what work needs to be done to mitigate suicide risk, and a timetable for completing the work.
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24. The County and the Sheriff will review and inspect housing areas on at least an annual basis to identify suicide hazards.
STATUS: PARTIAL COMPLIANCE The proposed revision to CDM 3-06/020.00 FACILITIES INSPECTIONS provides that each “facility shall conduct an annual inspection of all inmate housing areas identifying potential suicide hazards,” but the Department has not issued a new policy that reflects the Monitor’s comments. On June 29, 2016, the Department provided the Monitor with a new version of the annual suicide hazard inspection tool it intends to use to identify suicide hazards beginning in the third quarter of 2016. In response to the Monitor's comments, the Department has agreed to revise the tool further and re-submit it to the Monitor.
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: NON-COMPLIANCE The Proposed Revision of the Station Jail Manual requires that any arrestee who “displays obvious suicidal ideation or exhibits unusual behavior that clearly manifests self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, suicidal inmates. . .shall be under unobstructed visual observation or in a suicidal restraint location with 15 minute safety checks.” The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent for analysis to determine compliance with Paragraph 25 of the Agreement. The County’s Second SelfAssessment reports that the Department has not been able to provide the documentation required to demonstrate Substantial Compliance, but it is working to capture the data required “to comply with Paragraph 25.”
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: PARTIAL COMPLIANCE
Medical Service Bureau (“MSB”) 201.01 RECEPTION CENTERS HEALTH SCREENING, effective February 17, 2016, provides that prisoners “with urgent or emergent medical/mental health needs will be expedited to mental health for an evaluation,” and it requires a Registered Nurse to determine whether inmates with mental health conditions need to be expedited to the clinic for treatment. Section 2.2 of DMH 20.2 RECEPTION CENTER INITIAL ASSESSMENT, effective March 1, 2016, provides that inmates “who are identified as having emergent or urgent mental health needs will be evaluated by a clinician as soon as possible but no later than 4 hours from the time of identification.” Similar provisions are reflected in Section 4.1.1.2 of DMH 70.7 SUICIDE PREVENTION, effective July 7, 2016. Taken together, the policies and procedures in these provisions address the requirements of Paragraph 26 of the Agreement.
Substantial Compliance requires the Department to “review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC to confirm that 95% of the forms “include the required mental health information” and “90% of the prisoners having urgent or emergent needs are seen by a QMHP within four hours.” The County’s Self-Assessment reports that it has not achieved compliance with either of these requirements; while 91% of the forms reviewed by the Department had the required mental health information, only 50% of the prisoners having the urgent or emergent mental health needs were seen by a QMHP within four hours.2 The Department's Self-Assessment indicates that the 50% compliance rate is partially because the randomly selected dates were early in the reporting period when the Department was still implementing new practices.
2 Notwithstanding the low 50% compliance with the four-hour requirement, the Monitor believes that the Department has achieved Partial Compliance in this Reporting Period based upon the policies that were issued in the quarter and that 91% of the forms had the required mental health information.
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.
STATUS: PARTIAL COMPLIANCE
MSB 201.01, effective February 17, 2016, provides that “[e]ach newly booked inmate into the Los Angeles County jail shall receive a medical/mental health screening prior to housing;” “[a]bsent extraordinary circumstance, each inmate at the entry into booking front will be asked questions listed on the Medical/Mental Health Screening Questionnaire by trained custody or medical personnel within 12 hours of arrival into the Reception Center;” and the Medical/Mental Health transfer summary or Arrestee Medical Screening form are supposed to “be reviewed during the intake screening.” A nurse is also supposed to “[p]rovide a hard copy of the arrestee screening form or transfer summary to the mental health clinician if the records have not been scanned into the patient’s medical record.” This policy addresses the requirements of paragraph 27.
The Compliance Measures require the Department to review the records of "randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC” to determine compliance with this provision. The County’s Second Self-Assessment reports that Qualified Medical Personnel or trained custody staff filled out a Medical/Mental Health Screening Questionnaire for all of the 100 randomly selected prisoners within 12 hours of their arrivals in the jails, and that the required documents were available to QMHPs who conducted further assessments of 19 inmates identified as having mental health needs.3
Notwithstanding the reported results, during a site visit the Mental Health Subject Matter Expert observed that not all inmates are privately screened as required by Paragraph 27.4 When inmates are shackled to chairs prior to screening, the screening was sometimes done in a public area. At CRDF, the deputies indicated that there were areas where the assessments of female inmates could be done in private, and prisoners could be taken directly to the clinic, but the process for private assessments was not clear.
The Mental Health Subject Matter Expert also noted that the quality of the
3Although the data supports the Department’s conclusion that all of the randomly selected prisoners were seen within 12 hours of arrival in the jails, the Monitor and Subject Matter Expert have not undertaken a qualitative analysis of whether inmates having mental health needs are being identified at intake. 4 The Monitor and Mental Health Subject Matter Expert will meet with the County to discuss the Subject Matter Expert's comments and observations regarding the Department's Compliance with Paragraph 27 and other provisions of the Settlement Agreement so that the Department and DMH will know what they must do to achieve Substantial Compliance with these provisions in future Reporting Periods.
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completed Arrestee Medical Screening form was uneven; some were incomplete and some were inconsistent with information conveyed by inmates at intake. For these reasons, the Monitor believes that the Department is in Partial Compliance with Paragraph 27.
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28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.
STATUS: SUBSTANTIAL COMPLIANCE (at IRC as of January 1, 2016)
NON-COMPLIANCE (at CRDF)
CDM 5-03/030.00 PRE-SCREENING, which was revised effective August 25, 2016, provides for expedited booking for inmates with urgent or emergent mental health needs and requires the Department to maintain “unobstructed visual observation of the prisoner when necessary to protect his or her safety,” and to “conduct 15-minute safety checks if the prisoner is in a cell.” This policy addresses the requirements of Paragraph 29 of the Settlement Agreement.
The Compliance Measures require the Department to review the records of randomly selected prisoners at CRDF and IRC who have urgent or emergent mental health needs to determine whether they were expedited through the booking process. The County’s Second Self-Assessment reports that it has achieved Substantial Compliance at IRC as of the first quarter of 2016, where 97% of the inmates with urgent or emergent needs were expedited through booking, and 100% were under constant observation in the IRC clinic during a site visit. The County also reports that it did not achieve Substantial Compliance at CRDF because only 20% of the inmates were expedited through booking.5
The Monitor and Mental Health Subject Matter Expert toured CRDF and IRC on May 12 and 13, 2016, and reviewed the process for expediting prisoners at intake who have emergent and urgent mental health needs. At IRC, an inmate with urgent or emergent mental health needs is initially detained on a bench directly in front of the officer’s station. He is then brought directly to the clinic where he “goes to the top of the list” to be assessed by clinicians. The inmate is under constant observation in the clinic until he is transferred to a High Observation Housing unit.6 At CRDF, the initial screening and assessment of female inmates usually takes place in front of the officers’ station on a series of benches.
5 In addition, the Department did not observe any inmates with urgent or emergent needs during the quarterly unannounced visit to CRDF. 6This was confirmed by the Subject Matter Expert on a second visit when he again observed inmates at IRC under direct observation during a site visit.
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29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016) Section 2.1 of DMH 20.2 RECEPTION CENTER INITIAL ASSESSMENT, effective March 1, 2016, requires that “[w]ithin 24 hours on weekdays (or within 72 hours on weekends and legal holidays) of an intake nursing assessment in the [Reception Centers], a mental health clinician (Qualified Mental Health Professional) shall provide an initial assessment of all inmates referred for mental health evaluation who have nonemergent-urgent mental health needs.” This policy addresses the requirements of Paragraph 29 of the Settlement Agreement. The Compliance Measures require the Department to review randomly selected records of the prisoners who are identified in the intake nursing assessment as having non-emergent mental health needs to determine if the Department completed mental health assessment for 85% of the prisoners within the required time periods. The County’s Second Self-Assessment reports that the Department achieved Substantial Compliance as of the first quarter of 2016 by completing mental health assessments for 89% of the inmates within the required time periods. The reported results for the first quarter 2016 have been verified by the Monitor’s auditors.
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30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: PARTIAL COMPLIANCE Section 2.3 of DMH 20.2, effective March 1, 2016, requires that, “[t]he initial assessment” of inmates with non-emergent-urgent mental health needs “shall include a brief initial treatment plan that addresses housing recommendations and preliminary release information.” Section 3.1.5 provides that “[t]he initial assessment shall identify any emergent issues and determine whether a referral for a more comprehensive mental health evaluation is clinically indicated." These policies address the requirements of Paragraph 30 of the Settlement Agreement The Compliance Measures require the Department to review randomly selected initial mental health assessments and report on (1) the percentage of assessments that have all of the information required by Paragraph 30, and (2) whether the housing recommendations were followed. The Second Self-Assessment reports that 98% of the housing assignments reviewed in the first quarter of 2016 followed the housing recommendations in the initial treatment plans, which exceeds the 95% threshold for Substantial Compliance. It also reports, however, that only 44% of the initial mental health assessments had the information required by Paragraph 30, which is well below the 85% threshold. In addition, the Mental Health Subject Matter Expert reviewed several of the County’s reviews of the mental health assessments, and he has “many questions about the accuracy of the data that need to be addressed before the next round.”
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31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk; (b) hoarding medications; and (c) prior suicide attempts.
STATUS: PARTIAL COMPLIANCE Section 3.1 of DMH 80.1 MENTAL HEALTH ALERTS, effective February 4, 2016, provides that electronic medical records (“EMR”) alerts shall “apply” to the “client circumstances” that include the risk factors identified above. Section 3.5.1 requires that “EMR alerts shall be initiated whenever a JMHS psychiatrist or clinician become[s] aware of one or more of the client circumstances[.]” This policy addresses the requirements of paragraph 31. The Compliance Measures require the Department to review randomly selected electronic medical records for prisoners in certain at-risk groups to determine if the required mental health alerts are in 85% of the records reviewed, which is the threshold for Substantial Compliance. The County’s Self-Assessment Reports that only 61% of the records reviewed contained the required mental health alerts.
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32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016) Section 3.5.1 of DMH 80.1, effective February 4, 2016, requires that electronic medical records (“EMR”) “alerts” shall be “initiated” whenever a JMHS psychiatrist or clinician becomes aware of certain prisoner circumstances, including “Suicide Risk” and “Prior Suicide Attempts.” Although it does not specifically require an alert when there is “a serious suicide attempt,” such an attempt would presumably fall within the categories that are covered. Section 4.4.5 of DMH 70.7, effective July 7, 2016, requires clinicians to “summarize the [Suicide Risk] assessment including the level of risk” in the prisoners EMR “within the same time frame as the documentation of the assessment.” The Compliance Measures require the Department to review the electronic medical records of all prisoners who had a serious suicide attempt in the prior quarter and provide the Monitor and Subject Matter Experts with a random sample of 10% of the records reviewed by the Department. The Second Self-Assessment reports that 100% of the electronic medical records of prisoners who had a serious suicide attempt in the first quarter 2016 reflect the suicide attempt and 100% reflect that the information was entered into the record within one day of the attempt. The results exceed the 95% and 85% thresholds for Substantial Compliance. The records reviewed by the Subject Matter Expert are consistent with the Department’s reported results, which have been verified by the Monitor’s auditors.
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33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:
(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;
(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;
(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and
(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.
STATUS: PARTIAL COMPLIANCE The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected prisoners from each clinician’s caseload. The County has provided the required tool, and the Monitor will measure compliance in accordance with the Department’s proposal to the DOJ for conducting the review required by paragraph 33(c) beginning in the next Reporting Period
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34. The County and the Sheriff will conduct discharge planning and linkage to community mental health providers and aftercare services for all prisoners with serious mental illness as follows:
(a) For prisoners who are in Jail seven days or less, a preliminary treatment plan, including discharge information, will be developed.
(b) For prisoners who are in Jail more than seven days, a QMHP will also make available:
(i) for prisoners who are receiving psychotropic medications, a 30-day prescription for those medications will be offered either through the release planning process, through referral to a re-entry resource center, or through referral to an appropriate community provider, unless clinically contraindicated;
(ii) in-person consultation to address housing, mental health/medical/substance abuse treatment, income/benefits establishment, and family/community/social supports. This consultation will also identify specific actions to be taken and identify individuals responsible for each action;
(iii) if the prisoner has an intense need for assistance, as described in DMH policies, the prisoner will further be provided direct linkage to an Institution for Mental Disease ("IMD"), IMD-Step-down facility, or appropriately licensed hospital;
(iv) if the prisoner has a moderate need for assistance, as described in DMH policies, and as clinically appropriate to the needs of the prisoner, the prisoner will be offered enrollment in Full Service Partnership or similar program, placement in an Adult Residential Facility (“Board and Care”) or other residential treatment facility, and direct assistance accessing community resources; and
(v) if the prisoner has minimal needs for assistance, as described in DMH policies, the prisoner will be offered referrals to routine services as appropriate, such as General Relief, Social Security, community mental health clinics, substance abuse programs, and/or outpatient care/support groups.
(c) The County will provide a re-entry resource center with QMHPs available to all prisoners where they may obtain information about available mental health services and other community resources.
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STATUS (34):

STAYED PENDING LITIGATION

Paragraph 34 is the subject of on-going litigation as a result of a First Amended Complaint in Intervention challenging the provisions relating to discharge planning. The County’s Self-Assessment reports that, “[a]ccordingly, the Department has stayed its compliance efforts with respect to this provision.”

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35. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team ("JMET") member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: NON-COMPLIANCE7
The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral (“BOMHR”) records for prisoners referred by custody staff to a QMHP or JMET member to determine the timeliness of the referrals.
Although the County’s Self-Assessment reports that 92% of the referrals were timely, which exceeds the 85% threshold for Substantial Compliance, the Monitor and Mental Health Subject Matter Expert have concerns regarding the reported results.
First, the Mental Health Subject Matter Expert notes that all of the cases appear to be emergent cases “demanding immediate response,” rather than routine cases of inmates who have “a potential need for routine mental health care” as required by Paragraph 35 of the Settlement Agreement.8 Timely referrals of prisoners with "emergent or urgent" needs does not necessarily show that prisoners with less apparent, routine needs are also being timely referred. Accordingly, the County needs to base the results on randomly select records from a different inmate population to establish Substantial Compliance.9
Second, the BOMHR includes the date and time of the incident, but does not include a place for the date and time of the referral to a QMHP or a JMET. Instead, the County’s reported results appear to be based upon the time the inmate is seen by medical personnel or mental health staff, or in some cases when the form was reviewed by a supervisor. The BOMHR form needs to be revised to reflect the date and time of the referral by custody staff personnel.
Third, the Monitor’s staff reviewed the County’s reported results and concluded that only 42 of the 50, or 84%, of the BOMHR records reflect that the inmate was seen by a medical personnel or mental health staff, or the form was reviewed by a supervisor,
7 This is without prejudice to the County's right to re-submit records for inmates who needed routine mental health care in the Second Reporting for purposes of assessing the triggering date of the County's Substantial Compliance. 8 The Settlement Agreement does not require Custody Operations staff to fill out a BOMHR if an inmate has an emergent or urgent mental health need (compare Paragraph 37, which requires the Court Services Division to fill out the form if an inmate displays “obvious suicidal ideation” or manifests a “clear indication of mental health crisis”), although it does require the form if an inmate “threatens or exhibits self-injurious behavior.” (See Paragraph 73.) 9 Although the Monitor and Subject Matter Expert have other concerns as set forth above, the Non Compliance determination is because the Department's results are not based on the population of inmates with routine mental health needs.
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before the end of the deputy’s shift. Although this is just below the 85% threshold, one of the cases involved an incident that occurred five minutes before the end of a shift and the inmate was seen by medical personnel within an hour.
For purposes of determining Substantial Compliance in future reporting periods, a referral of an inmate who is "demonstrating a potential need for routine mental health care" within an hour prior to the end of a deputy's shift will be deemed timely if the referral is made within one hour after the end of the deputy's shift.
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36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: PARTIAL COMPLIANCE
Section 4.4 of DMH 70.7 SUICIDE PREVENTION, effective July 7, 2016, and DMH 70.2.1 MENTAL HEALTH TREATMENT PROGRAMS, effective February 4, 2016, address the requirements of Paragraph 36.
The Compliance Measures require the Department to review randomly selected records of prisoners newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; conduct quarterly unannounced visits (with the Monitor and Subject Matter Expert on at least one occasion), and provide a staffing schedule for on-call services. The County reports that 97% of the assessments were completed within four hours, but the two inmates seen during unannounced visits (one at TTCF and one at CRDF) were not under unobstructed visual observation. The documentation provided to the auditors does not always reflect the times that the auditors need to verify the Department’s conclusions.
During tours of TTCF and CRDF, the Monitor and Subject Matter Expert visited housing areas to observe where prisoners with adverse triggering events are housed pending a QMHP evaluation. The process and procedures for observing prisoners following adverse triggering events were highly variable. Although deputies understood that they had to observe the prisoners who expressed suicidal ideation pending the evaluation by a QMHP, the prisoners were not always under constant observation. For example, in a General Population dorm at CRDF, deputies reported using the dayroom or the recreation area as well as the area directly in front of the officers’ station, and not necessarily handcuffing the prisoners. Since this was a General Population dorm, such incidents are relatively rare and the severity of the event varies. In one HOH setting in TTCF, Deputies noted that they would sometimes move a prisoner to a cell with better visibility, but it did not appear to allow for true unobstructed visual observation.
The Monitor and Subject Matter Expert believe that greater clarity on definitions, options, and expectations is necessary. In particular, when there is an "adverse triggering event," which by definition is a serious event "such as a suicide attempt, suicide threat, self-injurious behavior, or any clear de-compensation of mental health status," the inmate
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must be brought to an area directly in front of an officer's station in the facility,10 and remain in unobstructed visual observation until a QMHP has completed his or her evaluation.
The on-call staffing schedules provided by the Department show the schedules for IRC for January through March and the on-call psychiatrists for January and February. There are no schedules for CRDF or for the on-call psychiatrists for March.
10 The area does not necessarily have to be in the housing unit where the event occurred, but can be in front of an officer's station in a nearby housing unit.
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37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: NON-COMPLIANCE The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter and review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner; incident reports for self-injurious behavior by prisoners appearing in the selected courts; and BOMHR forms completed by the Court Services Division staff in the selected courts to determine compliance with this provision. The County’s augmented Second Self-Assessment reports significant problems with the use and completion of the BOMHR form for this and other provisions of the Settlement Agreement, and that it is working on finalizing a revised form to “at least partially alleviate some of the issues it has been experiencing.” Further, it is not clear from the source documents what is the basis for the percentages of compliance reported for the courts selected during the quarter, which as the Department has acknowledged are well-below the percentages required to achieve Substantial Compliance. The Mental Health Subject Matter Expert also has a number of comments regarding “completion of the BOMHR,” the unobstructed visual observations, and the County’s interpretation of inmates covered by this provision, which the Monitor and the Subject Matter Expert will discuss with the County during the next reporting period.
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38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016)
Section 3.1.7 of DMH 70.2.3 DISCIPLINARY SEGREGATION, effective December 31, 2015, addresses the requirements of Paragraph 38.
The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision.
Substantial Compliance requires that (1) 90% of the required weekly cell-by-cell checks were completed; and (2) 85% of the out-of-cell interviews requested were granted, absent documented justification for denial of the request.
The County's First Self-Assessment reported 100% success for the third and fourth quarters in 2015, but the Monitor’s auditors were unable to verify these results. The Second Self-Assessment reports 100% success for the first quarter in 2016, which has been verified by the auditors.
During a tour of CRDF on May 12, 2016, the Monitor and Mental Health Subject Matter Expert observed the JMET team make cell-by-cell rounds in disciplinary segregation. The deputy and mental health professional worked well together as a team and interacted with the prisoners to an appropriate degree. We were very impressed with their communications skills and professionalism. During a tour of MCJ on May 20, 2016, the Monitor observed the JMET team make cell-by-cell rounds in disciplinary segregation in that facility. Again, the members of the team worked well together, and interacted with the prisoners to an appropriate degree. Finally, the Subject Matter Expert observed the JMET rounds at TTCF on June 10, 2016, and noted that the JMET deputy “went to each cell, asked appropriate questions, and identified inmates needing further [Mental Health] services.”
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39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their requests to custody staff or other prisoners.
STATUS: PARTIAL COMPLIANCE
DMH 70.10 SELF-REFERRAL/REQUESTS, which was issued on April 11, 2016, sets forth policies and procedure for handling “self-referrals/requests for mental health services.” Paragraph 3.1 provides that inmates who want “to submit a selfreferral/request for mental health care may do so by placing a request form in designated envelopes, if desired, available in each housing area.” Paragraphs 3.3 sets forth the procedures for handling the self-referrals/requests and, in particular, requires DMH coordinators and JMET to “[r]efer unmet requests to the appropriate psychiatrist or clinician for resolution and follow up to ensure that the request has been addressed timely.” This addresses the requirements of Paragraph 39 of the Agreement. Although CDM 8-03/020.00 HEALTHCARE INMATE GRIEVANCES, effective July 15, 2016, is still primarily directed at grievances, it addresses requests for healthcare services that are supposed to receive “priority handling by line staff,” who are directed to “deliver them to an on-duty supervising staff nurse[.]”
During multiple tours of all of the facilities in the Second Reporting Period, the Monitor randomly checked to see if confidential self-referral forms and envelopes were available to prisoners wanting to request mental health care. With the exception of Service Area modules (MOH housing) in TTCF, a couple of modules at NCCF, and some dorms at PDC South, all of the housing areas had both grievance forms and self-referral envelopes. With respect to the Service Area modules in TTCF and the modules in NCCF, the staff explained that prisoners empty the boxes almost as soon as the forms are put in the boxes and use the forms for other than the intended purposes (e.g., drawing). From a control booth in the Service Area, the Monitor watched as a deputy re-stocked the boxes and the prisoners who were out of their cells immediately began to empty the box. The Monitor noted that the forms and sealed envelopes were readily available in the areas adjacent to these housing areas, and prisoners are able to ask staff for the forms and envelopes if the box is empty.
The Monitor spoke to a sergeant at CRDF who was in the process of picking up the forms from the housing units, and he explained that he takes these forms directly to the medical clinic without opening them. The Monitor confirmed with nurses in the clinics in various facilities that they receive the sealed envelopes at least daily, and sometimes each shift, and they determine how to address the prisoner’s requests for medical or mental health services.
Only a few of the electronic kiosks that the Department intends to use for selfreferrals, grievances, and requests have been installed. The prisoners who were interviewed by the Monitor and Subject Matter Expert indicated that the IPADs were easy to use and generally reliable. Although the Compliance Measures require the electronic kiosks to be functional, this is beyond what the Agreement actually requires.
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Based upon a review of the County’s policies and procedures, tours of the facilities, interviews, and the County’s report, and with the concurrence of the Department of Justice regarding the kiosks, the Monitor is satisfied that Department has adequate processes and procedures for inmates at MCJ, TTCF and CRDF to make confidential self-referrals for mental health care. Although there were a few instances in which the forms were not in the boxes in the housing areas in TTCF, it is not practical for the Department to immediately and constantly re-stock the forms, which are readily available to the prisoners from the staff.
Substantial Compliance requires the Department to review randomly selected self-referrals for mental health care received by the Department from prisoners during one week per quarter and confirm that (i) the referrals "were forwarded to DMH" by the Department," and that "DMH documented the timeliness and nature of DMH's response to the self-referrals[.]" The County’s augmented Second Self-Assessment reports that 94% of the self-referrals at CRDF,11 and 100% at MCJ and TTCF in the first quarter of 2016 were reviewed by the Department and forwarded to DMH, and that DMH documented 100% of its responses to the self-referrals as required by the Compliance Measures.
The documentation provided to the Monitor does not support the reported results in the Second Self-Assessment because, in some instances, it does not reflect the nature of DMH’s response. The Monitor and Subject Matter Expert do not believe a mere reference in the referral form to “seen by a clinician” is sufficient to document the nature of DMH’s response. In other instances, the forms reflected what the clinicians did to address the inmates’ requests.
11 The underlying results reported by the Department reflect 91% compliance at CRDF.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 39 of 102 Page ID #:2493
40. The County and the Sheriff will ensure a QMHP will be available on-site, by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: PARTIAL COMPLIANCE Section 2.2 of the Proposed Revision of DMH 70.2.1 MENTAL HEALTH TREATMENT PROGRAMS addresses the requirements of Paragraph 40 of the Agreement. Substantial Compliance requires DMH (1) to provide the Monitor with on-call schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week, and (2) randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify compliance with Paragraph 40. The County’s Second Self-Assessment reports “that a QMHP was assigned 24 hours a day, 7 days per week,” but “that a QMHP responded to 99% -- instead of the required 100% -- of referrals” and that “86% -- instead of the required 90% of referrals. . .were responded to within four hours.”
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41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016) Sections 4.8 and 4.9 of revised DMH 70.7, effective July 7, 2016, address Paragraph 41 of the Agreement. Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. The County’s augmented Second Self-Assessment reports that it examined the records of the only two prisoners who were (a) on suicide watch in the randomly selected month of March and (b) discharged from FIP before the end of the quarter. The source documents indicate that the step-down protocols required by Paragraph 41 were followed for the two prisoners who were transferred to mental health housing at TTCF.
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42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement “step-down” procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: NON-COMPLIANCE
Section 4.10 of revised DMH 70.7 addresses the requirements of Paragraph 42 of the Agreement.
Substantial Compliance requires the Department to review the medical records of all prisoners in HOH who are placed on risk precautions for one randomly selected month each quarter, and to submit a report on the implementation of the step-down protocols and the results of the medical records review. The County’s Second Self-Assessment reports that for the first quarter of 2016, only “5% -- instead of the required 90% -- of the records [reviewed] reflected that the QMHP determined on an individualized basis whether to implement step-down procedures” and only “33% -- instead of the required 85% -- of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable.” The County reports that, ‘[i]n response, the JMHS [Jail Mental Health Services] compliance team has taken steps to improve compliance.” The Monitor and Mental Health Subject Matter Expert will meet with the County in the next Reporting Period to discuss the County's source documents.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 42 of 102 Page ID #:2496
43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
STATUS: PARTIAL COMPLIANCE
Sections 3.1.1, 3.1.2 and 3.1.7 of DMH 70.2.3 DISCIPLINARY SEGREGATION, effective December 31, 2015, address requirements of Paragraph 43. CDM 5-09/050 LIMITATIONS ON DISCIPLINARY ACTIONS and CDM 5-09/080.00 LOCATION OF DISCIPLINE, effective as of March 14, 2016, address the requirements of Paragraph 43(a). In response to comments by the Monitor and DOJ, the Department is revising its discipline policies applicable to Paragraph 43 of the Agreement.
Substantial Compliance requires the Department to maintain a log documenting weekly walks by a QMHP in each disciplinary housing area, review the medical records of prisoners who were in mental health housing units or were receiving psychotropic medication before being assigned to disciplinary housing, and report the results of its reviews.
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The County’s augmented Second Self-Assessment for Paragraph 43 reports that for the first quarter of 2016 only “20% -- rather than the required 90% of the records reviewed reflected that a QMHP met with inmates receiving psychotropic medications and transferred [to discipline housing]”12 at MCJ and TTCF within 24 hours of the placement. Elsewhere, the Assessment reports only 67% of the records reviewed for inmates at CRDF reflected the required meeting. The Second Self-Assessment also reports that 100% of the records reviewed confirmed that a QMHP "walked through each disciplinary housing unit at least once per week" at all three facilities.
The Second Self-Assessment also reports that "[n]o inmate[s] at TTCF were transferred to discipline housing from mental health housing during the randomly selected month of March 2016." The County's response to the Monitor's draft of this Second Report indicates that it has "stopped the practice of moving inmates with mental illness to that housing." Further, the County reports that "the Department did not remove behavioral credits from inmates with mental illness in the first quarter of 2016," and therefore did not have anything to report with respect to Paragraph 43(d), which requires that “the disciplinary decision-maker will receive and take into consideration information from a QMHP” before taking away behavioral credits of inmates in mental health housing for disciplinary reasons.
12 The County's comments on the Monitor's draft of this Second Report clarified that this is the correct percentage for MCJ and TTCF.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 44 of 102 Page ID #:2498
44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016) During the Initial Reporting Period, the Monitor and Subject Matter Experts observed that the Department installed protective barriers on the second floor tier of High Observation Housing areas and most Moderate Observation Housing areas at TTCF and the CRDF during the Initial Reporting Period. During that period, the Department also provided the Monitor with a plan for the installation of additional protective barriers in other areas in mental health housing as required by Paragraph 44. On March 31, 2016, the Monitor verified that the Department completed the installation of the barriers in the remaining MOH modules at TTCF in accordance with the plan provided to the Monitor.
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45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.

STATUS:

SUBSTANTIAL COMPLIANCE (for all facilities other than MCJ, IRC and PDC North as of October 1, 2015; as of January 1, 2016 for MCJ, IRC and PDC North)

Substantial Compliance requires the Department to verify once each quarter that each control booth or officer’s station in each housing unit has both a first-aid kit and a Suicide Intervention Kit that contains an emergency cut-down tool, and to include training in the use of both the Suicide Intervention Kit and the first-aid kit in the curricula for Custody Assistants in the Academy, for new Deputy Sheriffs in the Jail Operations Continuum, and for existing deputies in the two-hours of Suicide Prevention Training. The Department has reported 100% compliance as of October 1, 2015 at all jail facilities except for Men’s Central Jail, and 100% compliance as of January 1, 2016, at all facilities, including Men’s Central Jail. The auditors noted, however, that there were no results for IRC reported for the fourth quarter of 2015, but were reported for the first quarter of 2016, and the results reported for PDC North for the fourth quarter of 2015 were seemingly inconsistent.

As in the past, during visits to all of the jail facilities in this period the Monitor and Subject Matter Experts inspected control booths and staff stations on a random basis and verified that each inspected control booth and station had both a first-aid kit and a Suicide Intervention Kit. On these visits, the Monitor also asked Custody staff show him the kits, and Custody staff always knew where the kits were located. The Monitor also randomly asked Custody staff to open Suicide Intervention Kits and verified that each kit contained an emergency cut-down tool.

Training in the use of the Suicide Intervention Kit is included in the Department’s Suicide Prevention Training and in comprehensive training in the Department’s mandated First Aid Training.

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46. The County and the Sheriff will immediately interrupt, and if necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to review the documentation from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment. The Department has posted results showing that "85%, rather than [the required] 95%, of the documents reviewed indicated that appropriate aid and immediate interruption of selfinjurious behavior was provided by the Department."
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 47 of 102 Page ID #:2501
47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: PARTIAL COMPLIANCE The County’s augmented Second Self-Assessment sets forth what the County has done to implement each of the paragraphs of the Settlement Agreement and provides “updates about JMHS staffing, which is part of its overall effort to implement the terms of the Agreement.” The augmented Second Self-Assessment reports on two Critical Incidents that fall within the subject matter of the Agreement (inmate suicides) and one that does not (an upgrade of the electronic medical record system), and it notes that the “Departments have been discussing the appropriate definition of ‘critical incident’ with both the monitor and DOJ.” The Monitor is of the view that, in addition to inmate deaths and suicides, Critical Incidents should include, at least, serious suicide attempts, assaults on staff by inmates in mental health housing units or on mental health caseloads resulting in injuries to staff or criminal referrals, and Category 3 uses of force (or a statement that no such incidents occurred).
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 48 of 102 Page ID #:2502
48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations ("CCR") Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016) The Department’s revised CDM 5-11/020.00 SANITATION issued on July 6, 2015, requires each facility to “have a written housekeeping, sanitation and inspection plan.” The Department has provided Unit Orders for each facility that, for example, “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility." As required by the Compliance Measures, the Department provided the most recent Local Detention Health Inspection Report pursuant to California Health & Safety Code Section 101045 and Corrective Action Plans for each facility. The Monitor, after consultation with the Subject Matter Expert, certified in the Initial Report that the Department’s plans satisfy the requirements of CCR Title 15, §1280 and have been implemented as of January 1, 2016. On April 14 and 15, 2016, the Monitor and a Subject Matter Expert inspected each of the facilities to assess the Department’s compliance with Paragraph 48 of the Agreement. On May 20 and 24, 2016, the Monitor again inspected the facilities (other than CRDF). During these inspections, we again interviewed facility staff and inmates and again inspected the food service departments, medical departments, intake areas and random housing units. We again found that there was “an acceptable level of cleanliness, sanitation, repair and safety” in each facility. The Department has confirmed that it has a continuing obligation under the Agreement to comply with its plans and maintain “an acceptable level of cleanliness, sanitation, repair and safety” in each facility in the future.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 49 of 102 Page ID #:2503
49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016)
CDM 4-07/020, effective January 26, 2016, requires Unit Commanders to establish plans for their facilities that address the requirements of Paragraph 49 of the Agreement. Unit Orders for each facility have been issued to, for example, “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility.” Unit Orders address procedures for handling maintenance requests and the eUDAL and Maximo automated systems are used to track such requests while on-site. The Unit Orders indicate that the Facilities Services Bureau (“FSB”) is to be notified when there is mold, and it will be responsible for treating the problems. The Department submitted a memorandum from FSB, dated February 3, 2016, indicating what steps FSB takes to treat the problem, which was required to establish Substantial Compliance with Paragraph 49.
Each facility has written maintenance plan for responding to routine and emergency needs and for addressing small and large mold infestations (minor mold infestations are handled by facility staff and inmate work crews and large mold infestations are reported to FSB for handling). Each facility also has a maintenance coordinator who serves as the point person between the facility, maintenance contractors and the Internal Services Departments, as well as serving as coordinator for inmate work crews.
On April 14 and 15, 2016, the Monitor and a Subject Matter Expert inspected each of the facilities for the purpose of assessing the Department’s compliance with Paragraph 49. During the inspections we again interviewed facility staff and inmates and again inspected lighting systems, heating, ventilation and cooling systems for functionality and upkeep. We again found that these systems were “adequately maintained and installed.”
Again, the Department has confirmed that it has a continuing obligation under the Agreement to adequately maintain lighting systems, heating, ventilation and cooling systems in each facility in the future.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 50 of 102 Page ID #:2504
50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.
STATUS: SUBSTANTIAL COMPLIANCE (at all facilities other than PDC South and PDC East as of January 1, 2016)
PARTIAL COMPLIANCE (at PDC South and PDC East)
CDM 5-11/030.00 CONTROL OF VERMIN, effective December 14, 2015, addresses the requirements of Paragraph 50 of the Settlement Agreement. On April 14 and 15, 2016, the Monitor and Subject Matter Expert again inspected each of the facilities found that there was “an acceptable level of cleanliness, sanitation, repair and safety” in each facility. The Monitor again inspected the facilities (other than CRDF) on May 20 and 24, 2016, and again found the acceptable level. During the inspections they again interviewed facility staff and inmates and inspected the food service departments, medical departments, intake areas and random housing units. The food service areas are serviced frequently for pest, rodent and insect control, but medical areas and housing units are not serviced as often. There was no indication of any pest control problems in the housing units, the medical units, kitchen, food storage areas, or elsewhere in the facilities.
Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with a copy of a contract with an outside vendor for regular pest control services at each jail facility and, on a quarterly basis, a schedule of the pest control activities at each facility in the previous quarter; a pest control compliance checklist of the pest control activities taken at each facility in the previous quarter; documentation from the outside vendor reflecting visits to each jail facility and the work performed during the visits; and a copy of the most recent report by the County Department of Public Health concerning pest control in the jail facilities.
During the last Reporting Period, the Monitor and Subject Matter Expert reviewed copies of the Department’s contracts with outside vendors for regular pest control services for the jail facilities; the pest control compliance checklists of the pest control activities taken at each facility in the previous quarter; documentation from the outside vendor reflecting visits to each jail facility and the work performed during the visits; and a copy of the most recent report by the County Department of Public Health concerning pest control in the jail facilities. The Second Self-Assessment reports that the Department has achieved Substantial Compliance at all facilities other than PDC South and East, where the Department is missing some of the required documentation for the first quarter of 2016. The County’s report has been verified by the Monitor’s auditors.
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Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 51 of 102 Page ID #:2505
51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016 for all facilities other than CRDF)
PARTIAL COMPLIANCE (for CRDF)
The Department has provided the Monitor with a photograph of an Admission Kit and a copy of the form allowing existing prisoners to order admission kits. The Department also issued revised CDM 5-13/090.00 PERSONAL CARE ITEMS AND SUPPLIES FOR INMATES, effective February 24, 2016, which requires that Admission Kits be provided to new prisoners and to existing prisoners upon request in accordance as required by CCR Title 15 § 1265, and was required to establish Substantial Compliance with Paragraph 51.
During tours of CRDF and TTCF on May 12 and 13, 2016, MCJ and TTCF on May 20, 2016, and the facilities in the Pitchess Detention Center on May 24, 2016, the Department provided the Monitor and Subject Matter Expert with the Admission Kits for female and male inmates. The Monitor and Subject Matter Expert randomly inspected control booths and officers’ stations and verified that the kits were readily available and regularly provided to the prisoners at all of the facilities. The kits are also provided to female inmates upon intake at CRDF with instructional materials in both English and Spanish, but not to the male inmates at IRC, which is a transit facility. The male inmates receive the kits without instructional materials when they arrive at their assigned facilities.
The Initial Self-Assessment reported Substantial Compliance for all facilities in the fourth quarter of 2015 based upon inspections and reviews of vendor documentation during the designated month of October. The Second Self-Assessment reports Substantial Compliance for all facilities except CRDF for the first quarter of 2016 based upon inspections and reviews of vendor documentation during the designated month of March. The Second Self-Assessment reports Partial Compliance rather than Substantial Compliance for CRDF because 20 of 50 signature sheets confirming receipt of hygiene kits were signed by custody staff rather than the inmate. The reported results are subject to verification by the Monitor’s auditors.
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52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: PARTIAL COMPLIANCE
The Department's ALLOWABLE INMATE PROPERTY policies – CDM 5/06.010.05 for male inmates and CDM 5/06.010.10 for female inmates – require that property restrictions for inmates in mental health housing be determined by “a mental health professional after a clinical assessment has been conducted." The County’s Second Self-Assessment reports that DMH 70.7, which set forth property restrictions in HOH, is being revised in response to the Monitor’s comments to require the same level of property restrictions where two inmates in mental health housing are co-housed in a single cell.
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52.
The County’s initial Self-Assessment and its augment Self-Assessment report that it has not achieved Substantial Compliance at either TTCF or CRDF, which are the only facilities with HOH, with any of the Compliance Measures for Paragraph 52. The County reports that 66% and 67% of the inmates initially placed in HOH at TTCF and CRDF, rather than the required 95%, were provided the property required by Paragraph 52, and that 90% and 93% of the inmates placed in HOH "for more than 24 hours," rather than the required 95% had "allowable property as recommended by a QMHP[.]" The
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County also reports that 34% of the records reviewed for TTCF reflected a QMHP recommendation regarding allowable property based upon a clinical assessment "within 24 hours of initial placement in HOH" and 0% of the records of the Electronic Medical Records reviewed "reflected that property restrictions after 24 hours were based upon the clinical judgment and assessment by a QMHP.” For CRDF, 0% of the records reviewed reflected clinical assessments either within or after 24 hours of the inmates' initial placements in HOH.
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53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: NON-COMPLIANCE (at CRDF and TTCF)
NOT SUBJECT TO MONITORING (at MCJ)
CDM 5-13/100.00 RELIGIOUS PROGRAMS, CDM 5-13/130.00 INMATE EDUCATION (which is subject to a revision required by the Monitor), and CDM 501/020.00 INMATE WORKER ASSIGNMENTS address the requirements of Paragraph 53 of the Settlement Agreement.
Substantial Compliance requires the Department to audit the records of prisoners who were eligible and rejected or disqualified for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone. The County’s augmented Second Self-Assessment and comments to the Monitor's draft of this Report indicate that only 50% of the records reviewed at CRDF and 66% of the records at TTCF “reflected that the relevant inmates were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone,” which is well below the 90% threshold for Substantial Compliance.
Although the Department’s augmented Second Self-Assessment reports that it has achieved Substantial Compliance at MCJ, there were no inmates in mental health housing at MCJ who requested work or programs. The Monitor intends to measure the 12-month period for Substantial Compliance at MCJ from the date upon which MCJ achieves Substantial Compliance based upon inmates requests at MCJ. If, however, there are no such requests before the end of the 12-month period(s) in which TTCF and CRDF achieve Substantial Compliance, the Monitor will deem the entire Department to be in Substantial Compliance with this provision for purposes of Paragraph 111 of the Agreement.
The Monitor and Subject Matter Expert have had concerns that inmates with mental health needs may not be able to participate in programs that are only available at the Pitchess Detention Center because the Department is not able to house and provide mental health care for such inmates at the Pitchess facilities. Based upon the comments from the parties, we understand that this paragraph and Paragraph 54 are "aimed at the three downtown facilities, not Pitchess," and they do not require that programs at Pitchess be available to inmates with mental illnesses who are housed at the downtown facilities. Nevertheless, on a recent tour of the Pitchess Detention Center, the Monitor was advised that the Department is currently housing 68 inmates with some mental illnesses in one of the dorms at the North facility, with plans to house up to 320 such inmates in one of the four modules at that facility.13
13 There are four dorms in each module and each dorm can house up to 80 inmates with mental illnesses.
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54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016 at MCJ and NCCF) NON-COMPLIANCE (as TTCF and CRDF)
The Proposed Revisions of CDM 5-13/100.00 RELIGIOUS PROGRAMS, CDM 5-13/130.00 INMATE EDUCATION (which is subject to a revision required by the Monitor), and CDM 5-01/020.00 INMATE WORKER ASSIGNMENTS address the requirements of Paragraph 54 of the Settlement Agreement. See Implementation Status of Paragraph 53, supra.
Substantial Compliance requires the Department to audit the records of prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. The County’s Second Self-Assessment reports that the Department has achieved Substantial Compliance at MCJ and NCCF as of the first quarter 2016, but not at TTCF or CRDF. The reported results are subject to verification by the Monitor based upon the audit by the Monitor's auditors.
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55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.
STATUS: PARTIAL COMPLIANCE Sections 3.5.2.3 and 3.5.3.2 of DMH Policy 70.2.1, effective February 4, 2016, require "relevant custody, medical and mental health staff" to meet in accordance with the requirements of Paragraph 55. The Monitor and the Mental Health Subject Matter Expert attended a weekly HOH meeting at CRDF on November 18, 2015, and were impressed with the level of communications among custody, medical, and mental health personnel. The Monitor and Subject Matter Expert understand that there are daily HOH meetings at CRDF with fewer participants, which we did not attend. The County’s augmented Second Self-Assessment reports that the Department has not achieved Substantial Compliance for Paragraph 55. According to the Assessment, the Department “did not meet the compliance percentages because individual meetings were either missing a member from one of the departments, or the sign-in sheet for the meetings was not located.”
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56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016) 4.4.6 of DMH 70.7, effective July 7, 2016, provides that “JMHS and LASD shall ensure that custody, medical and mental health staff communicate regarding any change in an inmate’s housing assignment following a suicide threat or attempt, other selfinjurious behavior or other indication of an obvious and serious change in mental health condition.” Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH; and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing. The County’s augmented Second SelfAssessment reports that it has achieved Substantial Compliance with more than 95% of the records reviewed for the first quarter of 2016 reflecting the required medical and/or mental health approvals. These reported results have been verified by the Monitor's auditors.
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57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57):

SUBSTANTIAL COMPLIANCE (at MCJ as of January 1, 2016)

PARTIAL COMPLIANCE (at CRDF and TTCF)

CDM 4-11/030.00 INMATE SAFETY CHECKS and CDM 4-11/030.05 TITLE 15 SCANNER, address the requirements of Paragraph 57, except for 57(e).

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit in two randomly selected weeks to determine if the safety checks were staggered and conducted as required by Paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit for one randomly selected week to determine if a QMHP approved the new mental health housing assignments as required by Paragraph 57(e). The Monitor met with the Department to review its new data system and concluded that it captures the timing of staggered safety checks to determine whether the Department is meeting the times required by Paragraphs 57 and 58. The Monitor has also observed Custody staff conduct safety checks at MCJ, TTCF, CRDF, and PDC North which are the facilities that house inmates with mental illnesses.

The County’s augmented Second Self-Assessment reports that it has achieved Substantial Compliance with both of these Compliance Measures in the Hope Dorm at MCJ, which is Moderate Observation Housing, in the first quarter of 2016. The reported results for MCJ have been verified by the Monitor's auditors, who created a Microsoft Excel worksheet based upon the direct-feed data from the Department and confirmed that the times between the checks were less than 30 minutes for 95% of the checks, The auditors also verified that a QMHP approved the housing assignments of inmates in the Hope Dorm during the during the randomly selected week. The County also reports that QMHPs approved new mental housing assignments at TTCF and CRDF as required by Paragraph 57, but it has not achieved the threshold for conducting staggered safety checks.

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58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells;
(b) At least every 30 minutes in dormitory-style housing units where the unit does not provide for unobstructed direct supervision of prisoners from a security control room;
(c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes;
(d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing;
(e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(f) Custody staff will document their checks in a format that does not have pre-printed times;
(g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and
(h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
STATUS: SUBSTANTIAL COMPLIANCE (at PDC South, PDC North, and PDC East as of January 1, 2016)
PARTIAL COMPLIANCE (at NCCF)
NON-COMPLIANCE (at remaining facilities)
CDM 4-11/030.00 and 4-11/030.05 address the requirements of Paragraph 58.
Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by Paragraph 58. The County’s augmented Second Self-Assessment and its response to the Monitor's draft
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of this Report indicate that the Department has achieved Substantial Compliance at PDC South, PDC North, and PDC East. Based upon a review of the County's data. the Monitor has also concluded that the County achieved Partial Compliance at NCCF, but not at CRDF, MCJ, or TTCF, where the compliance percentages were well below the percentages required by the Compliance Measures. The Substantial Compliance results have been verified by the Monitor's auditors. The Monitor has also observed safety checks being conducted at NCCF, PDC North, and PDC South and reviewed with Department supervisors the systems in place for ensuring that safety checks are performed timely by Department personnel at these facilities.
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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.
STATUS: PARTIAL COMPLIANCE CDM 4/11-020.00 requires shift floor sergeants to visit housing areas under their supervision once per shift to review the UDAL "for accuracy, and to ensure all inmate safety checks and other required officer activities are conducted and documented properly." CDM 4/11.030.00 requires the sergeants to "conduct an unannounced check of each housing area under their supervision, not less than once per shift, to ensure all inmate safety checks are conducted and properly documented." These provisions address the requirements of Paragraph 59 of the Agreement. Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if the supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. Although the County’s augmented Second Self-Assessment reports that the Department is in Substantial Compliance with this provision at all facilities, the Monitor has not been able to determine from the documentation if custodial supervisors conducted the required unannounced daily rounds to ensure that custodial staff had conducted necessary safety checks.14 The e-UDAL forms need to be modified to include a specific notation that the Supervisor verified that the safety checks are being conducted.
14 Although the Monitor's First Report accepted the Department's conclusion that it had achieved Substantial Compliance at PDC South as of October 1, 2015, the report noted that the "results will be subject to verification by the Monitor based upon the audit by the Monitor's auditors."
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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: NON-COMPLIANCE DMH Policy 50.1 CONTINUOUS QUALITY IMPROVEMENT, effective December 31, 2015, is intended "to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program" that focuses on "identifying and addressing clinical issues that place inmates at significant risk of suicide or self-injurious behavior[.]" Substantial Compliance requires the County's Self-Assessments to set forth (a) any identified clinical issues in the areas identified in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods. The County’s augmented Second Self-Assessment reports that the “Department’s compliance reporting with this provision is in progress.”
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts:
(i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints;
(c) Psychotropic medications;
(d) Access to care, timeliness of service, and utilization of the Forensic Inpatient Unit; and
(e) Elements of documentation and use of medical records.
STATUS: NON-COMPLIANCE
DMH 50.1 CONTINUOUS QUALITY IMPROVEMENT, effective December 31, 2015 is intended "to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program."
Substantial Compliance requires the County’s Self-Assessments to set forth (a) any identified clinical issues in the areas set forth in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods.
The County’s augmented Second Self-Assessment reports that the JMHS quality improvement programs “are in the preliminary stages” and that Exhibit A to the assessment “captures some initial activity by both CCSB and the JMHS quality improvement program.” It also reports that “monthly meetings that take place are being expanded to cover some of the quality improvement subjects covered by this provision.”
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE DMH 50.1 CONTINUOUS QUALITY IMPROVEMENT, effective December 31, 2015, is intended "to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program." CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU, effective February 4, 2016, provides that “[p]ersonnel from CCSB will conduct follow up assessments upon the completion of corrective action reports to verify that any identified deficiencies have been addressed" and "will participate in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program." Substantial Compliance requires the County's Self-Assessments to set forth (a) any identified clinical issues in the areas set forth in paragraph 61 of the Agreement that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods. As noted by the County, Exhibit A to the Second Self-Assessment “captures some initial activity by both CCSB and the JMHS quality improvement program” in that it identifies issues in the areas set forth in Paragraph 61, and it "includes recommendations and potential corrective action, status of the development of the corrective action and status of the implementation of corrective action plans on a variety of issues, including, and organized by, the mandated topics."
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63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.

STATUS: PARTIAL COMPLIANCE

The Compliance Measures require that the County's Self-Assessment set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period; (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. Substantial Compliance requires “the immediate availability of HOH and MOH beds at TTCF and CRDF 95% of the time.”

The County’s augmented Second Self-Assessment reports the following results of its review of Department records for the randomly selected weeks to determine the immediate availability of HOH and MOH beds:

TTCF CRDF

MOH 100% 50%

HOH 57% 36%

On August 15, 2016, the County reported on the average daily populations in HOH and MOH units at CRDF and at TTCF, the average number of beds, and the average number of step-downs per week, but not "the number of days in which there was a waiting list for HOH or MOH housing." The County also reported on the immediate availability of HOH and MOH beds during the entire reporting period as required by the Compliance Measures as follows:

TTCF CRDF

MOH 100% 83%

HOH 37% 43%

With the exception of the availability of beds in MOH housing at TTCF, the percentages are well below the 95% required by the Compliance Measure. Nevertheless, the County has achieved compliance "on some, but not all, of the material components" of Paragraph 63.

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64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in an initial 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed. On January 22, 2016, the Department submitted a short-term plan to the Monitor. On March 2, 2016, it certified that it had implemented the short-term plan. On June 30, 2016, the Department submitted the long-term plan to the Monitor. The Mental Health Subject Matter Expert comments that the short-term plan “is a reasonable plan and addresses capacity not just by adding beds but by other sound programmatic enhancements designed to decrease utilization[.]” Because the County has “recently decided to step back from [its] plans to use outside facilities in the long-term plan, however, it “undercut[s] some of the short-term plan” and leaves a “gap” in the long-term plan.
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the County's Self-Assessments to set forth the (1) the results of weekly medication Administration Audits documenting the visual observation of the administration of medication during the quarter; (2) unauthorized medications found as a result of cell searches during the reporting period; and (3) incidents involving confirmed prescription drug overdoses. The reported results are subject to the Monitor’s conclusions, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner. The County’s augmented Second Self-Assessment concludes that the Department “achieved substantial compliance with this provision,” based upon “the result[s] of Administrative Audits documenting the visual observation of the administration of medication” of 92% for outpatients (in the jail facilities) and 100% for inpatients in CTC. While these unaudited percentages exceed the 85% threshold for Substantial Compliance, both the Monitor and Subject Matter Expert observed a pill call at CRDF that was not sufficiently rigorous in the identifying inmates and conducting mouth checks to prevent the possibility of misuse, hoarding and overdose.
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66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NON-COMPLIANCE Section 2.3 of DMH policy 70.3.7 provides that prisoners in HOH units, and any prisoners in MOH units "who are refusing medications and are having significant symptomatology due to refusing, and clients with Serious Mental Illness (SMI) housed in other areas of the jails shall remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications. . . . " and "shall be managed in such a way as to increase the likelihood of psychotropic medication compliance." The policy needs to be further revised so to make it clear that it applies to all HOH and all MOH prisoners who refuse medications, not just those "having significant symptomatology due to refusing." The County’s Second SelfAssessment reports that the policy has been revised, but the “revisions have not been published.” Substantial Compliance requires the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with SMI to assess whether they remain on an active mental health caseload, have been offered structured mental health treatment, and have been seen by a QMHP at least monthly, regardless of whether they refuse medications. The County’s augmented Second Self-Assessment reports that the Department has not achieved Substantial Compliance because it has not been able to obtain documentation to establish compliance with this provision. It reports that the "Department expects to see more comprehensive and increasingly results over the next few quarters."
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings; (c) the use of clinically appropriate interventions with such prisoners to
encourage medication compliance; (d) consideration of the need to transfer non-compliant prisoners to higher
levels of mental health housing; and (e) individualized consideration of the appropriateness of seeking court orders
for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a). STATUS: NON-COMPLIANCE Section 4.5 of DMH 70.3.7 addresses the requirements of Paragraph 67(a) through (e) for prisoners in HOH or MOH units (and others) who refuse psychotropic medications for specified periods. Substantial Compliance requires the County to review the electronic medical records (EMR) of prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records reflect the documentation and consideration of the matters required by the terms of Paragraph 67. The County’s augmented Second Self-Assessment reports that “less than 1% -- instead of the required 85% -- of the EMRs reviewed . . . reflected the documentation and consideration of the matters required by paragraph 67.” As explained by the County, “[m]uch of this provision entails new procedures and requires massive changes across DMH and MSB” so that they can "track refusals, collect related data and take action based on that information."
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.
STATUS: SUBSTANTIAL COMPLIANCE (at MCJ, NCCF, PDC East, PDC South, and PDC North as of January 1, 2016) NON-COMPLIANCE (at TTCF and CRDF)
The Proposed Revision of CDM 5-08/010.00 SEARCHES, which requires contraband searches on a regular, but staggered basis in all housing units, and visual inspection of HOH housing units prior to housing prisoners with mental health issues in HOH units, addresses the requirements of Paragraph 68. Pending approval of this policy, which has been pending at the Department since February, the Department has issued a Directive "to establish additional procedures for conducting inmate contraband searches with respect to the hoarding of medication."
Substantial Compliance requires Self-Assessments to include a summary of searches conducted in the previous quarter15 and to randomly select and review 25 Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units. The County’s augmented Second SelfAssessment reports that the Department achieved Substantial Compliance at MCJ, IRC, NCCF, PDC East, PDC South, and PDC North, but not at CRDF, where 87% and 81% of the modules were searched in the relevant quarters, or at TTCF, where only 35% and 42% of the modules were searched. In addition, only 44% of the HOH cells at TTCF and 36% of the HOH cells at CRDF were visually inspected as required by Paragraph 68. The reported Substantial Compliance results have been verified by the Monitor's auditors.
15 The Monitor agrees with the County that this should be the second quarter of the last reporting period and the first quarter of this current reporting period.
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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: PARTIAL COMPLIANCE
The County’s policies on who can approve clinical restraints are confusing. CDM 7-03/030.00 MEDICALLY ORDERED RESTRAINT DEVICES, which County advised that Monitor on June 8, 2016 had been revised, permits multi-point restraints to be authorized by a MSB “medical provider or with the approval of a . . .licensed psychiatrist who has performed an individual assessment and an appropriate Forensic Inpatient order.” Although DMH 100.8 CLINICAL RESTRAINTS defines a “clinical restraint” as a device “that has been ordered or approved by a licensed psychiatrist for the purpose of managing behavior that appears to be symptomatic of a mental illness,” it is “guided by” Section 2-1f of the CTC Policy and Procedures Manual, which, as the Mental Health Subject Matter Expert notes, “speaks to a physician ordering restraints but does not specify licensure or that it must be a psychiatrist." Thus, it is not clear that the clinical restraints can only be ordered with the approval of a licensed psychiatrist. The policy also does not require an individual assessment by a psychiatrist.
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved, and documented, and that the results of medical welfare checks on restrained prisoners were also documented, as required by Paragraph 69 of the Agreement. The County’s augmented Second Self-Assessment reports that “50% -- rather than the required 95% -- of electronic medical records reviewed. . .reflected that, for inmates placed in clinical restraints, the restraints were used, approved and documented as required.” As the County noted in response to the draft of this Report, however, the Department achieved close to 100% compliance with most of the components of the Compliance Measure.
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016)
CDM 7-03/000.05 FIXED RESTRAINTS, effective August 31, 2016, provides as follows: "Fixed restraints shall never be used as a form of punishment and shall only be used in the least restrictive means and for the shortest period of time necessary to provide safety." CDM 7-03/000.15 SECURITY RESTRAINTS IN MENTAL HEALTH HOUSING, effective August 31, 2016, provides as follows: "Security restraints in High Observation Housing (HOH) and Moderate Observation Housing (MOH), and for inmates awaiting housing assignments in the Correctional Treatment Center (CTC), will not be used as an alternative to mental health treatment and will be used only when necessary to ensure safety. Security restraints will not be used to punish inmates. Custody Personnel assigned to HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas." This addresses the requirements of Paragraph 70(a), (b), and (c). CDM 7-03/010.00 WAIST-CHAIN PROCEDURES, effective August 31, contains a similar provision. In addition, it provides that “[i]f the inmate appears to be in mental health crisis, custody staff will immediately refer the inmate to Jail Mental Health (JMH) personnel, which addresses the requirements of Paragraph 70(d). CDM 701/240.00 HANDLING INSUBORDINATE, RECALCITRANT, HOSTILE OR AGGRESSIVE INMATES also provides that “[w]hen the inmate is, or appears to be mentally ill, personnel shall request a sergeant and a mental health professional to respond unless there is an immediate threat of physical harm” as required by Paragraph 70(d).
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71. The County and the Sheriff will ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71. The County’s Second Self-Assessment reports that “60% -- rather than the required 90% -- of electronic medical records reviewed . . . reflected that, for inmates placed in clinical restraints, the inmates received therapeutic services as required by this provision.” The Mental Health Subject Matter Expert comments that the Department is “generally responding to those released from restraints and addressing these issues in most cases[.]”
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72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.
STATUS: PARTIAL COMPLIANCE
CDM 4-10/05.00 INMATE DEATH – REPORTING AND REVIEW PROCESS requires certain notifications in the event of an inmate death, along with corrective action plans as necessary. Although it does not specifically require the Department to determine "whether staff engaged in any violations of policies, rules, or laws," it now provides that the final written report shall include “[a] reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any.”
CDM 4-10/060.00 CRITICAL INCIDENT REVIEW COMMITTEE – SUICIDAL INMATES, issued on February 24, 2016, covers attempted suicides as "serious suicidal behavior," but not "serious self-injurious behavior." The County’s Second Self-Assessment reports that this will be addressed in the next revision of the policy expected by the end of the third quarter of 2016. This policy requires the Critical Incident Review Committee to consider, within 30 days of the incident "whether violations of policy or laws by department personnel were a factor. The review will also consider improvements to policy, training, programs or the facility are warranted." Further, it provides that "Correction action plans (CAP) which identify areas in need of improvement and propose solutions will be developed and documented."
DMH 50.2 CRITICAL INCIDENT REVIEW, effective February 4, 2016, encompasses “actual or suspected suicides” as well as “serious self-injurious behavior” in the review process that includes “determining whether staff engaged in any violations of policies, rules or laws and whether improvements to policy, training, operations or treatment programs are warranted.”
In addition to approval of written policies and procedures that address the requirements of Paragraph 72, Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings to review incidents that involve serious self-injurious behavior in the reporting period. The Monitor attended two suicide review meetings, which addressed the requirements of Paragraph 72.
Although the Department reports Substantial Compliance, as observed by the Mental Health Subject Matter Expert (and confirmed by the Monitor) the reviews “do not uniformly cover all the topic areas specified in measure 72(a) and (b)” and “most do not go into adequate depth.” In particular, while the CIRC meetings review the incidents involving serious self-injurious behavior, they do not always specifically address whether staff violated any policies or whether improvements are warranted. In many instances,
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the answer to either or both of these issues may be negative, but that information needs to be reflected in the documentation to establish that the issues were considered. Further, the Subject Matter Expert was not able to confirm from the data provided by the County that 90% of incidents involving self-injurious behavior were reviewed to determine these matters.
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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: NON COMPLIANCE
The Proposed Revision of CDM 4-05/000 BEHAVIORAL OBSERVATION AND MENTAL HEALTH REFERRAL REPORTS requires "[a]ll custody personnel who identify an inmate, either through observation, information received from another person (i.e. relative, clergy, etc.), intake screening, or exhibited behavior indicative of possible mental illness, or who threatens or exhibits self-injurious behavior" to complete a BOMHR "no later than the end of shift." Proposed revision of CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU requires the Custody Compliance and Sustainability Bureau ("CCSB") to promptly notify the County Office of Inspector General (OIG) of all apparent or suspected suicides occurring at the Jails. These propose revisions, when issued, will address the requirements of Paragraph 73.
Substantial Compliance requires the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicide during the reporting period. The County’s augmented Second SelfAssessment reports that “28% -- instead of the required 90% -- of records reviewed. . . had the information required by provision 73. The Subject Matter Expert notes, however, that the County may be under-reporting its success since it seems to require the presence of a BOMHR, an injury report, and an incident report in each case, even though all three reports are not necessarily required.
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74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016) Substantial Compliance requires the Department to provide the Monitor with an Executive Suicide Death Review reflecting the results of the Department’s investigation of any suicide in the Jails within six months of the suicide. The review must reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded. There were two suspected suicides during the Second Reporting Period for which the first Executive Suicide Death Review for the suicide that occurred on February 29, 2016, was due on or before August 28, 2016. On August 25, 2016, the County timely provided an Executive Inmate Death Review of the first of the two suicides. The Review includes a thorough and objective report from the Department's Detective Division – Homicide Bureau of its investigation of the suicide. The detective's report lists the persons who were interviewed and whether the interviews were recorded. With one possible exception, it appears that all of the interviews were recorded and, therefore, the Department met the 90% threshold for Substantial Compliance
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75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
STATUS: PARTIAL COMPLIANCE
Sections 4.2, 4.7.2 and 4.8 of DMH 50.2, effective February 4, 2016, and CDM 410/060.00 CRITICAL INCIDENT REVIEW COMMITTEE—SUICIDAL INMATES, effective February 24, 2016, address the requirements of Paragraph 75.
Substantial Compliance requires (a) DMH to randomly select and review documentation of suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (b) the Department and DMH reviewed the relevant information known at that time, the status of any corrective actions taken, and that it considered the need for additional corrective action if necessary; and (c) that the information is reflected in the Department's database for tracking and statistical analysis. The County’s augmented Second SelfAssessment reports “that 49% -- instead of the required 85% -- of the documentation reviewed pursuant to this provision was compliant with compliance measure 75-5(a);” “45% -- instead of the required 95%” for measure 75-5(b); and “100% -- 5% more than the required 95%” for measure 75-5(c). Further, as the County notes in its response to the Monitor's draft of this Report, DMH and the Department achieved compliance with most of the elements of Paragraph 75 and the corresponding Compliance Measures.
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The Mental Health Subject Matter Expert has a number of comments regarding the County’s compliance with paragraph 75. He notes that the “accuracy and completeness of the reviews is variable, but most are fairly good, a few quite good. The chief problem. . .is that the analysis and related CAPs are very uneven;” in particular, "[w] the information reviewed is sufficiently thorough, [the County’s] identification of potential corrective actions is highly variable and tends to neglect systems issues, especially as they relate to access to care, isolation of the mentally ill, and systems practices.”
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76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

PARTIAL COMPLIANCE

CDM 4-10/050.00 DEATH REPORTING REVIEW PROCESS, issued on March 1, 2016, addresses each of the requirements of Paragraph 76. It provides that within two working days personnel from DMH, the Custody Division and the Medical Services Bureau will meet "to review the circumstances surround[ing] all in-custody deaths," including in the case of an apparent or suspected suicide "a discussion of the inmate's mental health status known at the time of the suicide." It also requires the Custody Compliance and Sustainability Bureau ("CCSB") "to conduct a death review within seven (7) working days and again within thirty (30) working days," which "will include a discussion of relevant information known at that time, including the events preceding and following the suicide[.]" It also provides for a final report within six months. Section 4.7 of the DMH policy 50.2 CRITICAL INCIDENT REVIEW is consistent with these provisions.
There was a suicide at TTCF on February 29, 2016. An initial Death Review was held within two working days of the death on March 2, 2016, and the seven-day review was held on March 8, 2016. I attended both meetings, which included command-level personnel from the Department and DMH and reviewed the information known about the suicide and corrective or preventive actions taken or required by Paragraph 76. The 30day death review, which I was not able to attend, was held on April 6, 2016. The Executive Inmate Death Review discussed below summarizes the discussion during the 30-day review of the status of the corrective action plan.16
There was another suicide at TTCF on May 8, 2016. An initial Death Review was held within two working days of the death on May 10, 2016, and the seven-day review was held on May 17, 2016. I attended both meetings, which included commandlevel personnel from the Department and DMH and reviewed the information known about the suicide and corrective or preventive actions taken or required by Paragraph 76. The 30-day death review, which I was not able to attend, was held on June 17, 2016.
Paragraph 76(c) requires the County to provide a "final written report regarding the suicide" within six months of a suicide that address 10 subparts of subparagraph (c). On August 25, 2016, the County timely provided an Executive Inmate Death Review the report for the suicide that occurred on February 29, 2016.17 The Monitor reviewed the report and concluded that it meets most of the requirements in the ten subparts.
DOJ has raised concerns about two of the subparts addressed in the Executive
16 Although not required by the Settlement Agreement, the County also conducted a 60-day and a 90-day review of the incident and the corrective action plans. 17 The Subject Matter Expert notes that the two-day reviews for both suicides are “thorough and identify appropriate CAPs,” except that “neither speak to the adequacy of mental health treatment other than medications, which was an issue in both cases in my opinion.”
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Inmate Death Review, which concerns the Monitor shares. The timeline required by (c)(ii) should reflect information that can be obtained from the video of the incident and the Clinical Morbidity and Mortality Review required by (c)(viii) should provide more analysis of the adequacy of the mental and medical health care received by the inmate prior to the suicide.
DOJ has also raised a concern about the adequacy of the Executive Inmate Death Review in addressing (c)(i), which requires the preparation of "incident reports and any supplemental reports. . .from custody staff who were directly involved in and/or witnessed the incident." In the case of the suicide that occurred on February 29, no member of the Custody staff witnessed the suicide, which occurred inside the inmate's cell before he was discovered by a member of the Custody staff, and it is not clear what (c)(i) means to be "directly involved in . . . the incident" under these circumstances.
Assuming no Department member witnesses the acts resulting in the suicide, the issue is whether (c)(i) requires more than report or reports from the member or members of the Custody staff who first discover the suicide, which was all that was included in the Executive Inmate Death Review in this case. The Monitor will seek input from the Subject Matter Experts on this issue and have further discussions with the parties during the next reporting period before reaching any conclusions regarding the scope of (c)(i).
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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU, effective February 4, 2016, provides for the creation of a bureau "to oversee, monitor, and audit the Department's jail suicide prevention program" in coordination with DMH. The Department provided the Monitor and Subject Matter Experts with an initial organizational chart for CCSB, but it has not updated the chart to reflect recent staff changes.
The Self-Assessment submitted to the Monitor on CCSB’s activities on June 30, 2016, reports that on the first Monday of each month during the reporting period, the Department and DMH held an administrative review meeting to discuss at total of 28 suicide attempts (including suicides), which occurred in the months immediately prior to the meeting.” In addition, “[b]eginning January 4, 2016, [there were] four Critical Incident Review Committee meetings” in which “a total of twenty-four incidents” were discussed. The Self-Assessment also reports on the “corrective actions taken by the
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Department to mitigate suicide risks;” CCSB’s efforts with the Facility Services Bureau and the Data Services Bureau to enhance the infrastructure and e-UDAL system; “staffing, personnel/disciplinary, prisoner classification and mental health service delivery issues;” “remedial measures, including policy revisions,” staff training, and drills; and summaries of monthly Suicide Prevention Sub-Committee Meetings with members from DMH, CCSB, MSB, MCJ and TTCF “to develop, implement, and trace corrective actions plans.”
The Mental Health Subject Matter Expert comments that the “County has made great strides in conducting these reviews [required by 77(a)] both in terms of thoroughness and the establishment of meaningful corrective actions plans. He is concerned, however, that the reviews are “bereft of analysis of the adequacy of staffing and mental health service delivery;” and there is a lack “evidence that they have truly examined the adequacy of treatment,” “no discussion of the adequacy of nonpharmacological treatment, access to care, and such.” Finally, much of the SelfAssessment is a description of CCSB's activities without a substantive assessment or analysis of those activities.
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of June 1, 2016) Section 4.13 of DMH 70.7, effective July 7, 2016, requires DMH and LASD to “maintain a Suicide Prevention Advisory Committee” open to the representatives of the entities identified in Paragraph 78. The augmented Second Self-Assessment reports that a second meeting of the Suicide Prevention Advisory Committee was held on May 11, 2016, which the Monitor attended. Substantial Compliance requires (1) the Committee to meet twice per year and (2) “recommend coordinated approaches to suicide prevention in the Jails.” At the second meeting of the Suicide Prevention Advisory Committee, Dr. J. Neil Ortego, the Chief Psychiatrist from the Department of Mental Health discussed various recommendations by DMH, including, as the Mental Health Subject Matter Expert notes, “staffing and provision of necessary mental health services.” Although this was largely a presentation by Dr. Ortego, there was some input and recommendations from other members of the Committee as required by Paragraph 78. The other members need to be more engaged, however, if the Committee is to serve as an effective advisory body that “will address system issues and recommend coordinated approaches to suicide prevention in the Jails.” This will require input from the other members in advance of the meeting so that there can be a meaningful discussion of their recommendations at the meeting.
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: NON-COMPLIANCE
DMH 70.2.1, effective February 4, 2016, sets forth “policy and procedures for mental health treatment programs” in the jails. Sections 3.2.7 and 3.5 provide for individual visits and group programming as required by Paragraph 79(a) and (c). Section 3.5.4 addresses the requirements of Paragraph 79(b).
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; to provide a description of the medication support services available for prisoners who are not in mental health housing and who are receiving psychotropic medications; and to randomly select and review electronic medical records of prisoners who reside outside of mental health housing and receive psychotropic medications to confirm that medication support services were provided to these prisoners.
Although the County’s augmented Second Self-Assessment reports that it has complied with the compliance measures that require the Department to maintain records and describe the support services available to prisoners who are not in mental health housing and were receiving psychotropic medications, it was unable to establish compliance with measures that require the Department “to confirm that medication support services were provided to” prisoners who “resided outside of mental health housing and were receiving psychotropic medications at the end of the quarter.”
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business work day. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

NON-COMPLIANCE

Section 3.5.2 of DMH 70.2.1, effective February 4, 2016, requires inmates in HOH areas to “be offered ten hours per week structured therapeutic or programmatic time unless individually clinically contraindicated[.]” The Department has not provided a similar provision requiring “unstructured out-of-cell recreational time” for HOH inmates, which the augmented Second Self-Assessment reports will be provided to the Monitor “for review by the end of the third quarter.”

For the First Reporting Period, the Department provided an “Out of Cell Offered Tracker” for the week of 12/13/15 to 12/19/15 that listed the names of the inmates in HOH at CRDF and TTCF; the amount of unstructured out-of-cell recreation time and structured therapeutic or programming time offered to these inmates; if the inmates have refused the time offered; and (in many cases) the reasons for the refusals. Based on the Average Daily Population in HOH during the prior two weeks and the tracker, CCSB reports that 28.9% of the inmates in HOH units at CRDF and TTCF were offered 10 hours of unstructured out of cell time during that week.

Paragraph 80 requires that "[b]y no later than 12 months after the Effective Date [of July 1, 2015], [the County] will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week." On August 15, 2016, the Department reported that 57% of the inmates in HOH units at CRDF were offered more than 10 hours of out-of-cell time and 0% were offered more than 10 hours of therapeutic or programing time by the end of the Second Reporting Period. The Department also reported that 16% of the inmates in HOH units at TTCF were offered more than 10 hours of out-of-cell time and 3% were offered therapeutic or programing time by the end of the Second Reporting Period.

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81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development);18 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.17.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
Policies approved by the Rosas Monitors and adopted by the Department in the First Reporting Period implemented the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture). The Department’s implementation of these policies at CRDF and the Pitchess Detention Center will be assessed by the Monitor and the Use of Force Subject Matter Expert.
In the Second Reporting Period, the Rosas Monitors approved policies to implement the following provisions of the Rosas Implementation Plan: Paragraphs 6.16.20 (grievance system); Paragraph 8.2 (combining “Complaints of Retaliation”). They also reviewed revised policies to implement Paragraphs 13.1-13.2 (discipline for PREA violations, dishonesty, and failure to report force incidents).
In the Second Reporting Period, the Monitor and Subject Matter Expert reviewed eight randomly selected completed force packages for CRDF, NCCF, and PDC North and concluded that the Department is adhering to its new force policies in these institutions, and that the force packages were thorough and in compliance with the Department new
18 As requested by the Department of Justice, these provisions were reviewed and approved by the Monitor’s Use of Force Subject Matter Expert.
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policies. As of the end of the Second Reporting Period, the Department had completed a total of 42 investigations of force incidents at these facilities that occurred during the Second Reporting Period.19 The Monitor and Subject Matter Expert will review and report on additional completed force packages in the next reporting period.
Among the observations the Use of Force Subject Matter Expert made are that the “use of force packages were comprehensive and complete;” inmates against whom force was used “were promptly provided medical attention,” “[s]taff and inmate witnesses were consistently interviewed;” “proper protocols were followed” in a cell extraction; force reports “were consistent” with videos of the force incidents; uses of force “were promptly reported;” all of the incidents were reviewed by Watch Commanders, Unit Commanders, and Commanders, although there seemed “to be a significant lag time in this [last] review” from the incident to the completion of the Commanders’ reviews; and some incidents were subject to reviews by the Custody Force Response Team were “promptly completed.”
In one case, there was a violation of the policy regarding the authorized use of weapons because a Custody Assistant who was not trained to use a taser, did so at the directions of a supervising deputy. In addition, the taser was not properly secured in a desk. There were exigent circumstances for the use of the taser in this instance, and the policy violation was identified in the force package with the Custody Assistant receiving a letter of reprimand. The Subject Matter Expert concluded that, “[c]onsidering the totality of circumstances, it seems like a reasonable resolution,” although he believes the supervising deputy “should also have received some type of remedial consequences.”
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 of the Rosas Implementation Plan reflect training requirements that are supposed to be completed by December 31, 2016. Paragraphs 4.10 and 9.1 are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Finally, the Early Warning System to implement Paragraphs 19.1-19.3 will be completed in future reporting periods.
19 The overwhelming number of completed investigations involved force incidents at CRDF.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: PARTIAL COMPLIANCE The Rosas Monitors have approved a de-centralized inmate grievance system, which includes an Inmate Grievance Team co-located at Century Regional Detention Facility. The Department published its new grievance policies on July 15, 2016. Under CDM 8-01/020.00 RESPONSIBILITIES, the Inmate Grievance Team is comprised of “a supervising deputy, a custody assistant and/or other appropriate professional staff” under the supervision of “at least one sworn supervisor of the minimum rank of sergeant who will serve as the Unit Inmate Grievance Coordinator and report to the Division Inmate Grievance Coordinator.” Members of the team are “responsible for collecting from centrally located collection bins those requests and grievances not handled by line sergeants.” The Department reports that "grievance teams have begun training relevant staff" and it "expects that approximately 100 sergeants will have completed the training by October 1, 2016."
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83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement (“Common Areas”), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.

STATUS:

SUBSTANTIAL COMPLIANCE (at MCJ and IRC as of July 1, 2015; TTCF as of October 1, 2015; and CRDF as of April 1, 2016)

NOT CURRENTLY SUBJECT TO MONITORING (REMAINING FACILITIES)

On September 2, 2015, the Monitor and Subject Matter Experts toured TTCF, MCJ and IRC and confirmed that closed circuit security cameras had been installed and were operational in the Common Areas. On October 13, 2015, the Department provided the Monitor and Subject Matter Experts with summaries showing the number of cameras needed and installed at these facilities as of November 27, 2012, and the number of additional cameras needed and installed at MCJ as of May 12, 2014 and at TTCF as of August 11, 2014. The Department also provided a spreadsheet listing the completed work orders for the installation of the cameras installed in the Common Areas in TTCF, MCJ and IRC. The Monitor believes, and the Department of Justice concurs, that it is not necessary for the Monitor’s auditors to review the actual work orders to verify the list since the Monitor and Subject Matter Experts have toured the facilities and confirmed that the cameras have been installed and are operational.

The Department has provided the Monitor with inventories and videos of 10 randomly selected force incidents in the Common Areas of TTCF, MCJ, and IRC during the third and fourth quarters of 2015, and the first and second quarters of 2016. Per an understanding with the Department and DOJ, the Monitor is to determine the Department’s compliance with Paragraph 83 of the Settlement Agreement by viewing the videos to verify the accuracy of the information reflected on the inventory. Based upon the review of these videos by the Monitor and the Monitor's staff, the Monitor has determined that the Department is in Substantial Compliance with Paragraph 83 at MCJ and IRC as of the third quarter of 2015 and at TTCF as of the fourth quarter 2015.

On February 19, 2016, the Monitor and Subject Matter Expert toured CRDF and confirmed that closed circuit security cameras have been installed and are operational in

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the Common Areas, although the display screens in Central Control were not operational. On March 25, 2016, the Monitor confirmed that the display screens in Central Control at CRDF were operational and the system was fully functional. The Department also provided the Monitor and Subject Matter Experts with summaries showing the number of cameras needed and installed at CRDF as of January 7, 2016, and a spreadsheet listing the completed work orders for the installation of the cameras installed in the Common Areas in TTCF. Finally, the Department has provided inventories and videos of 10 force incidents in the Common Areas of CRDF in the second quarter of 2016. Based upon the review of these videos by the Monitor and the Monitor's staff, the Monitor has determined that the Department is in Substantial Compliance with Paragraph 83 at CRDF as of the second quarter of 2016.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:
(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and
(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016) Substantial Compliance under the Compliance Measures requires the Department to demonstrate that 95% of the investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies. Although Paragraph 84 requires the Department to implement policies for the "timely and thorough" investigation of force incidents, the subparagraphs and the Compliance Measures are focused on the timeliness of the completion of the investigations resulting in the imposition of discipline. The County’s augmented Second Self-Assessment reports that the Department has achieved Substantial Compliance with Paragraph 84 because all six of the administrative investigations in the first quarter of March 2016 that resulted in a “founded” finding were completed within the required time frames. The reported results have been verified by the Monitor's auditors.
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85. The County and the Sheriff will ensure that Internal Affairs Bureau management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training. The County's SelfAssessment that was posted on July 25, 2016, reports that only 13% of the IAB investigators completed all of the required training.
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86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: SUBSTANTIAL COMPLIANCE (at MCJ and CRDF as of April 1, 2016)
PARTIAL COMPLIANCE (at remaining facilities)
The Proposed Revision of CDM 7-08/100 ACCOUNTABILITY OF WEAPONS requires each facility to “establish procedures for the storage, issuance, reissuance, accountability, and periodic inventory of all weapons. . . stored at, or issued from the facility,” which includes detailed requirements for the “Inventory, Control, and Accountability of Aerosol Chemical Agents.” The subsequent proposed revision to this policy that was submitted to the Monitor on June 9, 2016, provides the necessary guidelines for the unit orders for all weapons, in addition to aerosol chemical agents, at the facilities. Pending adoption of the proposed revision, the Department issued Custody Directive 15-008, dated December 10, 2015, “to establish additional procedures for the accurate inventory and adequate control of personally assigned aerosol chemical agents[.]”
In addition to providing written policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment, Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with up-to-date Unit Orders for each jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons.
The Monitor and Subject Matter Expert inspected the armory of each jail facility and reviewed the inventory logs of the weapons in the armories on April 14 and 15, 2016. We noted that the inventory logs in the MCJ and CRDF armories were checked daily, both facilities have up-to-date unit orders, and all of the weapons in the armories were accounted for on the inventories. On August 3, the Department submitted the required armory audit logs for both MCJ and CRDF for the first quarter of 2016.
The inventory logs for two of the other facilities were not routinely checked, but all of the weapons were accounted for on the inventories. In the remaining facilities, there were still a few instances in which discrepancies were noted in the control of, and accountability for, OC canisters. Further, the unit orders of some facilities still need to be updated. These issues need to be addressed in addition to the required armory audit logs in order for these other facilities to be in Substantial Compliance with Paragraph 86.
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APPENDIX

NO. PROVISION

STATUS

18 Suicide Prevention Training Partial Compliance

COMPLIANCE DATE

19 Crisis Intervention &

Partial Compliance

Conflict Resolution Training

20 Training at NCCF, PDC and Not Currently Subject to

CRDF

Monitoring

21 CPR Certification

Substantial Compliance (NCCF, PDC East, North & South & IRC) Non Compliance (Remaining Facilities)

(10/1/16 at PDC East, and South & IRC, 1/1/16 at NCCF, North and IRC)

22 Use of Arresting and Booking Documents

Substantial Compliance

(7/1/16)

23 Suicide Hazard Mitigation Plans

Partial Compliance

24 Suicide Hazard Inspection Partial Compliance

25 Transportation of Suicidal Inmates

Non-Compliance

26 Identification and Evaluation Partial Compliance of Suicidal Inmates

27 Screening for Mental Health Partial Compliance Care and Suicide Risk

28 Expedited Booking of Suicidal Inmates

Substantial Compliance (at IRC) (1/1/16 at IRC) Non-Compliance (at CRDF)

29 Mental Health Assessments Substantial Compliance

(1/1/16)

30 Initial Treatment Plans

Partial Compliance

31 Electronic Medical Records Partial Compliance Alerts

32 Electronic Medical Records Substantial Compliance – Suicide Attempts

(1/1/16)

Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 99 of 102 Page ID #:2553
APPENDIX

33 Supervisor Reviews of

Partial Compliance

Electronic Medical Records

34 Discharge Planning

Stayed Pending Litigation

35 Referral for Mental Health Care

Non-Compliance

36 Assessments After Triggering Events

Partial Compliance

37 Court Services Division Referrals

Non-Compliance

38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

39 Confidential Self-Referral Partial Compliance

40 Availability of QMHPs

Partial Compliance

41 FIP Step-Down Protocols Substantial Compliance

42 HOH Step-Down Protocols Non-Compliance

43 Disciplinary Policies

Partial Compliance

44 Protective Barriers

Substantial Compliance

45 Suicide Intervention and First Aid Kits

Substantial Compliance

46 Interruption of Self-Injurious Partial Compliance Behavior

47 Staffing Requirements

Partial Compliance

48 Housekeeping and Sanitation Substantial Compliance

49 Maintenance Plans

Substantial Compliance

(1/1/16)
(1/1/16)
(1/1/16) (10/1/15 at all facilities other than MCJ, IRC & North) (1/1/16 at MCJ, IRC & North)
(1/1/16) (3/1/16)

Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 100 of 102 Page ID #:2554
APPENDIX

50 Pest Control
51 Personal Care & Supplies
52 HOH Property Restrictions 53 Eligibility for Education,
Work and Programs
54 Privileges and Programs
55 Staff Meetings 56 Changes in Housing
Assignments 57 Inmate Safety Checks in
Mental Housing
58 Inmate Safety Checks in Non-Mental Housing
59 Supervisor Rounds 60 Implementation of Quality
Improvement Program 61 Requirements of Quality
Improvement Program 62 Tracking of Corrective
Action Plans

Substantial Compliance (at MCJ, TTCF, CRDF, NCCF & North) Partial Compliance (at PDC East & South)

(1/1/16)

Substantial Compliance (at all facilities other than CRDF) Partial Compliance (at CRDF)

(3/1/16 at all facilities other than CRDF)

Partial Compliance

Non-Compliance (at CRDF and TTCF) Not Subject to Monitoring (at MCJ)

Substantial Compliance (at MCJ and NCCF) Non-Compliance (at CRDF and TTCF) Partial Compliance

(1/1/16 at MCJ and NCCF)

Substantial Compliance

(1/1/16)

Substantial Compliance (at MCJ) (1/1/16 at MCJ) Partial Compliance (at CRDF and TTCF

Substantial Compliance (at PDC South, North and East) Partial Compliance (at NCCF) Non-Compliance (remaining facilities)

(1/1/16 at PDC South, North and East)

Partial Compliance

Non-Compliance

Non-Compliance

Partial Compliance

Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 101 of 102 Page ID #:2555
APPENDIX

63 Sufficient HOH and MOH Housing

Partial Compliance

64 Plans for Availability of Inpatient Health Care
65 Administration of Psychotropic Medication
66 Active Mental Health Caseloads
67 Prisoner Refusals of Medication

Partial Compliance Partial Compliance Non-Compliance Non-Compliance

68 Contraband Searches

Substantial Compliance (at MCJ, NCCF, PDC East, South and North) Non-Compliance (at CRDF and TTCF)

(1/1/16 at MCJ, NCCF, PDC East, South and North)

69 Clinical Restraints in CTC Partial Compliance

70 Security Restraints in HOH Substantial Compliance and MOH

(9/1/16)

71 Therapeutic Services for

Partial Compliance

Inmates in Clinical Restraints

72 Administrative Reviews

Partial Compliance

73 Reporting of Self-Injurious Non-Compliance Behavior and Threats

74 Law Enforcement Investigations of Suicides

Substantial Compliance

(9/1/16)

75 Management Reviews of Suicide Attempts

Partial Compliance

76 Management Reviews of Suicides

Partial Compliance

Case 2:15-cv-05903-DDP-JEM Document 121 Filed 09/01/16 Page 102 of 102 Page ID #:2556
APPENDIX

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Substantial Compliance

Committee

79 Therapeutic Services in

Non-Compliance

Mental Health Housing

(6/1/16)

80 Out-of-Cell Time in HOH Non-Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

82 Collection of Grievances at Partial Compliance CRDF

83 Closed Circuit Cameras

Substantial Compliance (MCJ, TTCF, IRC, and CRDF)
Not Currently Subject to Monitoring (Remaining Facilities)

(7/1/15 at MCJ, IRC) (10/1/15 at TTCF) (4/1/16 at CRDF)

84 Investigation of Staff Misconduct

Substantial Compliance

(1/1/16)

85 Internal Affairs Bureau Training

Non-Compliance

86 Maintenance and Inventory Substantial Compliance (at MCF (4/1/16 at MCJ and

of Security Equipment

and CRDF)

CRDF)

Partial Compliance (remaining

facilities

 
 Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 1 of 108 Page ID #:2559

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) 601 West Fifth Street, 12th Floor

3 Los Angeles, CA 90071-2025

4

Telephone: (213) 613-4655 Facsimile: (213) 613-4656

5 Email: rdrooyan@scheperkim.com

6 Monitor 7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

WESTERN DIVISION

11

12 UNITED STATES OF AMERICA,

13

Plaintiff,

14

15

v.

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR’S THIRD REPORT

16 COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF
17 JIM MCDONNELL, in his Official Capacity,
18 Defendants.
19

20

21

22

23

24

25

26

27

28

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR'S THIRD REPORT

Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 2 of 108 Page ID #:2560

1

Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and the

4 Los Angeles County Sheriff during the six-month period from July 1, 2016, to

5 December 31, 2016, “to implement the Agreement and evaluating the extent to

6 which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

12

13 DATED: March 1, 2017

Respectfully submitted,

14

SCHEPER KIM & HARRIS LLP

15

RICHARD E. DROOYAN

16

17

18

By: /s/ Richard E. Drooyan Richard E. Drooyan

19

Monitor

20

21

22

23

24

25

26

27

28

- 1 -

CASE NO. 15-cv-05903 DDP (JEMx)

MONITOR’S THIRD REPORT

Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 3 of 108 Page ID #:2561
MONITOR’S THIRD REPORT
This Third Report sets forth the Monitor’s assessments of the implementation of the terms of the Settlement Agreement (the “Agreement”) between the County of Los Angeles (the “County”) and the United States Department of Justice (“DOJ”) by the Los Angeles Sheriff’s Department (the “Department”) and the County's Department of Mental Health (“DMH”).1 It covers the County's reported results for the period from July 1, 2016, through December 31, 2016 (the “Third Reporting Period”), and reflects the observations and comments of the Subject Matter Experts regarding the County's compliance during that period.
As used herein, “Substantial Compliance” means that the County has “achieved compliance with the material components of the relevant provisions of this Agreement in accordance with the [agreed-upon Compliance Measures for assessing Substantial Compliance],” which it must maintain for twelve-consecutive months; “Partial Compliance” means that the County has achieved “compliance on some, but not all, of the material components of the relevant provision of this Agreement;” and “NonCompliance” means that the County has not met “most or all of the material components of the relevant provisions of this Agreement.”
This Third Report is based upon the Monitor's review of the policies, procedures and directives proposed and/or implemented by the Department and DMH, assessments of the Subject Matter Experts, multiple tours of the jails by the Monitor and the Subject Matter Experts, the County’s Third Self-Assessment Status Report (the “Third SelfAssessment”), which was received on December 15, 2016, and the augmented Third SelfAssessment Status Report, which was received on January 23, 2017. It also takes into consideration the comments the Monitor received from the County and DOJ on the draft of this Report that was submitted to the parties on February 1, 2017, and results posted by the County after the draft was submitted.
This Third Report also reflects the results of audits by the Monitor's auditors to verify results reported by the County. The Monitor has deemed the County to be in Substantial Compliance “as of” the beginning of the quarter reported by the County if the auditors have verified that the County has met the thresholds in the Compliance Measures. If the auditors were not able to verify the results reported by the County, the twelve-month period for maintaining Substantial Compliance will commence in a future period when the County's reported results are verified by the auditors. If the County maintains Substantial Compliance with a provision for twelve consecutive months, pursuant to Paragraph 111 of the Agreement, the Monitor and Subject Matter Experts will “no longer. . .assess or report on that provision” in future reporting periods.
Some of the Substantial Compliance results reported by the County in the Third Reporting Period have not been audited by the Monitor’s auditors and cannot be
1 As a result of a reorganization, the Department of Mental Health is now part of the County's Department of Health Services (“DHS”).
1

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considered final until verified by the auditors. The County will not be deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the twelve-month compliance period in the Monitor's future reports if the results are not verified by the Monitor’s auditors.
During the Third Reporting Period, the Mental Health Subject Matter Expert, with the assistance of two clinicians retained by the Monitor, began to perform qualitative assessments of the County's compliance with certain of the Substantive Provisions of the Settlement Agreement. The Subject Matter Expert and the clinicians will be reviewing the methodology used by the Department in reporting its assessments of some of the mental health provisions. The Monitor expects to report the initial results of those qualitative assessments and methodology reviews in the Monitor's next report.
Attached to this Third Report is an Appendix showing the status of each of the 69 provisions of the Agreement that are subject to monitoring and the twelve-month compliance triggering dates where the County is deemed to be in Substantial Compliance.
As has been the case since the beginning of the Initial Reporting Period, the County cooperated completely with the Monitor and the Subject Matter Experts during the Third Reporting Period. The Department, DMH (now DHS), and County Counsel facilitated our visits and inmate interviews, answered our questions, and responded to our requests for documents and information. We appreciate their responsiveness, transparency, professionalism, and courtesy in handling our monitoring requests.
Richard Drooyan, Monitor March 1, 2017
2

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EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the County and the Department are in Substantial Compliance with 22 provisions, in Partial Compliance with 27 provisions, and in Non-Compliance with 10 provisions. In addition, there are 6 other provisions in which the Department is in Substantial Compliance at some facilities and in Partial Compliance or Non-Compliance at other facilities, and one other provision in which the Department is in Partial Compliance at some facilities and in Non-Compliance at other facilities. There is also one provision (Paragraph 20) that is Not Currently Subject to Monitoring, one provision (Paragraph 34), that has been stayed pending litigation initiated by third party intervenors. and one provision (Paragraph 83) for which the Department is in Substantial Compliance at certain facilities and that is not currently subject to monitoring at other facilities. There are 29 provisions for which the County and the Department are in Substantial Compliance at some or all of the facilities.2
As of the date of this Report, and subject to verification by the Monitor's auditors in some cases, the County and the Department are in Substantial Compliance at some or all of the facilities with the following provisions of the Settlement Agreement:
The County has provided documentation reflecting that, as of October 1, 2015, through September 30, 2016, it achieved Substantial Compliance with Paragraph 21, which requires that custody staff have active certifications in cardiopulmonary resuscitation and first aid, at the East and South facilities in the Pitchess Detention Center (“PDC”). The County also reported that the Department had achieved Substantial Compliance at North County Correctional Facility (“NCCF”), as of January 1, 2016, through December 31, 2016, at the PDC North facility, and the Inmate Reception Center (“IRC”) as of January 1, 2016, through September 30, 2016, and at the Century Regional Detention Facility (“CRDF”) and Twin Towers Correctional Facility (“TTCF”) as of April 1, 2016, through September 30, 2016. These reported results have been verified by the Monitor's auditors. The County has now maintained Substantial Compliance for a period of twelve consecutive months at PDC East, PDC South, and NCCF as required by Paragraph 111 of the Settlement Agreement.
The County has achieved Substantial Compliance as of July 1, 2016, through December 31, 2016, with Paragraph 22, which requires the County and the Sheriff to provide instructional material on the use of arresting and booking documents to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.
The County has achieved Substantial Compliance as of January 1, 2017, with Paragraph 23, which requires the County and the Sheriff to create short and long term Suicide Hazard Mitigation Plans. These plans must be updated six weeks before the next two Monitor's reports are due.
2 Under Paragraph 111 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis.
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The County has achieved Substantial Compliance as of July 1, 2016, through September 30, 2016, at CRDF with Paragraph 27, which requires the County and the Sheriff to ensure that all prisoners are privately screened by a QMHP within 12 hours to identify the need for mental health care and the risk for suicide or self-injurious behavior.
The County has provided documentation reflecting that, as of Apri1 1, 2016, through September 30, 2016, it achieved Substantial Compliance with Paragraph 30, which requires initial mental health assessments. The reported results are subject to verification by the Monitor’s auditors.
The County has provided documentation reflecting that, as of January 1, 2016, it achieved Substantial Compliance with Paragraph 32, which requires that a serious suicide attempt be entered in the prisoner’s electronic medical record in a timely manner. The records reviewed by the Subject Matter Expert are consistent with the County's reported results, which have been verified by the Monitor’s auditors through December 31, 2016. The reported results for the fourth quarter of 2016 are still subject to a qualitative assessment by the Subject Matter Expert.
The County has provided documentation reflecting that, as of July 1, 2016, and through September 30, 2016, it achieved Substantial Compliance with Paragraph 33, which requires mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy. These results are subject to the Monitor’s requests for additional source documentation and verification by the Monitor’s auditors.
The County has provided documentation reflecting that, as of January 1, 2016, through December 31, 2016, it achieved Substantial Compliance with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules to identify prisoners with mental illnesses and grant prisoner's requests for out-of-cell interviews. The auditors have verified the reported results, which are consistent with the observations of the Monitor and the Mental Health Subject Matter Expert during tours of MCJ, TTCF, and CRDF. The County has now maintained Substantial Compliance for a period of twelve consecutive months as required by Paragraph 111 of the Settlement Agreement.
The County has provided documentation reflecting that, as of January 1, 2016, through September 30, 2016, it achieved Substantial Compliance with Paragraph 41, which requires the Department and DMH to implement step-down protocols when prisoners are discharged from FIP after being on a suicide watch. The source documents indicate that the step-down protocols required by Paragraph 41 were followed for the two prisoners who were transferred to mental health housing at TTCF.
The County has achieved Substantial Compliance as of January 1, 2016, through December 31, 2016, with Paragraph 44, which requires the Department to install protective barriers in High Observation Housing and other mental health housing areas. The Monitor and Subject Matter Experts have observed that these barriers have been
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installed as required in TTCF and CRDF. The County has now maintained Substantial Compliance for a period of twelve consecutive months as required by Paragraph 111 of the Settlement Agreement.
The County has achieved Substantial Compliance with Paragraph 45, which requires Suicide Prevention Kits and first-aid kits in control booths, as of October 1, 2015, through September 30, 2016, for all facilities other than MCJ and PDC North, and as of January 1, 2016 through December 31, 2016, for MCJ and PDC North. The County has now maintained Substantial Compliance for a period of twelve consecutive months as required by Paragraph 111 of the Settlement Agreement.
The County has achieved Substantial Compliance as of January 1, 2016, through December 31, 2016, with Paragraph 48, which requires the Department to have written housekeeping, sanitation, and inspection plans to ensure proper cleaning in accordance with California regulations. The County has now maintained Substantial Compliance for a period of twelve consecutive months as required by Paragraph 111 of the Settlement Agreement.
The County has achieved Substantial Compliance as of March 1, 2016, through December 31, 2016, with Paragraph 49, which requires the Department to have maintenance plans to respond to routine and emergency maintenance needs.
The County has achieved Substantial Compliance as of January 1, 2016, through September 30, 2016, at all facilities other than PDC South and PDC East, with Paragraph 50, which requires the Department to provide pest control in the jails. The County has achieved Substantial Compliance at PDC South and PDC East as of April 1, 2016, through September 30, 2016.
The County has provided documentation reflecting that, as of January 1, 2016, through June 30, 2016, it achieved Substantial Compliance at all facilities other than CRDF with Paragraph 51, which requires the Department to ensure that all prisoners have access to basic hygiene supplies in accordance with state regulations. The results have been verified by the Monitor's auditors.
The County has provided documentation reflecting that, as of January 1, 2016, through September 30, 2016, it achieved Substantial Compliance with Paragraph 54, which requires the Department to ensure that prisoners who are not in mental health housing are “not denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.” The reported results for the second and third quarters, but not for the first quarter, have been verified by the Monitor's auditors.
The County has provided documentation reflecting that, as of July 1, 2016, through December 31, 2016, it achieved Substantial Compliance at PDC North with the provision of Paragraph 55 that requires custody, medical and mental health staff meet at least once a week in Moderate Observation Housing. The reported results have been
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verified by the Monitor's auditors through September 30, 2016. The County also has provided documentation reflecting that, as of October 1, 2016, through December 31, 2016, it achieved Substantial Compliance at CRDF and TCCF with the provision of Paragraph 55 that requires custody, medical and mental health staff meet daily in High Observation Housing and weekly in Moderate Observation Housing. The reported results for the fourth quarter of 2016 have not been verified by the Monitor's auditors.
The County has provided documentation reflecting that, as of January 1, 2016, through September 30, 2016, it achieved Substantial Compliance with Paragraph 56, which requires custody, medical, and mental health staff to communicate regarding any change in a housing assignment following a suicide attempt or serious change in mental health condition. The reported results for January 1, 2016, through June 30, 2016, have been verified by the Monitor's auditors. The reported results for July 1, 2016, through September 30, 2016, are subject to verification by the Monitor’s auditors.
The County has provided documentation reflecting that, as of January 1, 2016, through September 30, 2016, it achieved Substantial Compliance at PDC South, North and East with Paragraph 58, which requires the Department to ensure that safety checks in non-mental health housing are completed and documented. The reported results have been verified by the Monitor's auditors.
The County has provided documentation reflecting that, as of January 1, 2016, through December 31. 2016, it achieved Substantial Compliance at all facilities other than TTCF and CRDF with Paragraph 68, which requires staggered contraband searches in housing units and visual inspection of HOH cells. The reported results have been verified by the Monitor's auditors. The County has maintained Substantial Compliance for twelve consecutive months at the facilities other than TTCF and CRDF as required by Paragraph 111 of the Agreement. The County also provided documentation that, as of October 1, 2016, through December 31, 2016, it achieved Substantial Compliance at CRDF. These results also have been verified by the Monitor's auditors.
The County has achieved Substantial Compliance as of September 1, 2016, through December 31, 2016, with Paragraph 70, which requires the Department to have “policies and procedures regarding the use of Security Restraints in HOH and MOH.”
The County has provided documentation reflecting that, as of July 1, 2016, through September 30, 2016, it achieved Substantial Compliance with Paragraph 71, which requires the County and the Sheriff to ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint. These results have been verified by the Monitor's auditors.
The County has achieved Substantial Compliance as of September 1, 2016, through December 31, 2016, with Paragraph 74, which requires the Department to have an objective law enforcement investigation of every suicide that occurs in the jails.
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The County has achieved Substantial Compliance as of September 1, 2016, through December 31, 2016, with Paragraph 76, which requires the Department to follow certain procedures whenever there is an apparent or suspected suicide.
The County has achieved Substantial Compliance as of June 1, 2016, through December 31, 2016, with Paragraph 78, which requires the Suicide Prevention Advisory Committee to meet twice a year.
The County has achieved Substantial Compliance as of July 15, 2016, through December 31, 2016, with Paragraph 82, which requires the Department to co-locate personnel responsible for collecting prisoners' grievances at CRDF.
The County has achieved Substantial Compliance with Paragraph 83, which requires it to install closed circuit security cameras throughout all of the common areas in the jails, as of July 1, 2015, through June 30, 2016, at MCJ and IRC; as of October 1, 2015, through September 30, 2016, at TTCF, and as of April 1, 2016, through December 31, 2016 at CRDF. The County has maintained Substantial Compliance at MCJ, IRC, and TTCF for over twelve consecutive months, but it needs to retain the videos for one year to achieve and maintain Substantial Compliance as required by Paragraph 111 of the Settlement Agreement.
The County has provided documentation reflecting that, as of January 1, 2016, through March 31, 2016, it has achieved Substantial Compliance with Paragraph 84, which requires the Department's investigations of force incidents and administrative actions to be completed timely. The results have been verified by the Monitor's auditors.
The County achieved Substantial Compliance with Paragraph 86, which requires inventory policies and control of weapons, as of April 1, 2016, through December 31, 2016, at MCJ and CRDF; as of October 1, 2016, through December 31, 2016, at PDC North; and as of February 1, 2017 at PDC South and PDC East.
The County has achieved and maintained Substantial Compliance for twelve consecutive months with the following paragraphs at some or all of the jails: 21(CPR certifications) (at PDC East, PDC South, and NCCF); 38 (Weekly Rounds); 44 (Protective Barriers); 45 (Suicide and First Aid Kits); 48 (Housekeeping and Sanitation); and 68 (Contraband Searches) (at MCJ, NCCF, PDC South, PDC North, and PDC East).
The County previously achieved Substantial Compliance with Paragraphs 28, 29, 57, and 59, but not in the Third Reporting Period. The twelve-month period for maintaining Substantial Compliance pursuant to Paragraph 111 will begin to run for these provisions when the County achieves Substantial Compliance in the future.
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18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016.
These trainings will include the following topics: (a) suicide prevention policies and procedures, including observation and
supervision of prisoners at risk for suicide or self-injurious behavior; (b) discussion of facility environments and staff interactions and why they
may contribute to suicidal behavior; (c) potential predisposing factors to suicide; (d) high-risk suicide periods and settings; (e) warning signs and symptoms of suicidal behavior; (f) case studies of recent suicides and serious suicide attempts; (g) emergency notification procedures; (h) mock demonstrations regarding the proper response to a suicide attempt,
including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance; (i) differentiating between suicidal and self-injurious behavior; and (j) the proper use of emergency equipment.
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STATUS (18):

PARTIAL COMPLIANCE

The Monitor, in consultation with the Mental Health Subject Matter Expert, concluded in the First Reporting Period that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015.

The County's Initial Self-Assessment Status Report delivered on December 14, 2015, reported that the Department commenced its suicide prevention training for new Deputy Sheriffs and Custody Assistants on July 1, 2015, and for existing Deputy Sheriffs and Custody Assistants before the Effective Date of the Settlement Agreement.

The County's augmented Third Self-Assessment reports that all new Deputies and all new Custody Assistants since July 1, 2015, have received the “training mandated by this provision[.]” The Monitor’s auditors have received training records reflecting that 95% of new deputies and new Custody Assistants hired after July 1, 2015, through December 31, 2015, received the required training. Notably, the auditors have not received any documentation from the Department reflecting the training of new deputies in 2016.

Assuming that the Department maintained Substantial Compliance for new personnel in 2016, and continues to do so in the future, Substantial Compliance under Paragraph 18 will be achieved when 85% of the existing deputies and Custody Assistants in Custody as of July 1, 2015, have received the required training. This was supposed to be completed on or before the Completion Date of December 31, 2016, but the County's Self-Assessment reports “that a significant portion of the training conducted in this reporting period used the wrong course.”

It is unclear when the County will reach the 85% threshold for the training of existing deputies and Custody Assistants to achieve Substantial Compliance. Although the Compliance Measures contemplated that the County would reach Substantial Compliance by December 31, 2016, the Monitor is of the view that a later date is acceptable as long as at least 95% of new deputies and Custody Assistance hired after July 1, 2015, continue to receive the required training until the County reaches the 85% threshold for Substantial Compliance for existing personnel.

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19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams (“JMET”) at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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STATUS (19):

PARTIAL COMPLIANCE

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution training and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and paragraphs 4.6, 4.7 and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert and the Rosas Monitors approved the training materials developed by the Department for the DeVRT on March 4, 2016.

The County's augmented Third Self-Assessment reports that the Department has conducted 61 DeVRT courses, and has trained 1,022 existing Deputies, 821 new Deputies, and 95 new Custody Assistants. As noted in the Monitor's Second Report, a number of the Deputies and Custody Assistants attended DeVRT classes before March 4, 2016, when the training materials developed by the Department for DeVRT were finally approved by the Monitor and the Rosas Monitors. The Third Self-Assessment does not indicate how many Deputies and Custody Assistants attended the classes before March 4, 2016, or how many Custody Assistants have received the eight hours of training in identifying and working with mentally ill prisoners as required by Paragraph 19(b).

The Monitor’s auditors have not received any training records for new deputies and Custody Assistants to determine whether the Department achieved (and has since maintained) Substantial Compliance as of October 1, 2015, which is the date that the Department’s Initial Self-Assessment reported that this provision was “[r]eady for monitoring.” The County reports that it anticipates it will begin to provide source documents in the second quarter of 2017.

Substantial Compliance will be achieved when 85% of the existing deputies and Custody Assistants in Custody Operations as of July 1, 2015, have received the required training, and 95% of the new deputies and Custody Assistants hired after that date have received the training, and those Deputies and Custody Assistants who attended DeVRT classes before March 4, 2016, receive the additional required DeVRT training in the first refresher course required under the Rosas Implementation Plan.

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20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

NOT CURRENTLY SUBJECT TO MONITORING

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the DeVRT curriculum for the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), which provides for 32 hours of Crisis Intervention and Conflict Resolution training that meets the requirements of Paragraph 20 of the Settlement Agreement. This training of Deputies assigned to the North County Correctional Facility (“NCCF”), the Pitchess Detention Center (“PDC”), and the non-Mental Health Housing Units in Century Regional Detention Facility (“CRDF”) is not required before July 1, 2017.

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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at PDC East and South (verified))
SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 at NCCF (verified))
SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through September 30, 2016, at PDC North and IRC (verified))
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through September 30, 2016, at CRDF and TTCF (verified))
NON-COMPLIANCE (at MCJ)
The Compliance Measures provide that “[t]he Department will provide semiannual Self-Assessment reports to the Monitor and Subject Matter Experts regarding the active certification of custody staff in cardiopulmonary resuscitation and first aid. The Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required certification for 12 consecutive months.”
The Monitor’s auditors have now verified that PDC South and PDC East were in Substantial Compliance as of October 1, 2015, through the third quarter of 2016 and that NCCF was in Substantial Compliance as of January 1, 2016, through December 31, 2016. Accordingly, pursuant to paragraph 111 of the Settlement Agreement, PDC South, PDC East, and NCCF are no longer subject to monitoring for Substantial Compliance with Paragraph 21.
The County's augmented Third Self-Assessment reports that the Department has been able to maintain Substantial Compliance at PDC North and IRC as of January 1, 2016, through September 30, 2016. The County has also reported that the Department is in Substantial Compliance at CRDF and TTCF as of April 1, 2016, through September 30, 2016. These results have been verified by the Monitor's auditors. Finally, the Department is not in compliance at MCJ.
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22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through December 31, 2016)
The Justice Data Interface Controller (“JDIC”) message the Department has been using since June 29, 2016, is sufficient to establish Substantial Compliance with Paragraph 22. The Monitor has confirmed that the Department has maintained Substantial Compliance from that date through the end of the year.
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23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2017) The Monitor has verified, with the advice of the Subject Matter Expert, that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department reports that it inspected all of the housing units by January 14, 2016, and it has provided the Monitor with completed checklists documenting the inspections. The County has modified and updated its Suicide Hazard Mitigation plan to address the comments of the Monitor and the Mental Health Subject Matter Expert. Although it addresses critical issues such as fixtures, parts of the plan consist of analysis or discussion rather than specific remedies with completion dates. Recognizing that the plan is not static, the Substantial Compliance finding is subject to the caveat that the plan must be updated at least six weeks before the Fourth and Fifth Reports are due, showing the status and completion of items in the plan.
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24. The County and the Sheriff will review and inspect housing areas on at least an annual basis to identify suicide hazards.
STATUS: PARTIAL COMPLIANCE The Department has submitted a revision to CDM 3-06/020.00 FACILITIES INSPECTIONS that requires Custody Support Services (CSS) to “review and inspect housing areas on a least an annual basis to identify suicide hazards.” On June 29, 2016, the Department provided the Monitor with a new version of the annual suicide hazard inspection tool it intends to use to identify suicide hazards. In response to comments from the Monitor and the Mental Health Subject Matter Expert, on December 13, 2016, the Department submitted a revised tool and indicated that it “is prepared to conduct an inspection once the Monitor has approved the tool.” The tool was further updated on February 9, 2017. The Monitor and Subject Matter reviewed the revised tool submitted on December 13, 2016, and approved it with the caveat that, in order to achieve Substantial Compliance, the sample sizes of randomly selected cells must be large enough to ensure that the cells are representative of each housing type at a facility. The updated tool submitted on February 9, 2017, is also approved with the same caveat. Further, if a problem is found in the randomly selected cells, a complete inspection or remediation of the area or setting should then be conducted.
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: NON-COMPLIANCE The Proposed Revision of the Station Jail Manual requires that any arrestee who “displays obvious suicidal ideation or exhibits unusual behavior that clearly manifest[s] self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, such inmates . . . shall be under unobstructed visual observation or in a suicidal restraint location with safety checks every 15 minutes.” The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent to determine compliance with Paragraph 25 of the Agreement. The County’s Third Self-Assessment reports that the Department is still working to capture the data to show when inmates arrive at a hospital. The Monitor and Subject Matter Expert have advised the Department that each station jail should identify a location with clear visibility to observe inmates with urgent and emergent mental health needs pending transportation to IRC, CRDF, or a medical facility. The Third Self-Assessment reports that the station jails are being informed that they need to identify the specific suicide resistant locations that will be used to observe inmates with urgent or emergent mental health needs. Further, the Department has created a log for the station jails to use to document unobstructed visual observations.
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: PARTIAL COMPLIANCE
Medical Service Bureau (“MSB”) 201.01 RECEPTION CENTERS HEALTH SCREENING, effective February 17, 2016, DMH 20.2 RECEPTION CENTER INITIAL ASSESSMENT, Section 2.2, effective March 1, 2016, and DMH 70.7 SUICIDE PREVENTION, Section 4.1.1.2, effective July 7, 2016, address the requirements of Paragraph 26 of the Agreement.
Substantial Compliance requires (1) the Department to “review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of 100 randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC” and (2)(i) that 95% of the forms “include the required mental health information” and (ii) 90% of the prisoners having urgent or emergent needs were “seen by a QMHP within four hours.” The County’s posted results reflect that 93% of the screening forms reviewed for the one randomly selected week in the Third Quarter had the required mental health information, and 50% of the prisoners were seen by a QMHP within four hours. The Monitor has noted on several visits to IRC and CRDF the steps that the Department is taking to expedite inmates with emergent or urgent mental health needs through the booking and evaluation process.3
3 The Monitor and Mental Health Subject Matter Expert have authorized the County to use a subset of the screening questions to identify a universe of potential cases. The Subject Matter Expert's qualitative review will assess whether this approach is sufficient going forward.
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.

STATUS:

SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through September 30, 2016, at CRDF (verified) (subject to qualitative assessment))

PARTIAL COMPLIANCE (at IRC)

MSB 201.01, effective February 17, 2016, addresses the requirements of paragraph 27.

The Compliance Measures require the Department to review the records of “randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC” to determine compliance with this provision. The County’s Third Self-Assessment reports that Qualified Medical Personnel or trained custody staff filled out a Medical/Mental Health Screening Questionnaire for all of the 100 randomly selected prisoners within 12 hours of their arrivals in the jails, and that the required documents were available to QMHPs who conducted further assessments of 32 inmates identified as having mental health needs. The Monitor's auditors have verified the County’s reported results for the third quarter of 2016.

The Mental Health Subject Matter Expert notes that, notwithstanding the quantitative results, the County “is not attempting to determine whether they are identifying those with mental health needs”" because it is not looking for “mentally ill prisoners who were not detected during the intake process.” The qualitative assessment that the Subject Matter Expert and the clinicians are undertaking “will examine this” to determine “whether the intake process is actually detecting the mentally ill.”

During site visits, the Monitor and the Mental Health Subject Matter Expert observed improvements in the processes for privately screening inmates at CRDF, but there are continuing challenges at IRC. As noted by the Subject Matter Expert, finding “a safe and private location at IRC for those who are agitated or otherwise present management problems present management challenges. . . [T]he County has identified a space in IRC that it intends to develop for this purpose, which is a reasonable solution, if fully implemented.”

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28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.
STATUS: PARTIAL COMPLIANCE
CDM 5-03/030.00 PRE-SCREENING, effective August 25, 2016, addresses the requirements of Paragraph 29 of the Settlement Agreement.
The Compliance Measures require the Department to review the records of randomly selected prisoners at CRDF and IRC who have urgent or emergent mental health needs to determine whether they were expedited through the booking process. The County’s Third Self-Assessment reports that it has “identified new challenges” in attempting “[to gather] data for this provision,” which it “expect[s] to discuss with the Monitor in the near future.”
Notwithstanding the lack of qualitative results, the Monitor and Mental Health Subject Matter Expert believe that the County has achieved Partial Compliance based upon what they have observed at CRDF and IRC. The Monitor and Mental Health Subject Matter Expert toured CRDF and IRC on October 6 and 7, 2016, and reviewed the process for expediting prisoners identified during intake as having emergent and urgent mental health needs. At IRC, an inmate with urgent or emergent mental health needs is initially detained on a bench directly in front of the officer’s station or brought to an area adjacent to the screening windows under the observation of custody personnel. He is then brought directly to the clinic where he “goes to the top of the list” to be assessed by clinicians. The inmate is under constant observation in the clinic until he is transferred to a HOH unit.
At CRDF, an inmate with urgent or emergent mental health needs is also initially detained on a bench directly in front of the officer’s station before she is transferred as soon as practical to Module 1200 for an assessment by clinician. Depending on the availability of beds, the inmate may remain in 1200 or be transferred to a HOH unit.
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29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.
STATUS: PARTIAL COMPLIANCE Section 2.1 of DMH 20.2 RECEPTION CENTER INITIAL ASSESSMENT, effective March 1, 2016, addresses the requirements of Paragraph 29 of the Settlement Agreement. The Compliance Measures require the Department to review randomly selected records of the prisoners who are identified in the intake nursing assessment as having non-emergent mental health needs to determine if the Department completed mental health assessment for 85% of the prisoners within the required time periods. The County’s Third Self-Assessment reports that the Department achieved Partial Compliance in the third quarter of 2016 by completing mental health assessments for 75% of the inmates within the required time periods. The Monitor agrees that this is sufficient to achieve Partial Compliance.
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30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through September 30, 2016) (unverified)
DMH 20.2, Sections 2.3, 3.1.5, effective March 1, 2016, address the requirements of Paragraph 30 of the Settlement Agreement.
The Compliance Measures require the Department to review randomly selected initial mental health assessments and report on (1) the percentage of assessments that have all of the information required by Paragraph 30, and (2) whether the housing recommendations were followed. The County's Third Self-Assessment reports that 100% of the housing assignments reviewed in the second quarter of 2016 followed the housing recommendations in the initial treatment plans, which exceeds the 95% threshold for Substantial Compliance, and that 91% of the initial mental health assessments had the information required by Paragraph 30, which exceeds the 85% threshold. The SelfAssessments reports 98% of housing assignments and 90% of the initial assessments complied with the requirements of Paragraph 30 in the third quarter of 2016. The results are subject to verification by the Monitor's auditors.
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31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk; (b) hoarding medications; and (c) prior suicide attempts.
STATUS: PARTIAL COMPLIANCE Section 3.1 of DMH 80.1 MENTAL HEALTH ALERTS, effective February 4, 2016, addresses the requirements of paragraph 31. The Compliance Measures require the Department to review randomly selected electronic medical records for prisoners in certain at-risk groups to determine if the required mental health alerts are in 85% of the records reviewed, which is the threshold for Substantial Compliance. The County’s Third Self-Assessment reports that 71% of the records reviewed contained the required mental health alerts in the third quarter of 2016, which is up from 68% in the second quarter and 61% in the first quarter. The Mental Health Subject Matter Expert notes the County methodology for “detecting hoarding cases” is “not clear,” and also that “the County needs to demonstrate that the alert for prior suicide attempts is current at the time of the assessment[.]”
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32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified)) (subject to qualitative assessment)

DMH 80.1, Section 3.5.1, effective February 4, 2016, and DMH 70.7, Section 4.4.5, effective July 7, 2016, address the requirements of Paragraph 32.

The Compliance Measures require the County to review the electronic medical records of all prisoners who had a serious suicide attempt in the prior quarter. The County reports that 100% of the electronic medical records of prisoners who had a serious suicide attempt in the second, third, and fourth quarters of 2016 reflect the suicide attempt and that the information was entered into the record within one day of the attempt.4 The results exceed the 95% and 85% thresholds for Substantial Compliance.

The Department’s reported results through the fourth quarter of 2016 have been verified by the Monitor’s auditors. In addition, under the Monitor's supervision, the Monitor's staff reviewed the Department's documentation and confirmed that the County was in Substantial Compliance in this reporting period. The results for the fourth quarter of 2016 still need a qualitative assessment by the Subject Matter Expert using an alternative methodology to confirm the Department's results. If the County's results are confirmed, the County will be in Substantial Compliance for twelve consecutive months,5 and this provision will no longer be subject to monitoring pursuant to Paragraph 111 of the Agreement.

4In one case, the medical records reflect that the information was entered in the record at the same time as the attempted suicide reflected in the County's supporting spreadsheet occurred. It appears that the County's spreadsheet may be in error as the medical records reflect that the attempt actually occurred 15 minutes before the information was recorded in the medical records. 5 The County's Second Self-Assessment previously reported Substantial Compliance in the first quarter of 2016.
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33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:
(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;
(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;
(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and
(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through September 30, 2016 (unverified))
The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected prisoners from each clinician’s caseload. The County has provided the required tool, and the County’s augmented Third Self-Assessment reports Substantial Compliance for the second and third quarters of 2016. The “process” the County used to complete its review of the second quarter is not clear, and the Monitor is unable to agree or disagree with the County’s conclusion for that quarter. While the simplified review process (consisting of supervisors confirming their clinician reviews) for the third quarter supports the County’s conclusion for that quarter, the source documents (the actual reviews) must be reviewed, and the results are subject to verification, by the Monitor's auditors.
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34. The County and the Sheriff will conduct discharge planning and linkage to community mental health providers and aftercare services for all prisoners with serious mental illness as follows:
(a) For prisoners who are in Jail seven days or less, a preliminary treatment plan, including discharge information, will be developed.
(b) For prisoners who are in Jail more than seven days, a QMHP will also make available:
(i) for prisoners who are receiving psychotropic medications, a 30-day prescription for those medications will be offered either through the release planning process, through referral to a re-entry resource center, or through referral to an appropriate community provider, unless clinically contraindicated;
(ii) in-person consultation to address housing, mental health/medical/substance abuse treatment, income/benefits establishment, and family/community/social supports. This consultation will also identify specific actions to be taken and identify individuals responsible for each action;
(iii) if the prisoner has an intense need for assistance, as described in DMH policies, the prisoner will further be provided direct linkage to an Institution for Mental Disease ("IMD"), IMD-Step-down facility, or appropriately licensed hospital;
(iv) if the prisoner has a moderate need for assistance, as described in DMH policies, and as clinically appropriate to the needs of the prisoner, the prisoner will be offered enrollment in Full Service Partnership or similar program, placement in an Adult Residential Facility (“Board and Care”) or other residential treatment facility, and direct assistance accessing community resources; and
(v) if the prisoner has minimal needs for assistance, as described in DMH policies, the prisoner will be offered referrals to routine services as appropriate, such as General Relief, Social Security, community mental health clinics, substance abuse programs, and/or outpatient care/support groups.
(c) The County will provide a re-entry resource center with QMHPs available to all prisoners where they may obtain information about available mental health services and other community resources.
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STATUS (34):

STAYED PENDING LITIGATION

Paragraph 34 is the subject of on-going litigation as a result of a First Amended Complaint in Intervention challenging the provisions relating to discharge planning. The County’s Third Self-Assessment reports that the litigation “has not been resolved” and, “[a]ccordingly, the Department has stayed its collection of compliance data with respect to this provision.”

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35. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team (“JMET”) member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: NON-COMPLIANCE The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral (“BOMHR”) records for prisoners referred by custody staff to a QMHP or JMET member for “routine” mental health care to determine the timeliness of the referrals. Previously the results reported by the County involved emergent cases “demanding immediate response[s],” rather than routine cases of inmates who have “a potential need for routine mental health care” as required by Paragraph 35. The County's Third SelfAssessment reports that the Department has changed its computer program so that data is “maintained in a manner that will allow a more refined search” for inmates with routine mental health needs. The Department is also adjusting its practices, and using a revised BOHMR, to better capture the time of the referral to the QMHP and to determine the “end of shift.” The County anticipates it “will take some time to adjust” to these changes.
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36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: PARTIAL COMPLIANCE
Section 4.4 of DMH 70.7 SUICIDE PREVENTION, effective July 7, 2016, and DMH 70.2.1 MENTAL HEALTH TREATMENT PROGRAMS, effective February 4, 2016, address the requirements of Paragraph 36.
The Compliance Measures require the Department to review randomly selected records of prisoners newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; conduct quarterly unannounced visits to observe inmates who had experience triggering events; and provide a staffing schedule for on-call services. The County's Third SelfAssessment reports that 87% of the assessments were completed within four hours, but there were no inmates who had experienced triggering events and were pending a QMHP evaluation during the Department's unannounced visits at TTCF and CRDF.
During tours of TTCF and CRDF, the Monitor and Subject Matter Expert visited housing areas to observe where prisoners with adverse triggering events are housed pending a QMHP evaluation. As in the case of the Department's own visits, there were no inmates who had experienced triggering events and were pending a QMHP evaluation.
The process of observing prisoners following adverse triggering events remained variable at CRDF. In a General Population dorm, deputies again reported using the dayroom or the recreation area as well as the area directly in front of the officers’ station, and not necessarily handcuffing the prisoners. In one HOH module and a different General Population dorm, the deputies indicated that such prisoners were seated at a table directly adjacent to the deputies' station.
In TTCF, the Department has installed benches in housing areas directly adjacent to the deputies' stations to seat prisoners who experience a triggering event pending a QMHP mental health evaluation.
The Monitor has proposed that Compliance Measures 36.3 and 36.4(b) be modified to require the Department to install benches in close proximity to the deputies'
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stations in all of the housing areas in TTCF and CRDF, but not require quarterly unannounced visits to observe inmates who had experienced triggering events since such events are random and variable. DOJ has suggested that the Department use a log or a form to document the actual monitoring, but the County does not believe that this is a "practical" solution. The Monitor and Mental Health Subject Matter Expert believe that the County needs to have some documentation to track compliance with this provision.
The County's augmented Third Self-Assessment reports Substantial Compliance at TTCF for the fourth quarter of 2016 because during an unannounced visit a prisoner who experienced a triggering event was “under unobstructed visual observation pending assessment” by a QMHP.6 Although this addresses Compliance Measure 36.4(b), it does not address Compliance Measure 36.4(a), which requires the Department to review the records of prisoners who experienced “an adverse triggering event during two randomly selected weeks per quarter” to determine the timeliness of the QMHP's assessment. For the third quarter of 2016, the County's Third Self-Assessment “concluded that 87% -rather than the required 95% -- of the records reviewed. . . reflected that the inmates received a QMHP assessment within four hours,” but there is no report for the fourth quarter of 2016.
The Department also needs to update the posted on-call staffing schedules to show that a QMHP was assigned 24 hour a day, 7 days a week.
6 The posted results indicate that two such inmates were observed during unannounced visits to CRDF in the fourth quarter, but neither was under unobstructed visual observation pending assessment by a QMHP
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37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: NON-COMPLIANCE The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter and to review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner; incident reports for self-injurious behavior by prisoners appearing in the selected courts; and BOMHR forms completed by the Court Services Division staff in the selected courts to determine compliance with this provision. The County’s Third Self-Assessment reports that significant problems with the use and completion of the BOMHR form by the Court Services Division continued through the third quarter of 2016. The results provided by the Department show that the staff assigned to only one court met the 90% threshold for Substantial Compliance during the second and third quarters of 2016.
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38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
Section 3.1.7 of DMH 70.2.3 DISCIPLINARY SEGREGATION, effective December 31, 2015, addresses the requirements of Paragraph 38.
The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision. Substantial Compliance requires that (a) 90% of the required weekly cell-by-cell checks were completed; and (b) 85% of the out-of-cell interviews requested were granted, absent documented justification for denial of the request.
The County's First Self-Assessment reported 100% success for the third and fourth quarters in 2015, but the Monitor’s auditors were unable to verify these results. The Second Self-Assessment reported 100% success for the first quarter in 2016, which was verified by the auditors.
The results provided by the Department for the second and third quarters of 2016 reflect 100% of the weekly cell-by-cell checks were completed at all the facilities to which this provision applies (CRDF, MCJ, NCCF, PDC North, and TTCF) and that with the exception of MCJ in the second quarter, 100% of the out-of-cell interviews were granted at the facilities in both quarters. At MCJ 95% of the interviews were granted in the second quarter. These results have been verified by the Monitor's auditors.
The recently posted results for the fourth quarter of 2016 reflect 100% of the weekly cell-by-cell checks were completed at all the facilities to which this provision applies and that 100% of the out-of-cell interviews were granted at all the facilities in the quarter. These results also have been verified by the Monitor's auditors. Accordingly, pursuant to paragraph 111 of the Settlement Agreement, County is no longer subject to monitoring for Substantial Compliance with Paragraph 38.
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39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their requests to custody staff or other prisoners.
STATUS: PARTIAL COMPLIANCE
DMH 70.10 SELF-REFERRAL/REQUESTS, issued on April 11, 2016, addresses the requirements of Paragraph 39 of the Agreement. CDM 8-03/020.00 HEALTHCARE INMATE GRIEVANCES, effective July 15, 2016, addresses priority requests for healthcare services.
During the Third Reporting Period, the Department created and started using a separate Healthcare referral form for prisoners requesting medical or mental health care. The Monitor has recommended that the form be modified slightly to make it clearer that it includes requests for mental health care as well as medical care. During tours of the jail facilities in the Third Reporting Period, the Monitor noted that the new forms and envelopes were available either in the modules or at the deputies' stations adjacent to these housing areas, and prisoners are able to ask staff for the forms and envelopes if the box is empty. In some areas in Men's Central Jail where the inmates are in single cells in rows (e.g., for K-10 inmates), the forms are in boxes outside of the rows and must be obtained from the deputies and Custody Assistants assigned to the areas.
Based upon a review of the County’s policies and procedures, multiple tours of the facilities, interviews, and the County’s Semi-Annual Report, the Monitor is satisfied that the Department has adequate processes and procedures for inmates to make confidential self-referrals for mental health care.
Substantial Compliance requires the Department to (a) verify that housing areas have the required forms and (b) review randomly selected self-referrals for mental health care from prisoners to confirm that (i) the referrals “were forwarded to DMH” by the Department,” and (ii) that “DMH documented the timeliness and nature of DMH's response to the self-referrals[.]”
The County's augmented Third Self-Assessment reports that it achieved Substantial Compliance with Paragraph 39 at PDC North in the second quarter of 2016 and at all facilities except for CRDF in the third quarter of 2016. The posted results show that more than 85% of the housing areas in all of the facilities other than CRDF had the self-referral forms required by Compliance Measure 39.4(a).
The County's Semi-Annual Report for Paragraph 39 reports that in the third quarter of 2016, 99% of the self-referrals forms from CRDF. TTCF and MCJ were forwarded to DMH as required by Compliance Measure 39.4(b), and DMH documented the timeliness and nature of its response in 98% of those referrals, as required by Compliance Measure 39.4(c). The County's report notes a number of changes to the process for handling confidential self-referrals for mental health care, and there have been significant improvements in documenting the nature of the response to requests for
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mental health care. The Monitor and Subject Matter Expert have, however, identified some problems with the County's methodology. On a few occasions, the County is counting a visit with the mental health professional before the self-referral, which may be appropriate in some cases,7 but not all. The Monitor’s auditors have requested additional information regarding these cases. The Monitor also notes that the universe of selfreferrals randomly selected by the County does not include any self-referrals from any facilities in the north County, and only one from CRDF.8
Finally, the Monitor is of the view that the “timeliness” requirement in Compliance Measure 39.4(c) requires more than the mere documentation of the time of the DMH response, and that it requires the DMH response to be timely and, by implication, to be responsive to the request.9 Absent extenuating circumstances, which must be documented, the Monitor believes that DMH must respond to self-referrals within seven days of DMH's receipt from the Department.
7 For example, there were instances in which a prisoner wanted different medication from what had been ordered by the mental health professional who met with the prisoner the day before. In another example, a prisoner complained of hearing voices the day after the mental health professional concluded that he was stable and suitable for general population housing. In these cases, the substance of the self-referral had been addressed by the mental health professional the day before the referral. 8 This was because the nurse assigned to review the referrals in the randomly selected week was on vacation and there was no back-up. 9 Thus, an initial response from a QMHP to a request regarding medications would not be timely if the QMHP simply referred the prisoner to a psychiatrist who could not see the prisoner for months.
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40. The County and the Sheriff will ensure a QMHP will be available on-site, by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: PARTIAL COMPLIANCE Section 2.2 DMH 70.2.1 MENTAL HEALTH TREATMENT PROGRAMS, Section 2.2, effective February 4, 2016, addresses the requirements of Paragraph 40 of the Agreement. Substantial Compliance requires DMH (1) to provide the Monitor with on-call schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week, and (2) randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify that a QMHP responded to all referrals, and 90% of the referrals within four hours. The County’s posted results for the second quarter 2016 show that a QMHP was assigned 24 hours a day, 7 days per week, but that a QMHP responded to 96% of referrals and 87% of referrals were responded to within four hours. The posted results for the third quarter show that a QMHP responded 99% of the time and 82% were within four hours. Future results reporting Substantial Compliance will be subject to a qualitative assessment that the QMHP provided “clinically appropriate mental health crisis intervention services” as required by Paragraph 40.
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41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through September 30, 2016)
Sections 4.8 and 4.9 of revised DMH 70.7, effective July 7, 2016, address Paragraph 41 of the Agreement.
Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. The County’s Third Self-Assessment reports that it examined the records of the 10 prisoners who were (a) on suicide watch in the randomly selected month of April and (b) the one prisoner who was discharged from FIP before the end of the quarter, and the 11 prisoners who were (a) on suicide watch in the randomly selected month of July and (b) the one prisoner who was discharged from FIP before the end of the quarter. The source documents indicate that the step-down protocols required by Paragraph 41 were followed for these two prisoners. Although the size of the pool is very small, subject to reviewing the records to verify the results, the County has demonstrated Substantial Compliance for the first three quarters of 2016.
The County's augmented Third Self-Assessment reports “that there were no inmates discharged from FIP during [the fourth quarter of 2016] who were discharged from FIP after being the subject of suicide watch.”10 The Monitor is of the view that
10 The Mental Health Subject Matter Expert questions whether the County is counting all of the prisoners on suicide watch. He notes that the County's self-assessment “seems to limit the pool of patients to those
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there is no basis for concluding that the County has or has not complied with requirements of the sub-parts of Paragraph 41 in the fourth quarter since the predicate for the County's obligations did not occur.
The Monitor believes that it is appropriate to wait until at least the next quarter to determine the County's Substantial Compliance under Paragraph 111 of the Agreement. If a prisoner is discharged from FIP after being on suicide watch in the first quarter of 2017, the County can provide an interim report to the Monitor regarding its compliance with Paragraph 41. If the County achieves Substantial Compliance in the first quarter of 2017, pursuant to Paragraph 111 of the Agreement, it will no longer be subject to monitoring of Paragraph 41. The County is not "penalized for the lack of reportable data" since it gets credit for the nine months in which it achieved Substantial Compliance, but the obligation is not discharged until it demonstrates twelve months of compliance, which is what is contemplated by Paragraph 111.
who were in restraints or on direct constant observation,” and may not include patients “formally placed on any form of suicide watch/protection status: safety gown, checks, restraint, or constant observation.”
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42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement “step-down” procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: PARTIAL COMPLIANCE
Section 4.10 of revised DMH 70.7 addresses the requirements of Paragraph 42 of the Agreement.
Substantial Compliance requires the Department to review the medical records of prisoners in HOH on risk precautions for one randomly selected month each quarter, and to report on the implementation of the step-down protocols and the results of the medical records review. The County’s Third Self-Assessment reports that for the third quarter of 2016 at CRDF, “61% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures” and “100% -- instead of the required 85% -- of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable.” For this quarter at TTCF, “35% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures” and “100% -- more than the required 85% -- of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable.”11
11 For TTCF, the 100% is based upon one prisoner for whom the QMHP determined on an individualized assessment to implement Step-Down Procedures; in that case the procedures met the requirements of Compliance Measure 42.4(c). There were, however, 11 prisoners for whom the assessments did not reflect that the QMHP had determined on an individualized basis whether to implement the Step-Down Procedures, which is the predicate for 42.4(c). For CRDF. the results are not as stark, but in both cases the 100% rating is based upon an incomplete universe of cases. It also appears that the County is reviewing only those prisoners for whom risk precautions had been discontinued. Although this may be the appropriate universe for Compliance Measure 42.4(c), it does not appear to be the correct universe for Compliance Measures 42.4(a) and (b).
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 42 of 108 Page ID #:2600
43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
STATUS: PARTIAL COMPLIANCE
Sections 3.1.1, 3.1.2 and 3.1.7 of DMH 70.2.3 DISCIPLINARY SEGREGATION, effective December 31, 2015, address requirements of Paragraph 43. CDM 5-09/050 LIMITATIONS ON DISCIPLINARY ACTIONS and CDM 5-09/080.00 LOCATION OF DISCIPLINE, effective as of March 14, 2016, address the requirements of Paragraph 43(a). In response to comments by the Monitor and DOJ, the Department is revising its discipline policies applicable to Paragraph 43. The Department met with the Monitor and the Mental Health Subject Matter Expert on January 25, 2017, to discuss the status of the revised policies. It expects to share drafts of these revised policies in the near future.
The County has reported to the Monitor and DOJ that it has “stopped the practice of moving inmates with mental illness to [disciplinary] housing.” Nevertheless, the Department reports that one inmate was transferred in the second quarter at CRDF and one inmate was transferred in the third quarter at TTCF, and in both cases a QMHP was
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 43 of 108 Page ID #:2601
consulted before the transfer as required by Compliance Measure 43.9(b). Although this exceeds the 95% threshold in Compliance Measure 43.9(b), the parties disagree about whether Paragraph 43(a) and Compliance Measure 43.9(b) apply to mentally ill inmates who are disciplined in place in HOH or MOH units. The County reports that the parties are trying to resolve the dispute.
The results posted by the Department for the third quarter of 2016 reflect that a QMHP met with inmates who were receiving psychotropic medication and assigned to disciplinary housing from an area outside mental health housing within 24 hours of the assignments 85% of the time at CRDF, 60% of the time at MCJ, and 56% of the time at TTCF.12 Although these percentages are below the 90% threshold for Substantial Compliance in Compliance Measure 43.9(c), they represent a significant improvement from the second quarter for each of the facilities.
The results reported by the Department reflect that a QMHP walked through each disciplinary housing unit at least once a week at each facility in both the second and third quarters as required by Compliance Measure 43.9(d).
Finally, the County has reported that “the Department did not remove any behavioral credits from inmates with mental illness . . . in the first quarter of 2016.” Consistent with the practice in the first quarter, the County did not have anything to report for the second, third, or fourth quarters with respect to Compliance Measure 43.9(e), which requires that a disciplinary decision-maker to consult with a QMHP 85% of the time before taking away behavioral credits of inmates in mental health housing for disciplinary reasons.
12 There are no results for NCCF or PDC North. In the future, the County should confirm if there are no prisoners on psychotropic medications who were referred to disciplinary housing at NCCF and PDC.
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 44 of 108 Page ID #:2602
44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
During the Initial Reporting Period, the Monitor and Subject Matter Experts observed that the Department had installed protective barriers on the second floor tier of High Observation Housing areas and most Moderate Observation Housing areas at TTCF and the CRDF. During that period, the Department also provided the Monitor with a plan for the installation of additional protective barriers in other areas in mental health housing as required by Paragraph 44. During multiple tours of TTCF and CRDF during the Second and Third Reporting Periods, the Monitor confirmed the second floor tier in all of the HOH and MOH areas at TTCF and CRDF have protective barriers.
The County has maintained Substantial Compliance with Paragraph 44 of the Agreement for twelve consecutive months since January 1, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, the Monitor and the Subject Matter Experts will “no longer . . .assess or report on that provision.”
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45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016, at CRDF, NCCF, PDC EAST, PDC SOUTH, and TTCF (verified))

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016, at MCJ and PDC North (verified))

Substantial Compliance requires the Department to verify once each quarter that each control booth or officer’s station in each housing unit has both a first-aid kit and a Suicide Intervention Kit that contains an emergency cut-down tool, and to include training in the use of both the Suicide Intervention Kit and the first-aid kit in the curricula for Custody Assistants in the Academy, for new Deputy Sheriffs in the Jail Operations Continuum, and for existing deputies in the two-hours of Suicide Prevention Training. The most recent result reported by the Department show 100% compliance at all facilities other than MCJ for both the second and third quarters of 2016. The results for MCJ were 97% in the second quarter and 100% in the third quarter.

As in the past, during all visits to the jail facilities in this reporting period, and as recently as February 7 and 8, 2017, the Monitor and Subject Matter Experts inspected control booths and staff stations on a random basis and verified that each inspected control booth and station had both a first-aid kit and a Suicide Intervention Kit. On these visits, the Monitor also asked Custody staff to show him the kits, and Custody staff always knew where the kits were located. The Monitor also randomly asked Custody staff to open Suicide Intervention Kits and verified that each kit contained an emergency cut-down tool.

Training in the use of the Suicide Intervention Kit is included in the Department’s Suicide Prevention Training and in comprehensive training in the Department’s mandated First Aid Training.

Based upon the reported results through the third quarter of 2016, the County has maintained Substantial Compliance with Paragraph 45 of the Agreement for twelve consecutive months at all of the facilities with housing areas. These results have been verified by the auditors, and pursuant to Paragraph 111 of the Settlement Agreement, the Monitor and Subject Matter Expert will “no longer . . . assess or report on that provision.”

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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 46 of 108 Page ID #:2604
46. The County and the Sheriff will immediately interrupt, and if necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to review the documentation from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment. The County's Third Self-Assessment reports that for the second quarter of 2016, “86% -rather than the required 95% -- of the records reviewed . . . reflected that the Department provided appropriate aid [and] immediately interrupted (when necessary) self-injurious behavior.” The County's augmented Third Self-Assessment reports that for the third quarter of 2016, 82% of the records reviewed reflected that the aid was provided and selfinjurious behavior was “immediately interrupted” when necessary.
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 47 of 108 Page ID #:2605
47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: PARTIAL COMPLIANCE The County’s Third Self-Assessment sets forth what the County has done to implement each of the paragraphs of the Settlement Agreement and provides a summary of “significant changes in mental health staffing at the County's custody facilities” – essentially the completed transition of the DMH and the upcoming transition of the Medical Services Bureau to the DHS, and the mental health staffing levels assigned to the Custody facilities under the new County-wide organization. The parties and the Monitor have agreed that Critical Incidents should include inmate deaths, inmate suicides, serious suicide attempts, assaults on staff by inmates in mental health housing units or on mental health caseloads resulting in serious injuries to staff, and Category 3 uses of force (or a statement that no such incidents occurred). The County’s Third Self-Assessment reports that the County is developing a list of Critical Incidents along with “an analysis of whether staffing levels were a factor” in those incidents. This analysis should include an assessment of custody staffing and medical staffing as well as mental health staffing levels.
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 48 of 108 Page ID #:2606
48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations (“CCR”) Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The Department’s revised CDM 5-11/020.00 SANITATION issued on July 6, 2015, requires each facility to “have a written housekeeping, sanitation and inspection plan.” The Department has provided Unit Orders for each facility that, for example, “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility.” As required by the Compliance Measures, the Department provided the most recent Local Detention Health Inspection Report pursuant to California Health & Safety Code Section 101045 and Corrective Action Plans for each facility. The Monitor, after consultation with the Subject Matter Expert, certified in the Initial Report that the Department’s plans satisfy the requirements of CCR Title 15, §1280 and had been implemented as of January 1, 2016.
On October 25 and 26, 2016, the Monitor and the Use of Force Subject Matter Expert inspected all of the facilities except for CRDF to assess the Department’s compliance with Paragraph 48 of the Agreement. On November 14, 2016, the Monitor inspected CRDF.13 During these inspections, the Monitor and Subject Matter Expert again conducted interviews, inspected the food service departments, medical departments, intake areas and random housing units, and found that there was “an acceptable level of cleanliness, sanitation, repair and safety” in each facility. The County also submitted the 2016 Local Detention Facility Health Inspection Report for each facility and the County's completed or scheduled corrections.
The most significant problems are in HOH units in TTCF when severely mentally ill inmates refuse to come out of their cells so that the cells can be cleaned of trash, debris, food, and sometimes human waste that has accumulated over a number of days. Although this occurs in relatively few cells, and recognizing that addressing this problem may involve cell extractions of mentally ill inmates, the Department needs to be more proactive in these situations. Overall, however, the common areas in the facilities were generally clean and relatively few of the cells had an undue buildup of trash and debris. The Department has confirmed that it has a continuing obligation to maintain “an acceptable level of cleanliness, sanitation, repair and safety” in each facility in the future.
13 The Monitor also toured the downtown jail facilities (MCJ, TTCF, and IRC) with the other Monitors in the Rosas case on two occasions during this Reporting Period. The Monitor and the Mental Health Subject Matter Expert toured the mental health units at CRDF and TTCF, and IRC on October 6 and 7, 2016, and the Monitor and the Use of Force Subject Matter Expert toured the North County facilities and Downtown Jail facilities on February 7 and 8, 2017, to confirm that the Sheriff's Department is maintaining “an acceptable level of cleanliness, sanitation, and safety.”
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 49 of 108 Page ID #:2607
49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016, through December 31, 2016)
CDM 4-07/020, effective January 26, 2016, requires Unit Commanders to establish plans for their facilities that address the requirements of Paragraph 49. Unit Orders for each facility have been issued, for example, to “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility.” Unit Orders address procedures for handling maintenance requests and the eUDAL and Maximo automated systems are used to track such requests while on-site. The Unit Orders indicate that the Facilities Services Bureau (“FSB”) is to be notified when there is mold, and it will be responsible for treating the problem. The Department submitted a memorandum from FSB, dated February 3, 2016, indicating what steps FSB takes to treat the problem.
Each facility has a written maintenance plan for responding to routine and emergency needs and for addressing small and large mold infestations (minor mold infestations are handled by facility staff and inmate work crews and large mold infestations are reported to FSB for handling). Each facility also has a maintenance coordinator who serves as the point person between the facility, maintenance contractors and Internal Services Departments, as well as the coordinator for inmate work crews.
On October 25 and 26, 2016, the Monitor and a Subject Matter Expert inspected each of the facilities (other than CRDF) for the purpose of assessing the Department’s compliance with Paragraph 49. The Monitor inspected CRDF on November 14, 2016, also for this purpose. During the inspections we again conducted interviews and again inspected lighting systems, heating, ventilation and cooling systems for functionality and upkeep.
There are frequent plumbing problems in all of the jail facilities, but based upon our conversations with facility supervisors, it appears that the Department addresses these problems as expeditiously as possible. This is confirmed by the 2016 Local Detention Facility Health Inspection Report for each facility and the County responses showing corrections made or scheduled for each facility. We again found that the lighting systems, heating, ventilation and cooling systems in each facility were “adequately maintained and installed.”
Again, the Department has confirmed that it has a continuing obligation under the Agreement to adequately maintain lighting systems, heating, ventilation and cooling systems in each facility in the future.
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 50 of 108 Page ID #:2608

50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through September 30, 2016, at all facilities other than PDC South and PDC East (verified))

SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through September 30, 2016, at PDC South and PDC East (verified))

CDM 5-11/030.00 CONTROL OF VERMIN, effective December 14, 2015, addresses the requirements of Paragraph 50 of the Settlement Agreement. The Monitor and Subject Matter Expert inspected the facilities (other than CRDF) on October 25 and 26, and the Monitor inspected CRDF on November 14, 2016. During the inspections they again conducted interviews and inspected the food service departments, medical departments, intake areas and random housing units. There was no indication of any pest control problems in the housing units, the medical units, kitchen, food storage areas, or elsewhere in the facilities.

Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with a copy of a contract with an outside vendor for regular pest control services at each jail facility and, on a quarterly basis, a schedule of the pest control activities at each facility in the previous quarter; a pest control compliance checklist of the pest control activities taken at each facility in the previous quarter; documentation from the outside vendor reflecting visits to each jail facility and the work performed during the visits; and a copy of the most recent report by the County Department of Public Health concerning pest control in the jail facilities.

The County's Second Self-Assessment reported that the Department had achieved Substantial Compliance at all facilities other than PDC South and East, where the Department was missing some of the required documentation for the first quarter of 2016. The Third Self-Assessment reports that the Department has maintained Substantial Compliance through the third quarter of 2016 at all facilities other than PDC South and East since January 1, 2016, and at PDC South and East since April 1, 2016. The results provided by the County have been verified by the Monitor's auditors.

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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 51 of 108 Page ID #:2609

51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through June 30, 2016 for all facilities other than CRDF (verified))

PARTIAL COMPLIANCE (at CRDF)

The Department issued revised CDM 5-13/090.00 PERSONAL CARE ITEMS AND SUPPLIES FOR INMATES, effective February 24, 2016, which requires that Admission Kits be provided to new prisoners and to existing prisoners upon request as required by CCR Title 15 § 1265.

During tours of the facilities in the Pitchess Detention Center on October 25, 2016, TTCF and MCJ on October 26, 2016, and CRDF on November 14, 2016, the Department provided the Monitor and Subject Matter Expert with Admission Kits for female and male inmates. The Monitor and Subject Matter Expert randomly inspected control booths and officers’ stations and verified that the kits were readily available and regularly provided to the prisoners at all of the facilities.

The Second Self-Assessment reported Substantial Compliance for all facilities except CRDF and Partial Compliance for CRDF because 20 of 50 signature sheets confirming receipt of hygiene kits were signed by custody staff rather than the inmate in the first quarter of 2016. The Monitor's auditors observed that 12 out of 50 were signed by staff in the second quarter of 2016. The Substantial Compliance results at the other facilities have been verified by the auditors. The County reports that the “results for the semi-annual period of the second half of 2016 are currently being compiled[.]” The reported results will be subject to verification by the auditors.

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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 52 of 108 Page ID #:2610
52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: PARTIAL COMPLIANCE
The Department's ALLOWABLE INMATE PROPERTY policies – CDM 5/06.010.05 for male inmates and CDM 5/06.010.10 for female inmates – require that property restrictions for inmates in mental health housing be determined by “a mental health professional after a clinical assessment has been conducted.” The County’s Second Self-Assessment reported that DMH 70.7, which set forth property restrictions in HOH, was being revised in response to the Monitor’s comments to require the same level of property restrictions where two inmates in mental health housing are co-housed in a single cell, but this has not been completed.
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52. The parties and the Monitor have agreed that for each month in a quarter beginning in January 2016, the Department will randomly select and review the medical records of all inmates, up to a maximum of 100 prisoners, who were placed in HOH during that month (and not include inmates who were already assigned to HOH).
During a tour of TTCF, the Monitor, the Mental Health Subject Matter Expert and the DOJ representative noted that the property of some inmates in the HOH units did not match the allowable property reflected on the door signs. The Third Self-Assessment
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 53 of 108 Page ID #:2611
reports that on October 7, 2016, the Department published a Custody Directive “establishing additional procedures for identifying allowable property for inmates housed in High Observation Housing.”
The County’s augmented Third Self-Assessment reports that it has not achieved Substantial Compliance at either TTCF or CRDF, which are the only facilities with an HOH. For the third quarter of 2016, the County reports that 67% and 76% of the inmates initially placed in HOH at TTCF and CRDF, rather than the required 95%, were provided the property required by Paragraph 52, and that 75% and 97% of the inmates placed in HOH “for more than 24 hours,” had “allowable property as recommended by a QMHP[.]” For the fourth quarter of 2016, the County reports that 81% of the inmates initially placed in HOH at both TTCF and CRDF, rather than the required 95%, were provided the property required by Paragraph 52, and that 88% and 100 % of the inmates placed in HOH “for more than 24 hours,” had “allowable property as recommended by a QMHP[.]” These results reflect continuing improvement in complying with this provision.
The County's augmented Third Self-Assessment reports the results for Compliance Measures 52.5(b) and 52.5(e), but it does not include results for 52.5(c) and (d), which are required to establish Substantial Compliance. These provisions are subject to qualitative assessments of the clinical assessments by the QMHPs.
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 54 of 108 Page ID #:2612
53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: NON-COMPLIANCE Revised CDM 5-13/100.00 RELIGIOUS PROGRAMS, CDM 5-13/130.00 INMATE EDUCATION, and CDM 5-01/020.00 INMATE WORKER ASSIGNMENTS address the requirements of Paragraph 53 of the Settlement Agreement. Substantial Compliance requires the Department to audit the records of prisoners who were eligible and rejected or disqualified for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone. The County reports that in the third quarter of 2016, only 39% of the mentally ill prisoners who were eligible for and denied work were not denied the work because of their mental health condition or a prescription for medication alone, which is well-below the 90% threshold for Substantial Compliance.14 Further, the County's methodology for this provision should be reviewed by the Mental Health Subject Matter Expert and the clinicians to ensure, on the one hand, that it includes the correct universe of prisoners being denied the opportunity for work, and on the other hand, that it correctly categorizes cases where the mentally ill prisoner is denied the opportunity for his or her own protection (e.g., the prisoner is suicidal) rather than because he or she is mentally ill.
14 The County's response to the Monitor's draft of this Report notes that the County expects much improved results for the fourth quarter of 2016.
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 55 of 108 Page ID #:2613

54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through March 31, 2016 (unverified); as of April 1, 2016, through September 30, 2016 (verified))

Revised CDM 5-13/100.00 RELIGIOUS PROGRAMS, CDM 5-13/130.00 INMATE EDUCATION, and CDM 5-01/020.00 INMATE WORKER ASSIGNMENTS address the requirements of Paragraph 54 of the Settlement Agreement.

Substantial Compliance requires the Department to audit the records of a maximum of 100 randomly selected prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. The County’s Third SelfAssessment reports that the Department has identified problems with its data sample used for the first and second quarters of 2016; it has adopted a more accurate way of obtaining the relevant sample; and it achieved Substantial Compliance for the third quarter of 2016. It also re-submitted the data for the first and second quarters of 2016, along with the results for the third quarter of the year.15 The reported results for the second and third quarters, but not for the first quarter, have been verified by the Monitor's auditors.

15 The universe of prisoners “who were denied privileges or programs” in Compliance Measure 54.4 is not limited to prisoners who have a mental health issue or are taking psychotropic medication. This impacts the effectiveness of the Compliance Measures.
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Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 56 of 108 Page ID #:2614

55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.

STATUS:

SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through September 30, 2016, at PDC North (verified); through December 31, 2016 (unverified))

SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2016, at CRDF and TTCF (unverified))

Sections 3.5.2.3 and 3.5.3.2 of DMH Policy 70.2.1, effective February 4, 2016, require “relevant custody, medical and mental health staff” to meet in accordance with the requirements of Paragraph 55. The Monitor and a DOJ representative attended a daily HOH meeting at CRDF on November 14, 2016, which included custody, medical, and mental health personnel who appeared to be very knowledgeable about the condition and issues of individual HOH inmates. The Mental Health Subject Matter Expert also has attended a number of meetings for HOH and MOH units at both CRDF and TTCF, which were well-attended and thorough, and the staff actively participated.

The County’s Third Self-Assessment reports that the Department has achieved Substantial Compliance as of the third quarter of 2016 at PDC North, which has one MOH housing dorm that is subject to the weekly meeting requirement. It reports that the required staff attended every meeting in the randomly selected month of July. These results have been verified by the Monitor's auditors.

The County's posted results show that the Department has achieved Substantial Compliance as of the fourth quarter at PDC North, CRDF, and TTCF. The County recently provided its semi-annual reports from CCSB “verifying the coordination and communication at the staff meetings” as required by Compliance Measure 55.6(c). The fourth quarter results are subject to verification by the Monitor's auditors.16

16 The County has acknowledged that Paragraph 55 also applies to the Hope Dorm in MCJ, and will be submitting data for MOH meetings in that dorm.
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56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through June 30, 2016 (verified); as of July 1, 2016, through September 30, 2016 (unverified))

4.4.6 of DMH 70.7, effective July 7, 2016, provides that “JMHS and LASD shall ensure that custody, medical and mental health staff communicate regarding any change in an inmate’s housing assignment following a suicide threat or attempt, other selfinjurious behavior or other indication of an obvious and serious change in mental health condition.”

Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH; and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing.

The County’s Third Self-Assessment reports that it has achieved Substantial Compliance for the second and third quarters of 2016 based upon medical records reflecting the required medical and/or mental health approvals 100% of the time in the second quarter, and over 99% of the time in third quarter. The Mental Health Subject Matter Expert concurs and notes that custody staff and medical/mental health staff “are doing fairly well with their cooperation and collaboration around placement decisions.” These reported results are subject to verification by the Monitor's auditors.

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57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57):

PARTIAL COMPLIANCE

CDM 4-11/030.00 INMATE SAFETY CHECKS and CDM 4-11/030.05 TITLE 15 SCANNER, address the requirements of Paragraph 57, except for 57(e).

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit in two randomly selected weeks to determine if the safety checks were staggered and conducted as required by Paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit for one randomly selected week to determine if a QMHP approved the new mental health housing assignments as required by Paragraph 57(e).

The Monitor has observed Custody staff conduct safety checks at MCJ, TTCF, CRDF, and PDC North which are the facilities that house inmates with mental illnesses. The County’s Third Self-Assessment reports that it has achieved Partial Compliance in the third quarter in the MOH units at MCJ and PDC North, and the HOH and MOH units at TTCF and CRDF.

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58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells; (b) At least every 30 minutes in dormitory-style housing units where the unit
does not provide for unobstructed direct supervision of prisoners from a security control room; (c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes; (d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing; (e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner; (f) Custody staff will document their checks in a format that does not have pre-printed times; (g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and (h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
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STATUS (58):

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through September 30, 2016, at PDC South, PDC North, and PDC East (verified))

PARTIAL COMPLIANCE (at TTCF, CRDF, and IRC)

NON-COMPLIANCE (at the MCJ and NCCF)

CDM 4-11/030.00 and 4-11/030.05 address the requirements of Paragraph 58.

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by Paragraph 58. The County’s Third Self-Assessment reports that the Department has achieved Substantial Compliance at PDC South, PDC North, and PDC East as of January 1, 2016. These results have been verified by the Monitor's auditors.

Based upon a review of the County's data, the Monitor has concluded that the County achieved Partial Compliance at CRDF, TTCF, and IRC, but not at MCJ or NCCF, where the compliance percentages were well below the percentages required by the Compliance Measures. In addition, on a recent visit to NCCF, deputies responsible for conducting safety checks stated that the checks are not staggered at NCCF. This needs to be addressed as both Subject Matter Experts have stressed the importance of staggering safety checks.

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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.
STATUS: PARTIAL COMPLIANCE CDM 4/11-020.00 and CDM 4/11.030.00 address the requirements of Paragraph 59 of the Agreement. Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if the supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. In response to the Monitor's comments, the Department's e-UDAL forms have now been modified to include a specific notation that the Supervisor verified that the safety checks are being conducted. The Department has also issued a Custody Operations Directive to advise custody staff of the new form.
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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
DMH Policy 50.1 CONTINUOUS QUALITY IMPROVEMENT, effective December 31, 2015, is intended “to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program” that focuses on “identifying and addressing clinical issues that place inmates at significant risk of suicide or self-injurious behavior[.]” Since the County submitted the written description of its quality improvement program, the Suicide Prevention Sub-Committee, which tracks and reviews Corrective Action Plans, has evolved into the Joint Quality Improvement Committee. This committee has a broader focus on “all areas of quality improvement monitoring by CCSB and the [Quality Management Committee], which was developed by the Jail Mental Health Services in January 2016 to identify and address clinical and systemic issues that put inmates at significant risk of suicide and selfinjurious behavior[.]” The activities of the Joint Quality Improvement Committee and the Quality Management Committee have been summarized by the County in its semiannual report provided to the Monitor and the Mental Health Subject Matter Expert.
The County also has hired a new Director of Quality & Performance Improvement for Correctional Health Services to implement “a state of the art quality assurance and quality improvement program for health care in the jails” using a model that “is a nationally validated approach to addressing events in a fair and consistent manner.” The Monitor, Mental Health Subject Expert, and the clinicians met with the new Director and were impressed with his approach and plans for enhancing the County's quality improvement program.
The Monitor, after consultation with the Mental Health Subject Matter Expert, approves the County's CQI program, subject to a review of future documentation of the workings of the CQI program. The Mental Health Subject Matter Expert has the following comments on the County's Quality Improvement Program: “The County is developing its quality improvement system and is taking appropriate steps to build out its capacity. At this point, the County is overly reliant on anecdotal information owing at least in part to limited informatics. Despite these challenges, the County has been reviewing a variety of self-harm incidents and has demonstrated steadily more thorough reviews. These reviews have led to the development of a number of important Corrective Action Plans. Once the County is able to augment its incident-driven reviews with aggregated data per measure 61, the County should achieve substantial compliance on this measure.”
Compliance Measures 60.2 and 3(b) require the County to prepare semi-annual reports setting forth (a) any identified clinical issues in the areas identified in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b)
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corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods. The County has submitted a Semi-Annual Report that describes the Quality Improvement Program and discusses issues related to “access of care” and “elements of documentation.” These areas are only discussed in very general terms, and the report does not discuss “clinical issues” or “corrective actions and systematic improvements to address these clinical issues” in the other areas of the program pertaining to “suicides and serious suicide attempts,” “use of clinical restraints,” and “psychotropic medications.”
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts:
(i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints;
(c) Psychotropic medications;
(d) Access to care, timeliness of service, and utilization of the Forensic Inpatient Unit; and
(e) Elements of documentation and use of medical records.
STATUS: NON-COMPLIANCE
DMH 50.1 CONTINUOUS QUALITY IMPROVEMENT, effective December 31, 2015 is intended “to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program.” The quality improvement program the County has implemented addresses the requirements of Paragraph 61.
Substantial Compliance requires that the County’s semi-annual reports (a) review, collect, and aggregate date in the areas set forth in paragraph 61; (b) recommend corrective actions and systemic improvements in those areas; and (c) assess the effectiveness of actions and improvements in prior reporting periods. The County's Third Self-Assessment reports that the “County is developing that process so that the monthly meetings that take place include the quality improvement subjects covered by this provision.”
The Mental Health Subject Matter Expert has observed that the policies are “adequate,” but the documentation “has yet to cover some of the key topic areas, including timeliness of access to care[.]” As noted above with respect to paragraph 60, the County has submitted a Semi-Annual Report that describes the Quality Improvement Program and discusses issues related to “access to care” and "elements of documentation.” It does not, however, “review, collect, and aggregate data in the areas set forth in paragraph 61” or “recommend corrective actions and systematic improvements” in all those areas.
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The Mental Health Subject Matter Expert notes that “the County is challenged to retrieve from its electronic medical record (EMR) much of the data that is needed to build robust quality improvement measures that require aggregated clinical information and the ability to track processes. The County’s other databases also have limitations in tracking many salient events owing to limitations in the ability to search these databases. The County is working to modify the EMR and taking other measures to develop better ways of obtaining data and tracking important processes. The County’s information systems will need to be developed and mined using a more robust, data-driven approach in order to achieve substantial compliance.”
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE DMH 50.1 CONTINUOUS QUALITY IMPROVEMENT, effective December 31, 2015, is intended “to provide Jail Mental Health Services (JMHS) staff policy and procedure for a Continuous Quality Improvement (CQI) program.” CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU, effective February 4, 2016, provides that “[p]ersonnel from CCSB will conduct follow up assessments upon the completion of corrective action reports to verify that any identified deficiencies have been addressed” and “will participate in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.” Substantial Compliance requires the County's semi-annual Self-Assessments to set forth (a) the “development of corrective action plans to address the most recent recommendations of the quality improvement program;” and (b) the “implementation and tracking of corrective action plans to address recommendations of the program in prior quarters.” The County has submitted a Semi-Annual Report that describes the Quality Improvement Program and discusses issues related to “access to care” and “elements of documentation,: including the development and implementation of corrective action plans to address the recommendations in those areas, but not in the other areas set forth in paragraph 61. Further, as noted by the Mental Health Subject Matter Expert, the County has not “address[ed] the implementation and tracking of the [corrective action plans] in a formal way.”
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63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.

STATUS: PARTIAL COMPLIANCE (at TTCF)

NON-COMPLIANCE (at CRDF)

The Compliance Measures require that the County's Self-Assessment set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period; (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. In addition, for two random weeks, the Department is required to review the count sheets documenting the number of occupied and available beds in the MOH and HOH units at TTCF and CRDF. Substantial Compliance requires “the immediate availability of HOH and MOH beds at TTCF and CRDF 95% of the time.”

The parties and the Monitor have agreed that beds in the SAT area in TTCF (a transition module on the seventh floor of Tower 1) shall be considered to be HOH beds for inmates who remain in the SAT area for less than two days, but HOH inmates who remain in the SAT area for more than two days will be deemed to be on a waiting list for HOH housing at TTCF. Beds in CRDF 1200 are not considered to be HOH beds. Inmates in 1200 who have been determined by a clinician to need HOH housing will be deemed to be on a waiting list for HOH housing at CRDF.

The County reports the number of days in which the total number of HOH and MOH beds (the available beds) was equal to or more than then number of HOH and MOH inmates for the two randomly selected weeks in the third quarter of 2016 as follows:

TTCF CRDF

MOH 100%
7%

HOH 57% 50%

On February 9, 2017, the County reported on the average daily populations in HOH and MOH units at CRDF and at TTCF, the average number of beds, the average number of step-downs per week, but not the number of days in which there was a waiting list for HOH or MOH housing. The County also reported on the immediate availability of beds during the entire reporting period as required by the Compliance Measures as follows:

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TTCF CRDF

MOH 99.5% 3.8%

HOH 89.7% 68.5%

With the exception of the availability of beds in MOH housing at TTCF, the percentages are below the 95% required by the Compliance Measure. The County has, however, achieved compliance “on some, but not all, of the material components” of Paragraph 63 at TTCF, but not CRDF. The County reports that the Department “will establish a corrective action plan to address the availability of MOH housing at CRDF.”

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64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in an initial 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed.
On January 22, 2016, the Department submitted a short-term plan to the Monitor. On March 2, 2016, it certified that it had implemented the short-term plan. On June 30, 2016, the Department submitted the long-term plan to the Monitor. The County's Third Self-Assessment reports that, in response to comments from the Mental Health Subject Matter Expert about “a ‘gap’ in the long-term plan,” the “Department has further revised its approach to include additional inpatient beds.” Specifically, the Department of Health Services “is exploring the feasibility of utilizing up to 24 licensed psychiatric inpatient community beds” at a mental health center operated by DHS. DHS also recently converted 19 beds in the medical section of the Correctional Treatment Center to 15 beds in the mental health section, and as of October 1, 2016, it has housed 81 patients in a step-down unit in module 141-F in Tower I at TTCF. Although the County's reliance upon “increased services to address the underlying mental health needs” as a basis for projecting a “decline” in the need for inpatient services is somewhat speculative, the other steps the County is taking will increase the availability of inpatient beds.
The Mental Health Subject Matter Expert is of the view that the County is “doing substantially better with generating a concrete [long-term] plan,” but there is “no methodology” for the County's projection that it will need 60 licensed inpatient beds over the next twelve months (which is the same number that was in the short-term plan submitted a year ago) and 80 licensed beds over the next five years. For example, the County is projecting an increase in the need for inpatient beds from 60 to 80 over a five year period, but it does not explain how that is consistent with a projected “decline” in the need for inpatient services or what accounts for the net increase. Assuming the “adequacy of the population projections,” the Subject Matter Expert believes that the long-term plan is reasonable.
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County's Self-Assessments to set forth the (1) the results of weekly medication Administration Audits documenting the visual observation of the administration of medication during the quarter; (2) unauthorized medications found as a result of cell searches during the reporting period; and (3) incidents involving confirmed prescription drug overdoses. The reported results are subject to the Monitor’s conclusions, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner.
The County’s Third Self-Assessment concludes that the Department “achieved substantial compliance with this provision.” This is based upon “the result[s] of Administrative Audits documenting the visual observation of the administration of medication” 94% of the time (but only 80% for inpatients in CTC). While this percentage exceeds the 85% quantitative threshold for Substantial Compliance, the significant number of times that medication was found during module or cell searches during the third quarter of 2016,17 and the five confirmed attempted (unsuccessful) suicides by overdose, cause both the Monitor and Subject Matter Expert to question how medications are being administered so as “to prevent misuse, hording, and overdose” as required by Paragraph 65.
As in the past at other facilities, the Mental Health Subject Matter Expert observed a pill call at TTCF that was not sufficiently rigorous in conducting mouth checks to prevent the possibility of misuse, hoarding and overdose. Further, he is concerned about “the accuracy of the documentation of the medication delivery when it is not done at the time the medication is administered (for example, when the patients reside on an upper tier, the nurse brings their medications in individual envelopes and later completes the Medical Administration Record rather than completing it after each administration).”
Based upon the search results, the overdose reports, and the observations at the pill calls, the Monitor and Mental Health Subject Matter Expert do not believe that the Department has achieved Substantial Compliance with this provision.
17 73 unknown medications were found during 124 unannounced searches at CRDF, 368 medications were found during 41 searches at TTCF, 208 medications during 435 searches at MCJ, 144 medications during 355 searches at PDC North, and 78 medications during 448 searches at NCCF. CCSB “was unable to confirm whether the medication was returned to medical personnel,” even though the Custody staff is required by CDM 5-03/050.00 to “return the found medication to medical staff” and “[p]rovide medical staff the name and booking number of the inmate[.]” The County reports that it is going to further revise CDM 5-03.050.00 to require documentation of the return.
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66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NON-COMPLIANCE Section 2.3 of DMH policy 70.3.7, effective August 5, 2016, has been revised to apply to all HOH and all MOH prisoners who refuse medications, not just those “having significant symptomatology due to refusing;” as revised, it address the requirements of Paragraph 66. Substantial Compliance requires the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with a Serious Mental Illness ("SMI") to assess whether they have remained on an active mental health caseload, been offered structured mental health treatment, and been seen by a QMHP at least monthly, regardless of whether they refuse medications. The County’s augmented Third Self-Assessment reports that the Department "identified an error" in its assessment of this provision and it has not achieved Substantial Compliance.
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings; (c) the use of clinically appropriate interventions with such prisoners to
encourage medication compliance; (d) consideration of the need to transfer non-compliant prisoners to higher
levels of mental health housing; and (e) individualized consideration of the appropriateness of seeking court orders
for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a). STATUS: NON-COMPLIANCE Section 4.5 of DMH 70.3.7, effective August 5, 2016, addresses the requirements of Paragraph 67(a) through (e) for prisoners in HOH or MOH units (and other housing units) who refuse psychotropic medications for specified periods. Substantial Compliance requires the County to review the electronic medical records (EMR) of prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records reflect the documentation and consideration of the matters required by the terms of Paragraph 67. The augmented Third SelfAssessment reports that the Department has experienced “on-going challenges implementing and assessing compliance with this provision” and “has been pursuing an IT solution[.]”
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016, at MCJ, NCCF, PDC East, PDC South, and PDC North (verified))

SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2016, at CRDF (verified))

PARTIAL COMPLIANCE (at TTCF)

The revision of CDM 5-08/010.00 SEARCHES, effective July 29, 2016. requires contraband searches on a regular, but staggered basis in all housing units, and visual inspection of HOH housing units prior to housing prisoners with mental health issues in HOH units. It addresses the requirements of Paragraph 68.

Substantial Compliance requires Self-Assessments to include a summary of searches conducted in the second quarter of the last reporting period and the first quarter of the current reporting period and to randomly select and review 25 Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units. The County’s Third Self-Assessment reports that the Department has maintained Substantial Compliance at MCJ, NCCF, PDC East, PDC South, and PDC North through the end of 2016. Further, the County reports that it achieved Substantial Compliance at CRDF, where 98% of the modules were searched in the fourth quarter and 96% of the HOH cells were visually inspected as required by Paragraph 68. The County did not achieve Substantial Compliance at TTCF during the fourth quarter. Although 96% of the modules were searched, which is a very significant improvement, only 92% of the HOH units were visually inspected, which is slightly below the 95% threshold. The Substantial Compliance results have been verified by the Monitor's auditors. The County has now maintained Substantial Compliance for a period of twelve consecutive months as required by Paragraph 111 of the Settlement Agreement for all facilities except CRDF and TTCF.

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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: PARTIAL COMPLIANCE
CDM 7-03/030.00 MEDICALLY ORDERED RESTRAINT DEVICES, effective September 29, 2016, provides that the “use of medically ordered restraint devices shall be determined by medical or mental health staff.”18 DMH 100.8 CLINICAL RESTRAINTS defines a “clinical restraint” as a device that “has been ordered or approved by a licensed psychiatrist for the purpose of managing behavior that appears to be symptomatic of a mental illness.” Section 2-1f (2)(e) of the CTC Policy and Procedures Manual provides a “physician shall evaluate a patient prior to writing an order for restraint or seclusion when possible,” with an exception for emergency situations, in which case the physician must be notified and, it appears,19 conduct a “face-to-face medical and behavior evaluation” within one hour of the inmate being placed in restraint.
The Subject Matter Expert believes that, in urgent situations, it is reasonable, and indeed maybe necessary, for a QMHP to call the psychiatrist, who may order the restraint over the phone based upon the psychiatrist's clinical assessment. In emergency situations, a QMHP may order restraints before calling the psychiatrist, who would then authorize the continued use of restraints or order the restraints to be removed. In the latter situations, a QMHP (including properly qualified nursing staff) must perform a clinical assessment before the restraint is used and before calling the psychiatrist. In both situations, the psychiatrist must still conduct an in-person assessment, which should be within one hour. Although the Manual requires “a description of the patient's behavior and the intervention used” to be documented in the patient's medical record, it does not require an initial clinical assessment by a QMHP before a restraint is used in emergency situations.
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved, and documented, and that the results of medical welfare checks on restrained prisoners were also documented, as required by Paragraph 69 of the Agreement. The County’s Third Self-Assessment reports that “89% -- slightly short of the required 95% -
18 Per agreement of the parties, with the concurrence of the Monitor and Subject Matter Expert, “a nonpsychiatrist physician can order medical/clinical restraints as long as it is for medical reasons.” 19 The Manual is somewhat unclear as it requires the physician to “be notified as soon as possible, and within one hour of the initiation of restraints” and also that a “1 hour face-to-face medical and behavior evaluation” be conducted, presumably by the physician.
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- of electronic medical records reviewed. . .reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required.” This is a significant improvement from the last reporting period.
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2016)
CDM 7-03/000.05 FIXED RESTRAINTS, effective August 31, 2016; CDM 703/000.15 SECURITY RESTRAINTS IN MENTAL HEALTH HOUSING, effective August 31, 2016; CDM 7-03/010.00 WAIST-CHAIN PROCEDURES, effective August 31, 2016; and CDM 7-01/240.00 HANDLING INSUBORDINATE, RECALCITRANT, HOSTILE OR AGGRESSIVE INMATES address the requirements of Paragraph 70. The Department has provided confirmation that these provisions were published in the Custody Division Manual and that Custody Support Services sent notice to Custody Operations managers on September 1, 2016.
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71. The County and the Sheriff will ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through September 30, 2016 (verified))
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71. The County’s Third Self-Assessment reports that “100% -- 10% over the required 90% -- of electronic medical records reviewed . . . reflected that, for inmates placed in clinical restraints, the inmates received therapeutic services as required by this provision” in the third quarter of 2016. The Mental Health Subject Matter Expert has reviewed the source documentation and concurs. The reported Substantial Compliance results have been verified by the Monitor's auditors.
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72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.
STATUS: PARTIAL COMPLIANCE
CDM 4-10/05.00 INMATE DEATH – REPORTING AND REVIEW PROCESS, effective March 1, 2016, requires certain notifications in the event of an inmate death, along with corrective action plans as necessary. It also provides that the final written report shall include “[a] reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any.”
CDM 4-10/060.00 CRITICAL INCIDENT REVIEW COMMITTEE – SUICIDAL INMATES, effective August 17, 2016, requires the Critical Incident Review Committee to consider, within 30 days of an incident classified as “serious suicidal behavior,”20 “whether violations of policy or laws were a factor. The review will also consider whether improvements to policy, training, operations, programs or to the facility are warranted.” Further, it provides that "Correction action plans (CAP) which identify areas in need of improvement and propose solutions will be developed and documented.”
DMH 50.2 CRITICAL INCIDENT REVIEW, effective February 4, 2016, encompasses “apparent or suspected suicides” as well as “serious self-injurious behavior” in the review process which includes “determining whether staff engaged in any violations of policies, rules or laws and whether improvements to policy, training, operations or treatment programs are warranted.”
In addition to approval of the above written policies and procedures, Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings to review incidents that involve serious self-injurious behavior in the reporting period.
There was one suicide during the Third Reporting Period, and the Monitor attended two suicide review meetings,21 which addressed the requirements of Paragraph 72.
The County reports that there were 15 incidents involving “serious self-injurious behavior” during the Third Reporting period that were reviewed at CIRC meetings to determine if there were staff violations and whether improvements were warranted. Although the County's Third Self-Assessment reports that 100% of the Serious Suicide
20 This now encompasses “serious self-injurious behavior” as well as attempted suicides. 21 These were the 48-hour and seven-day reviews for the one suicide that occurred during the reporting period.
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Attempts during this reporting period were reviewed as required by Paragraph 72, the Mental Health Subject Matter Expert analyzed summaries of the CIRC meetings posted by the County and found that they do not show that the meetings are “consistently” considering or addressing, in particular, the components of Paragraph 72(b)(ii). He noted that there “were almost no instances where improvements to policy, training or treatment programs were discussed,” or assessments of “how custody and mental health policies influence suicides and self-harm and can anything be done to impact their frequency.” Further, the CIRC reports focus on Jail Mental Health Services and “there is almost nothing about custody action, policies, [and] rules or facilities issues.”
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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: NON-COMPLIANCE CDM 4-05/000.00 BEHAVIORAL OBSERVATION AND MENTAL HEALTH REFERRAL REPORTS, effective December 13, 2016, and CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU, effective February 4, 2016, address the requirements of Paragraph 73. Substantial Compliance requires the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicide during the reporting period. The County’s Third Self-Assessment reports the “Department has had on-going challenges with incomplete BOMHRs” and it has “developed an new [sic] centralized system to maintain these forms;” “has revised policy to require personnel to scan these documents after completion;” and has “revised the form to explicitly include spaces required for compliance.” The total compliance percentage for the Third Quarter of 2016 reported by the County is only 24% as there were only 4 out of 17 incidents with all of the required reports or forms.
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74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2016)
Substantial Compliance requires the Department to provide the Monitor with an Executive Suicide Death Review reflecting the results of the Department’s investigation of any suicide in the Jails within six months of the suicide. The review must reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded.
There were two suspected suicides during the Second Reporting Period for which the Executive Suicide Death Reviews were due in the Third Reporting Period.22 The first suicide occurred on February 29, 2016, and the Executive Suicide Death Review was due on August 28, 2016. It was timely submitted to the Monitor on August 25, 2016, and it is referenced in the Monitor's Second Report filed on September 1, 2016.
The second suicide occurred on May 8, 2016, and the Executive Suicide Death Review was due on November 8, 2016. The Department timely submitted an Executive Inmate Death Review to the Monitor on November 7, 2016. Although the second review did not include a report from the Homicide Bureau of its investigation because the Homicide report was not ready when the written report of the review was due, the parties agreed that the review book need only reference the status of the report (or an interim report) if not completed within six months of the suicide. In this case, the Homicide report was not completed within six months of the suicide due to delays at the coroner's office, but the review book contains a log that references the activities of the Homicide Division.
The Monitor subsequently received the Homicide report from the Department. It reflects that the steps taken to preserve all of the evidence; and lists the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded. Many of the inmates who were in the module were interviewed, but they did not see anything of note. The Homicide report does not indicate whether any of these interviews were recorded, but presumably they were not recorded since they did not provide anything of evidentiary significance.
22 There was one suicide that occurred in the Third Reporting Period for which the review is required to be completed in the next reporting period.
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75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
STATUS: PARTIAL COMPLIANCE
Sections 4.2, 4.7.2 and 4.8 of DMH 50.2, effective February 4, 2016, and CDM 410/060.00 CRITICAL INCIDENT REVIEW COMMITTEE—SUICIDAL INMATES, effective February 24, 2016, address the requirements of Paragraph 75.
Substantial Compliance requires (a) DMH to review documentation of randomly selected suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (b) that the Department and DMH reviewed the relevant information known at that time and the status of any corrective actions taken, and they considered the need for additional corrective action if necessary; and (c) that the information is reflected in the Department's database for tracking and statistical analysis.
The County’s augmented Third Self-Assessment reports 87% of the suicide attempts and 75% of the serious suicides attempts were reviewed in the third quarter of 2016 as required by Paragraphs 75(a) and (b), which exceeds the 85% threshold in Compliance Measure 75.5(a), but is below the 95% threshold in Compliance Measure 75.5(b).
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76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2016) (subject to qualitative assessment by Mental Health Subject Matter Expert)

CDM 4-10/050.00 DEATH REPORTING REVIEW PROCESS, issued on March 1, 2016, addresses each of the requirements of Paragraph 76. Section 4.7 of the DMH policy 50.2 CRITICAL INCIDENT REVIEW is consistent with the provisions of CDM 4-10/050.00.

There was a death of an inmate at TTCF in July 2016. The Department did not know initially if it was a suicide, but ultimately concluded that it was not considered a suicide or potential suicide.23 Nevertheless, the Department conducted a two-day and a seven-day death review of the death.

There was also a death of an inmate the day following her release from custody that was determined to be a suicide. Although technically not within the requirements of Paragraph 76 because it did not “occur in the jails,” the Department conducted a two-day and seven-day death review to assess the County's housing and treatment of the inmate while in custody.

There was a suicide at MCJ on November 18, 2016. An initial Death Review was held within two working days of the death on November 22, 2016, and the seven-day review was held on December 1, 2016. The Monitor attended both meetings, which included command-level personnel from the Department and DMH and reviewed the information known about the suicide and corrective or preventive actions taken or required by Paragraph 76. The 30-day death review, which the Monitor attended, was held on January 4, 2017.24

As noted in the Monitor's Second Report, there was a suicide at TTCF on May 8, 2016. Paragraph 76(c) requires the County to provide a “final written report regarding the suicide” within six months of a suicide that addresses 10 subparts of subparagraph (c). On November 8, 2016, the County timely provided an Executive Inmate Death Review report for the suicide that occurred on May 8, 2016. The Monitor reviewed the report and concluded that it meets the requirements in the ten subparts based upon the parties' agreed upon understanding of the requirements pertaining to the Homicide report.

DOJ previously expressed concern about the adequacy of the Executive Inmate Death Review in addressing 76(c)(i), which requires the preparation of “incident reports and any supplemental reports. . .from custody staff who were directly involved in and/or witnessed the incident.” As was the case of a suicide on February 29, 2016, no member

23 The Monitor agrees with the Department's conclusion. 24 As the County notes, holidays and weekends appear to be excluded in determining the timeliness of the
seven- and thirty-day reviews.

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of the Custody staff witnessed the suicide that occurred on May 8, which occurred inside the inmate's cell before he was discovered by a member of the Custody staff. Assuming no Department members witness the acts resulting in the suicide, the issue is whether (c)(i) requires more than a report or reports from the member or members of the Custody staff who first discover the suicide.
After obtaining input from the parties, the Monitor is of the view that 76(c)(i) requires supplemental reports from [or interviews of] the deputies who first discovered the inmate and all deputies who participated in the rescue attempt of the inmate, including deputies who first responded and deputies who subsequently participated in, or helped with, life-saving efforts. It does not require reports from [or interviews of] deputies who merely provided security or cleared the area of inmates.
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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
CDM 2-00/070.00 CUSTODY COMPLIANCE AND SUSTAINABILITY BUREAU ("CCSB"), effective February 4, 2016, addresses the requirements of Paragraph 78.
The Self-Assessment submitted to the Monitor on CCSB’s activities for the period from June 1, 2016, through December 31, 2016, reports that there were six Critical Incident Review Committee meetings, during which 15 incidents were reviewed. For those 15 incidents, there were 38 corrective action plan items created, of which 31 have been closed. The Self-Assessment includes a summary of each of the seven administrative reviews of suicides and serious suicides attempts in the Third Reporting Period, multiple graphs and charts reflecting patterns and trends, corrective actions taken to mitigate suicide risks,25 technical assistance provided or obtained, an “analysis of
25 Including a new grading system for all Mental Health Inmates, more frequent, staggered security checks, a “Sterile Pod” for Mental Health Inmates at TTCF, new inmate mattress covers, Huddle meetings between
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staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts,” and remedial measures, including staff discipline.
Although Paragraph 77 is, as the County notes, directed at law enforcement personnel, it requires the Department to work “in coordination with the Department of Mental Health.” Further the Critical Incident Review Committee (“CIRC”) that analyzes suicides and suicide attempt is, in effect, a joint committee set up pursuant to CDM 410/060.00 and DMH 50.2, and it includes members of Jail Mental Health Services, the Medical Services Bureau, and CCSB, and it should be assessing how “mental health service delivery issues” impact suicides and serious suicide attempts.
The Mental Health Subject Matter Expert previously expressed a concern that the CIRC reviews were “bereft of analysis of the adequacy of . . . mental health service delivery;” and lack “evidence that they have truly examined the adequacy of treatment.” He notes that the County “is now looking sufficiently at the care provided to individual patients (. . .'service delivery issues')" and recent CIRC reviews “are now addressing the adequacy of the treatment provided in each case and directing remediation of clinical staff when necessary. This is much improved.” The County is not, however, “sufficiently considering the impact of policies and the availability of treatment programs on suicide and self-injury.” Further, while the County is looking at patterns, “there is no trend and statistical analysis” of the data.
custody staff, nursing, and mental health personnel, and caulking of inmate bunks in TTCF by the Facility Services Bureau.
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of June 1, 2016, through December 31, 2016)26
Section 4.13 of DMH 70.7, effective July 7, 2016, requires DMH and LASD to “maintain a county-level Suicide Prevention Advisory Committee” open to representatives of the entities identified in Paragraph 78. A third meeting of the Suicide Prevention Advisory Committee was held on November 10, 2016, which the Monitor attended.
Substantial Compliance requires (1) the Committee to meet twice per year and (2) “recommend coordinated approaches to suicide prevention in the Jails.” At the third meeting of the Suicide Prevention Advisory Committee, Dr. J. Neil Ortego, the Chief Psychiatrist from the Department of Mental Health discussed various initiatives by DMH, with greater input from other members of the Committee as required by Paragraph 78. This was the most comprehensive meeting of the Committee to achieve the objectives of Paragraph 78.
26 The County has scheduled the next meeting for May 10, 2017. Assuming that the Committee continues to recommend coordinated approaches, at that time it will have maintained Substantial Compliance for purposes of paragraph 111 of the Settlement Agreement.
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: PARTIAL COMPLIANCE
DMH 70.2.1, effective February 4, 2016, sets forth “policy and procedure for mental health treatment programs” in the jails. Sections 3.2.7 and 3.5 provide for individual visits and group programming as required by Paragraph 79(a) and (c). Section 3.5.4 addresses the requirements of Paragraph 79(b).
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; to provide a description of the medication support services available for prisoners who are not in mental health housing and who are receiving psychotropic medications; and to randomly select and review electronic medical records of prisoners who reside outside of mental health housing and receive psychotropic medications to confirm that medication support services were provided to these prisoners.
The County’s augmented Third Self-Assessment concludes that it is in Partial Compliance, apparently because only four of seven supervisors at TTCF reviewed the documentation of group sessions in the third quarter of 2016. It is not clear, however, that this is required to achieve Substantial Compliance. The Self-Assessment reports that 90% of the electronic records of prisoners who reside outside of mental health housing and were receiving psychotropic medications were “provided medication support services,” which is above the 85% threshold required by Compliance Measure 79.5(d) for Substantial Compliance. A finding of Substantial Compliance is, however, still subject to a determination by the Monitor, after consultation with the Subject Matter Expert, “that
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the treatments are clinically appropriate.” See Compliance Measure 79.5(c). The Mental Health Subject Matter Expert is of the view that, at this point, the County is “far from providing adequate treatment and [has] not even begun to establish a methodology for determining adequacy of treatment.“ This is the subject of on-going discussions among the Mental Health Subject Matter Expert, the clinicians, and the Department of Health Services.
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business work-day. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

NON-COMPLIANCE

Section 3.5.2 of DMH 70.2.1, effective February 4, 2016, requires inmates in HOH areas to “be offered ten hours per week structured therapeutic or programmatic time unless individually clinically contraindicated[.]” The Department has not provided a similar provision requiring “unstructured out-of-cell recreational time” for HOH inmates, which was supposed to be provided to the Monitor “for review by the end of the third quarter.”

Paragraph 80 requires that “[b]y no later than 12 months after the Effective Date, [the County] will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week.” It further requires that 100% of the prisoners received this time “no later than 18 months after the Effective Date.”27 The parties have agreed that up to five hours of the structured time can consist of education or work programs, but at least five hours of the time must be therapeutic.

The County's augmented Third Self-Assessment reports that the Department has installed Small Management Yard units to allow for out-of-cell time for individual prisoners or small groups. It also reports that DHS has “concerns about the data that is gathered to monitor therapeutic group hours for inmates housed in HOH” and it will need “a different tracking system” to monitor inmate participation required by Paragraph 80. The posted results for the third and fourth quarters of 2016 show that 56% of the HOH inmates received 10 hours of unstructured out-of-cell time at CRDF and 68.3% at TTCF, but none of the inmates at CRDF and only 3.6% of the inmates at TTCF received 10 hours of structured out-of-cell time.

27 Although the County did not meet either of these timelines, the twelve-month period for maintaining Substantial Compliance will begin once the County achieves the 100% required by Paragraph 80(c).
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81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
Policies approved by the Rosas Monitors and adopted by the Department in the First Reporting Period implemented the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
In the Second Reporting Period, the Rosas Monitors approved policies to implement the following provisions of the Rosas Implementation Plan: Paragraphs 6.16.20 (grievance system); Paragraph 8.2 (combining “Complaints of Retaliation”). They also approved revised policies to implement Paragraphs 13.1-13.2 (discipline for PREA violations, dishonesty, and failure to report force incidents).
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 of the Rosas Implementation Plan reflect training requirements that were supposed to be, but were not, completed by December 31, 2016. This is due in part to the delays that have occurred in the review and approval of the Department's use of force and investigations training program. The Monitor does not believe that it is essential for the training to have been completed by the end of 2016 as long as the Department continues to meet the required thresholds for new deputies until it achieves the thresholds for existing deputies. At that time, virtually all of the personnel in the jails will have received the required training in either the Jail Operations Continuum or in-service training.
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Paragraphs 4.10 and 9.1 are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Finally, the Early Warning System to implement Paragraphs 19.1-19.3 will be completed in future reporting periods.
In the Third Reporting Period, the Monitor and the Use of Force Subject Matter Expert reviewed 20 randomly selected completed force packages for CRDF, NCCF, PDC South, and PDC North and concluded that the Department is complying with its policies regarding the use of force and documentation of force incidents at these facilities, and that the force investigations are thorough and complete. Almost all of the incidents reviewed were captured on fixed closed circuit television cameras or with a handheld camera.
The Use of Force Subject Matter Expert noted that he “did not detect any abuse of inmates or excessive or inappropriate uses of force in my review of the use of force packages,” “facility supervisors are critical in their reviews of use of force incidents and report any discrepancies they may find,” and inmates are “promptly taken for medical examination and/or treatment following the force incident.” He was also “very impressed by the quality and detailed work the Custody Force Review Teams are performing.”
The Monitor notes that on a couple of occasions,Department personnel failed to maintain their distance from a restrained prisoner, which contributed to the need to use force to further restrain the prisoner. Considering the vast majority of force incidents reviewed, however, there was no serious issues with respect to the force used by Department personnel in these facilities.
Finally, the Monitor and Subject Matter Expert noted that on some occasions, Department personnel who were involved in the force incident also briefly escorted the prisoner to a cell or out of the area where the incident occurred, but these deviations were adequately explained in the force package.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 15, 2016, through December 31, 2016)
The Rosas Monitors have approved a de-centralized inmate grievance system, which includes an Inmate Grievance Team co-located at Century Regional Detention Facility. The Department published its new grievance policies on July 15, 2016.
Under CDM 8-01/020.00 RESPONSIBILITIES, the Inmate Grievance Team is comprised of “a supervising deputy, a custody assistant and/or other appropriate professional staff” under the supervision of “at least one sworn supervisor of the minimum rank of sergeant who will serve as the Unit Inmate Grievance Coordinator and report to the Division Inmate Grievance Coordinator.” The Monitor has confirmed that the grievance system is implemented and operational at CRDF.
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83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement (“Common Areas”), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.
STATUS: SUBSTANTIAL COMPLIANCE (as July 1, 2015, through June 30, 2016 at MCJ and IRC)
SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at TTCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through December 31, 2016, at CRDF)
NOT CURRENTLY SUBJECT TO MONITORING (REMAINING FACILITIES)
On September 2, 2015, the Monitor and Subject Matter Experts toured TTCF, MCJ and IRC and confirmed that closed circuit security cameras had been installed and were operational in the Common Areas. On October 13, 2015, the Department provided the Monitor and Subject Matter Experts with summaries showing the number of cameras needed and installed at these facilities as of November 27, 2012, and the number of additional cameras needed and installed at MCJ as of May 12, 2014, and at TTCF as of August 11, 2014. The Department also provided a spreadsheet listing the completed work orders for the installation of the cameras installed in the Common Areas in TTCF, MCJ, and IRC.
The Department has provided the Monitor with inventories and videos of 10 randomly selected force incidents in the Common Areas of TTCF, MCJ, and IRC during the third and fourth quarters of 2016. Per an understanding with the Department and DOJ, the Monitor is to determine the Department’s compliance with Paragraph 83 of the Settlement Agreement by viewing the videos to verify the accuracy of the information reflected on the inventory. Based upon the review of these videos by the Monitor and the Monitor's staff, the Monitor has determined that the Department has maintained Substantial Compliance with Paragraph 83 at MCJ and IRC since the third quarter of 2015 and at TTCF since the fourth quarter 2015.
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On February 19, 2016, the Monitor and Subject Matter Expert toured CRDF and confirmed that closed circuit security cameras have been installed and are operational in the Common Areas, although the display screens in Central Control were not operational. On March 25, 2016, the Monitor confirmed that the display screens in Central Control at CRDF were operational and the system was fully functional. The Department also provided the Monitor and Subject Matter Experts with summaries showing the number of cameras needed and installed at CRDF as of January 7, 2016, and a spreadsheet listing the completed work orders for the installation of the cameras installed in the Common Areas in TTCF. Finally, based upon the review of the videos by the Monitor and the Monitor's staff, the Monitor has determined that the Department has maintained Substantial Compliance with Paragraph 83 at CRDF since the second quarter of 2016.
Although the Department has maintained Substantial Compliance for over 12 months at MCJ, TTCF, and IRC, Paragraph 83 also requires the Department to provide evidence that all video recordings of force incidents were adequately stored and retained for a period of at least one year after the force incident occurs. Accordingly, this requirement of Paragraph 83 is still subject to monitoring at MCJ and IRC until June 30, 2017 and at TTCF until September 30, 2017.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:
(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and
(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through March 31, 2016 (verified))
Substantial Compliance under the Compliance Measures requires the Department to demonstrate that 95% of the investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies. Although Paragraph 84 requires the Department to implement policies for the "timely and thorough" investigation of force incidents, the subparagraphs and the Compliance Measures are focused on the timeliness of the completion of the investigations resulting in the imposition of discipline. The Monitor's determination of the Department's compliance with Paragraph 84 will be largely based upon the timeliness of the completion of the investigations, but the Monitor will also assess the thoroughness of the investigations.
The County’s augmented Third Self-Assessment reports that the Department reporting for the second and third quarters of 2016 is in progress.
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85. The County and the Sheriff will ensure that Internal Affairs Bureau management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training. The County's recently posted results show that 33% of the IAB investigators completed all three of the required courses as of December 31, 2016.
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86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through December 31, 2016 at MCJ and CRDF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2016 at PDC North )
SUBSTANTIAL COMPLIANCE (as of February 1, 2017 at PDC South and PDC East)
PARTIAL COMPLIANCE (at TTCF and NCCF)
CDM 7-08/080 ACCOUNTABILITY OF SPECIALWEAPONS, effective October 14, 2016, requires each facility to have units orders that “establish procedures for the storage, issuance, reissuance, accountability, maintenance, and periodic inventory of all weapons. . . stored at, or issued from, the facility,” which includes detailed requirements for the “Inventory, Control, and Accountability of Aerosol Chemical Agents.”
In addition to providing written policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment, Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with up-to-date Unit Orders for each jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons.
The Monitor and Subject Matter Expert inspected the armory of each jail facility other than CRDF and reviewed the inventory logs of the weapons in the armories on October 25 and 26, 2016. The Monitor inspected the armory at CRDF on November 14, 2016. The Monitor and the Subject Matter Expert also inspected the armories at PDC North, PDC South, PDC East, NCCF, and TTCCF on February 7 and 8, 2017.
The inventory logs were checked daily in MCJ, CRDF, and PDC North armories, weekly in the PDC South armory and regularly in the PDC East armory. 28 Each facility has reasonably up-to-date unit orders and shows all weapons are accounted for during the checks. The Department submitted the required armory audit logs for all of the facilities for the second, third, and fourth quarters of 2016.
28 Because PDC East is a fire camp with very few inmates, weapons in the armory are almost never used.
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The main armory at NCCF showed significant improvements, and is checked daily, but inventories for several of the sub-armories did not match the weapons in the sub-armories, and the unit order is from 1998. The armory at TTCF showed significant improvement and the inventory accounted for all weapons at the sub-armories and throughout the facility, but the unit order was last updated in 2008.
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APPENDIX

NO. PROVISION

STATUS

18 Suicide Prevention Training Partial Compliance

SUBSTANTIAL COMPLIANCE DATES

19 Crisis Intervention &

Partial Compliance

Conflict Resolution Training

20 Training at NCCF, PDC and Not Currently Subject to

CRDF

Monitoring

21 CPR Certification
22 Use of Arresting and Booking Documents

Substantial Compliance (NCCF, PDC East, North & South, CRDF, TTCF, & IRC) Non Compliance (MCJ)
Substantial Compliance

(10/1/15 – 9/30/16 PDC East, and South)1 (1/1/16 – 12/31/16 NCCF) (1/1/16 – 9/30/16 North and IRC) (4/1/16 – 9/30/16 CRDF) (7/1/16 – 12/31/16)

23 Suicide Hazard Mitigation Plans

Substantial Compliance

(1/1/17)

24 Suicide Hazard Inspection Partial Compliance

25 Transportation of Suicidal Inmates

Non Compliance

26 Identification and Evaluation Partial Compliance of Suicidal Inmates

27 Screening for Mental Health Substantial Compliance at CRDF (7/1/26 – 9/30/16)

Care and Suicide Risk

Partial Compliance at IRC

28 Expedited Booking of Suicidal Inmates

Partial Compliance

1 Substantial Compliance Dates in bold reflect that the Department has achieved Substantial Compliance for twelve consecutive months, verified by the Monitor's auditors when required, and the County or designated facilities are no longer subject to monitoring of this provision pursuant to paragraph 111 of the Settlement agreement.

Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 104 of 108 Page ID #:2662
APPENDIX

29 Mental Health Assessments Partial Compliance

30 Initial Treatment Plans

Substantial Compliance

31 Electronic Medical Records Partial Compliance Alerts

32 Electronic Medical Records Substantial Compliance – Suicide Attempts

33 Supervisor Reviews of

Substantial Compliance

Electronic Medical Records

34 Discharge Planning

Stayed Pending Litigation

35 Referral for Mental Health Care

Non Compliance

36 Assessments After Triggering Events

Partial Compliance

37 Court Services Division Referrals

Non Compliance

38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

39 Confidential Self-Referral Partial Compliance

40 Availability of QMHPs

Partial Compliance

41 FIP Step-Down Protocols Substantial Compliance

42 HOH Step-Down Protocols Partial Compliance

43 Disciplinary Policies

Partial Compliance

44 Protective Barriers

Substantial Compliance

(4/1/16 – 9/30/16) (1/1/16 – 12/31/16)2 (7/1/16 – 9/30/16)
(1/1/16 – 12/31/16) (1/1/16 – 9/30/16) (1/1/16 – 12/31/16)

2 Subject to qualitative assessment by Subject Matter Expert

Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 105 of 108 Page ID #:2663
APPENDIX

45 Suicide Intervention and First Aid Kits

Substantial Compliance

46 Interruption of Self-Injurious Partial Compliance Behavior

47 Staffing Requirements

Partial Compliance

48 Housekeeping and Sanitation Substantial Compliance

49 Maintenance Plans

Substantial Compliance

(10/1/15 – 9/30/16 CRDF, NCCF, TTCF, PDC East & PDC South) (1/1/16 -- 12/31/16 MCJ & PDC North)
(1/1/16 – 12/31/16) (3/1/16 – 12/31/16)

50 Pest Control
51 Personal Care & Supplies
52 HOH Property Restrictions 53 Eligibility for Education,
Work and Programs 54 Privileges and Programs 55 Staff Meetings
56 Changes in Housing Assignments

Substantial Compliance
Substantial Compliance (at all facilities other than CRDF) Partial Compliance (at CRDF) Partial Compliance Non-Compliance

(1/1/16 – 9/30//16 MCJ, NCCF, PDC North, TTCF, CRDF) (4/1/16 – 9/30/16 PDC South & East)
(1/1/16 – 6/ 30/16 all facilities other than CRDF)

Substantial Compliance

(1/1/16 – 9/30/16)

Substantial Compliance (at PDC North, CRDF & TTCF)3

(7/1/16 – 12/31/16 PDC North) (10/1/16 – 12/31/16 CRDF & TTCF)

Substantial Compliance

(1/1/16 – 9/30/16)

3 The County has acknowledged that Paragraph 55 also applies to the Hope Dorm at MCJ and will be submitting data for MOH meetings in that dorm.

Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 106 of 108 Page ID #:2664
APPENDIX

57 Inmate Safety Checks in Mental Housing
58 Inmate Safety Checks in Non-Mental Housing
59 Supervisor Rounds

Partial Compliance

Substantial Compliance (at PDC South, North and East) Partial Compliance (at TTCF, CRDF, & IRC) Non-Compliance (at MCJ and NCCF)

(1/1/16 – 9/30/16 PDC South, North and East)

Partial Compliance

60 Implementation of Quality Improvement Program
61 Requirements of Quality Improvement Program
62 Tracking of Corrective Action Plans
63 Sufficient HOH and MOH Housing

Partial Compliance
Non Compliance
Partial Compliance
Partial Compliance (at TTCF) Non Compliance (at CRDF)

64 Plans for Availability of Inpatient Health Care
65 Administration of Psychotropic Medication
66 Active Mental Health Caseloads
67 Prisoner Refusals of Medication
68 Contraband Searches

Partial Compliance

Partial Compliance

Non Compliance

Non Compliance

Substantial Compliance (at MCJ, NCCF, PDC East, South and North & CRDF) Partial Compliance (at TTCF)

(1/1/16 – 12/31/16 MCJ, NCCF, PDC East, South and North) 10/1/16 – 12/31/16 CRDF)

Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 107 of 108 Page ID #:2665
APPENDIX

69 Clinical Restraints in CTC Partial Compliance

70 Security Restraints in HOH Substantial Compliance and MOH

71 Therapeutic Services for

Substantial Compliance

Inmates in Clinical Restraints

72 Administrative Reviews

Partial Compliance

73 Reporting of Self-Injurious Non Compliance Behavior and Threats

74 Law Enforcement Investigations of Suicides

Substantial Compliance

75 Management Reviews of Suicide Attempts

Partial Compliance

76 Management Reviews of Suicides

Substantial Compliance

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Substantial Compliance Committee

79 Therapeutic Services in Mental Health Housing

Partial Compliance

80 Out-of-Cell Time in HOH Non Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

82 Collection of Grievances at Substantial Compliance CRDF

(9/1/16 – 12/31/16) (7/1/16 – 9/30/16) (9/1/16 – 12/31/16) (9/1/16 – 12/31/16) (6/1/16 – 12/31/16)
(7/15/16 – 12/31/16)

Case 2:15-cv-05903-DDP-JEM Document 123 Filed 03/01/17 Page 108 of 108 Page ID #:2666
APPENDIX

83 Closed Circuit Cameras

Substantial Compliance (MCJ, TTCF, IRC, and CRDF)
Not Currently Subject to Monitoring (Remaining Facilities)

(7/1/15 – 6/30/16 MCJ & IRC)4 (10/1/15 – 9/30/16 TTCF) (4/1/16 – 12/31/16 at CRDF)

84 Investigation of Staff Misconduct

Substantial Compliance

(1/1/16 – 3/31/16)

85 Internal Affairs Bureau Training

Non Compliance

86 Maintenance and Inventory Substantial Compliance (at MCJ, (4/1/16 – 12/31/16

of Security Equipment

CRDF, PDC North, PDC South MCJ and CRDF)

and PDC East)

(10/1/16 – 12/31/16

Partial Compliance ( NCCF & PDC North)

TTCF)

(2/1/17 PDC South

and East)

4 Paragraph 83 also requires the Department to maintain video recording of force incidents for at least one year. This requirement is still subject to monitoring at MCJ and IRC until 6/30/17 and at TTCF until 9/30/17.

 
 Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 1 of 107 Page ID #:2726

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) 601 West Fifth Street, 12th Floor

3 Los Angeles, CA 90071-2025

4

Telephone: (213) 613-4655 Facsimile: (213) 613-4656

5 Email: rdrooyan@scheperkim.com

6 Monitor 7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

WESTERN DIVISION

11

12 UNITED STATES OF AMERICA,

13

Plaintiff,

14

15

v.

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR’S FOURTH REPORT

16 COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF
17 JIM MCDONNELL, in his Official Capacity,
18 Defendants.
19

20

21

22

23

24

25

26

27

28

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR'S FOURTH REPORT

Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 2 of 107 Page ID #:2727

1

Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and

4 the Los Angeles County Sheriff during the six-month period from January 1,

5 2017, through June 30, 2017, “to implement the Agreement and evaluating the

6 extent to which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

12

13 DATED: September 1, 2017 Respectfully submitted,

14

SCHEPER KIM & HARRIS LLP

15

RICHARD E. DROOYAN

16

17

18

By: /s/ Richard E. Drooyan Richard E. Drooyan

19

Monitor

20

21

22

23

24

25

26

27

28

-1 -

CASE NO. 15-cv-05903 DDP (JEMx)

MONITOR’S FOURTH REPORT

Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 3 of 107 Page ID #:2728
MONITOR’S FOURTH REPORT
This Fourth Report sets forth the Monitor’s assessments of the implementation of the terms of the Settlement Agreement (the “Agreement”) between the County of Los Angeles (the “County”) and the United States Department of Justice (“DOJ”) by the Los Angeles Sheriff’s Department (the “Department”) and the County's Department of Health Services (“DHS”).1 It covers the County's reported results for the period from January 1, 2017, through June 30, 2017 (the “Fourth Reporting Period”).
As used herein, “Substantial Compliance” means that the County has “achieved compliance with the material components of the relevant provisions of this Agreement in accordance with the [agreed-upon Compliance Measures for assessing Substantial Compliance],” which it must maintain for twelve-consecutive months; “Partial Compliance” means that the County has achieved “compliance on some, but not all, of the material components of the relevant provision of this Agreement;” and “NonCompliance” means that the County has not met “most or all of the material components of the relevant provisions of this Agreement.”
This Fourth Report is based upon the Monitor's review of the policies, procedures, and directives proposed and/or implemented by the Department and DHS; assessments and observations of the Subject Matter Experts; multiple tours of the jails by the Monitor and the Subject Matter Experts; the County’s Fourth Self-Assessment Status Report (the “Fourth Self-Assessment”), which was received on June 15, 2017; and the augmented Fourth Self-Assessment Status Report (the "augmented Fourth Self-Assessment"), which was received on July 17, 2017. It also takes into consideration the comments the Monitor received from the County and DOJ on the draft of this Report that was submitted to the parties on August 1, 2017.
During the Fourth Reporting Period, the Mental Health Subject Matter Expert, with the assistance of two clinicians retained by the Monitor, conducted qualitative assessments of the County's compliance with certain Substantive Provisions in the Settlement Agreement, and they used different methodologies to test some of the County's reported results. Although the agreed-upon Compliance Measures did not include qualitative assessments, the parties agreed that the quality of the County's compliance with various provisions should be assessed, and they left it to the Monitor and the Subject Matter Expert to decide what assessments should be conducted and what impact, if any, the results would have on the determination of the County's compliance with these provisions. In this Report, the Monitor's determination of the County's compliance, with the advice of the Subject Matter Experts, is based upon on the quantitative thresholds in the Compliance Measures (and any other applicable requirements in the Compliance Measures), unless the quality of the County's performance is plainly inadequate or the results reported by Subject Matter Expert vary significantly from the results reported by the Department.
1 The Department of Health Services includes the Department of Mental Health's Custody Services Division.
1

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The Monitor and the Mental Health Subject Matter Expert believe the County has made substantial progress in establishing compliance with many of the Substantive Provisions of the Settlement Agreement, but there remain significant challenges to achieving and maintaining Substantial Compliance with respect to quality improvement plans, therapeutic services, out-of-cell time, and discharge planning.2 They believe that the County can achieve and maintain Substantial Compliance with most of the Substantive Provisions in the next 18 months, but achieving and maintaining Substantial Compliance in the challenging areas will likely take considerably more than 18 months.
As in prior reports, this Fourth Report reflects the results of audits by the Monitor's auditors to verify results reported by the County. The Monitor has deemed the County to be in Substantial Compliance “as of” the beginning of the quarter reported by the County if the auditors have verified that the County has met the thresholds in the Compliance Measures. If the auditors were not able to verify the results reported by the County, the twelve-month period for maintaining Substantial Compliance will commence in a future period when the County's reported results are verified by the auditors. If the County maintains Substantial Compliance with a provision for twelve consecutive months, pursuant to Paragraph 111 of the Agreement, the Monitor and Subject Matter Experts will “no longer. . .assess or report on that provision” in future reporting periods.
Some of the Substantial Compliance results reported by the County in the Fourth Reporting Period have not been audited by the Monitor’s auditors and cannot be considered final until verified by the auditors. The County will not be deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the twelve-month compliance period in the Monitor's future reports if the results are not verified by the auditors.
Attached to this Fourth Report is an Appendix showing the status of each of the 69 provisions of the Agreement that are subject to monitoring and the twelve-month triggering dates where the County is deemed to be in Substantial Compliance.
As has been the case since the beginning of the Initial Reporting Period, the County cooperated completely with the Monitor and the Subject Matter Experts during the Fourth Reporting Period. The Department, DHS, and County Counsel facilitated our visits and inmate interviews, answered our questions, and responded to our requests for documents and information. We appreciate their responsiveness, transparency, professionalism, and courtesy in handling our monitoring requests.
Richard Drooyan, Monitor September 1, 2017
2 The requirements for discharge planning under Paragraph 34 of the Settlement Agreement are the subject of on-going negotiations among the County, DOJ, and the intervenors.
2

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EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the County and the Department are in Substantial Compliance with 24 provisions, in Partial Compliance with 27 provisions, and in Non-Compliance with 10 provisions. In addition, there are four provisions in which the Department is in Substantial Compliance at some facilities and in Partial Compliance or Non-Compliance at other facilities, and one provision in which the Department is in Partial Compliance at some facilities and in NonCompliance at other facilities. There is also one provision (Paragraph 20) that is Not Currently Subject to Monitoring, one provision (Paragraph 34) that remains stayed pending litigation initiated by third party intervenors, and one provision (Paragraph 83) for which the Department is in Substantial Compliance at certain facilities and that is not currently subject to monitoring at other facilities. There are 29 provisions for which the County and the Department are in Substantial Compliance at some or all of the facilities.3
There are 10 provisions that are no longer subject to monitoring because the County and Department maintained Substantial Compliance for twelve consecutive months as required by Paragraph 111 of the Settlement Agreement.4 There are another four provisions for which some facilities are no longer subject to monitoring because those facilities maintained Substantial Compliance for twelve consecutive months.5
As of the date of this Report, and subject to verification by the Monitor's auditors and/or qualitative assessments in some cases, the County and the Department are in Substantial Compliance at some or all of the facilities with the following provisions of the Settlement Agreement:
The County has maintained Substantial Compliance for twelve consecutive months at PDC East, PDC South, PDC North, NCCF, IRC, and TTCF with Paragraph 21, which requires Custody personnel to maintain CPR certifications. The County has also provided documentation that it has maintained Substantial Compliance for twelve consecutive months at CRDF and for nine consecutive months at MCJ. The results for CRDF and MCJ are subject to verification by Monitor's auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 22, which requires the County and the Sheriff to provide instructional material on the use of arresting and booking documents to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.
3 Under Paragraph 111 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis. 4 There are two additional provision for which the Department's reported results showing Substantial Compliance for twelve consecutive months are subject to verification by the Monitor's auditors. 5 The provisions that are no longer subject to monitoring at some are all of the facilities are highlighted in bold in the Appendix to this Report.
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The County has provided documentation reflecting that, as of January 1, 2017 through March 31, 2017, it achieved Substantial Compliance with Paragraph 30, which requires initial mental health assessments. The reported results are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 32, which requires that a serious suicide attempt be entered in the prisoner’s electronic medical record in a timely manner.
The County has provided documentation reflecting that, as of July 1, 2016, and through March 31, 2017, it achieved Substantial Compliance with Paragraph 33, which requires mental health supervisors to review electronic medical records on a quarterly basis to assess their accuracy. These results are subject to verification by the Monitor's auditors and a qualitative assessment by the Subject Matter Expert.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules to identify prisoners with mental illnesses and grant prisoner's requests for out-of-cell interviews.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 44, which requires the Department to install protective barriers in High Observation Housing and other mental health housing areas.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 45, which requires Suicide Prevention Kits and first-aid kits in control booths in all facilities.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 48, which requires the Department to have written housekeeping, sanitation, and inspection plans to ensure proper cleaning in accordance with California regulations.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 49, which requires the Department to have maintenance plans to respond to routine and emergency maintenance needs.
The County has maintained Substantial Compliance for twelve consecutive months, with Paragraph 50, which requires pest control in the jails.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 51, which requires the Department to ensure that all prisoners have access to basic hygiene supplies in accordance with state regulations.
The County has provided documentation showing that it has maintained Substantial Compliance for twelve consecutive months with Paragraph 54, which
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requires the Department to ensure that prisoners not in mental health housing are “not denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.” The reported results are subject to verification by the Monitor's auditors.
The County has provided documentation reflecting that, as of October 1, 2016, through June 30, 2017, it achieved Substantial Compliance at CRDF and TCCF with the provision of Paragraph 55 that requires custody, medical and mental health staff to meet daily in High Observation Housing and weekly in Moderate Observation Housing. It has also provided documentation that as of April 1, 2017 through June 30, 2017, it achieved Substantial Compliance at MCJ and PDC North with Paragraph 55. The reported results are subject to verification by the Monitor's auditors.
The County has provided documentation reflecting that it has maintained Substantial Compliance for twelve consecutive months with Paragraph 56, which requires custody, medical, and mental health staff to communicate regarding any change in a housing assignment following a suicide attempt or serious change in mental health condition. The reported results are subject to verification by the Monitor's auditors.
The County has provided documentation reflecting that it has achieved Substantial Compliance at MCJ and PDC North from January 1, 2017, through March 31, 2017 with Paragraph 57, which requires safety checks in mental health housing. The reported results are subject to verification by the Monitor's auditors.
The County has provided documentation reflecting that it has maintained Substantial Compliance for twelve consecutive months at PDC South, North and East with Paragraph 58, which requires safety checks in non-mental health housing. The reported results are subject to verification by the Monitor's auditors.
The County has achieved Substantial Compliance at MCJ, PDC North, PDC East, and PDC South from January 1, 2017, through March 31, 2017 with Paragraph 59, which requires unannounced daily supervisory rounds to verify safety checks.
The County has maintained Substantial Compliance for twelve consecutive months at all facilities other than TTCF and CRDF with Paragraph 68, which requires staggered contraband searches in housing units and visual inspection of HOH cells. The County has provided documentation reflecting that it has maintained Substantial Compliance as of October 1, 2016, through June 30, 2017, at CRDF and as of January 1, 2017, through June 30, 2017 at TTCF. The reported results for CRDF and TTCF are subject to verification by the Monitor's auditors.
The County has maintained Substantial Compliance as of September 1, 2016, through June 30, 2016, with Paragraph 70, which requires the Department to have policies and procedures regarding the use of Security Restraints in HOH and MOH.
The County has provided documentation reflecting that, as of July 1, 2016,
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through March 31, 2017, it achieved Substantial Compliance with Paragraph 71, which requires the County to ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint. These results are subject to verification by the Monitor's auditors.
The County has maintained Substantial Compliance as of January 1, 2017 through June 30, 2017, with Paragraph 72, which requires the Department to report on meetings to review suicides and incidents of serious self-injurious behavior. These results are subject to qualitative assessment by the Subject Matter Expert and clinicians.
The County has maintained Substantial Compliance as of September 1, 2016, through June 30, 2017, with Paragraph 74, which requires the Department to have an objective law enforcement investigation of every suicide that occurs in the jails.
The County has maintained Substantial Compliance as of September 1, 2016, through June 30, 2017, with Paragraph 76, which requires the Department to follow certain procedures whenever there is an apparent or suspected suicide.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 78, which requires the Suicide Prevention Advisory Committee to meet twice a year.
The County has maintained Substantial Compliance as of July 15, 2016, through June 30, 2017, with Paragraph 82, which requires the Department to co-locate personnel responsible for collecting prisoners' grievances at CRDF.
The County has maintained Substantial Compliance with Paragraph 83, which requires it to install closed circuit security cameras throughout all of the common areas in the jails, as of July 1, 2015, through June 30, 2016, at MCJ and IRC; as of October 1, 2015, through September 30, 2016, at TTCF, and as of April 1, 2016, through March 31, 2017, at CRDF. Under the applicable Compliance Measures, the County needs to retain the videos from TTCF through September 30, 2017, and from CRDF through March 31, 2018, to achieve Substantial Compliance at these facilities.
The County has provided documentation reflecting that, as of July 1, 2016, through March 31, 2017, it has achieved Substantial Compliance with Paragraph 84, which requires investigations of force incidents and administrative actions to be completed timely. The results are subject to verification by the Monitor's auditors.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ and CRDF with Paragraph 86, which requires inventory policies and control of weapons. It has also maintained Substantial Compliance as of October 1, 2016, through June 30, 2017, at PDC North; as of February 1, 2017, through June 30, 2017, at PDC South and East, and as of March 1, 2017, through June 30, 2017 at NCCF, and as of April 1, 2017, through June 30, 2017, at IRC.
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18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016.
These trainings will include the following topics: (a) suicide prevention policies and procedures, including observation and
supervision of prisoners at risk for suicide or self-injurious behavior; (b) discussion of facility environments and staff interactions and why they
may contribute to suicidal behavior; (c) potential predisposing factors to suicide; (d) high-risk suicide periods and settings; (e) warning signs and symptoms of suicidal behavior; (f) case studies of recent suicides and serious suicide attempts; (g) emergency notification procedures; (h) mock demonstrations regarding the proper response to a suicide attempt,
including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance; (i) differentiating between suicidal and self-injurious behavior; and (j) the proper use of emergency equipment.
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STATUS (18):

PARTIAL COMPLIANCE

The Monitor, in consultation with the Mental Health Subject Matter Expert, concluded in the First Reporting Period that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015. On May 30, 2017, the Monitor, in consultation with the Subject Matter Expert, approved a revision to the two-hour course for existing Deputy Sheriffs and Custody Assistants.

The County's Initial Self-Assessment Status Report delivered on December 14, 2015, reported that the Department commenced its suicide prevention training for new Deputy Sheriffs and Custody Assistants on July 1, 2015, and for existing Deputy Sheriffs and Custody Assistants before the Effective Date of the Settlement Agreement.

The County's Fourth Self-Assessment reports that "the Department has continuously provided the required training for new Deputies in the Jail Operations Continuum and new Custody Assistants in the Custody Assistants Academy." It also reports that as of June 7, 2017, 1,028 Deputies and 269 Custody Assistants have been trained.

The Monitor’s auditors have received training records reflecting that 95% of new deputies and new Custody Assistants hired after July 1, 2015, through December 31, 2015, received the required training. Notably, the auditors have not received any documentation from the Department reflecting the training of new deputies in 2016 or 2017.

Assuming that the Department maintained Substantial Compliance for new personnel in 2016, and continues to do so in the future, Substantial Compliance under Paragraph 18 will be achieved when 85% of the existing deputies and Custody Assistants in Custody as of July 1, 2015, have received the required training.

It is unclear when the County will reach the 85% threshold for the training of existing deputies and Custody Assistants to achieve Substantial Compliance. Although the Compliance Measures contemplated that the County would reach Substantial Compliance by December 31, 2016, the Monitor is of the view that a later date is acceptable as long as at least 95% of new deputies and Custody Assistants hired after July 1, 2015, continue to receive the required training until the County reaches the 85% threshold for Substantial Compliance for existing personnel.

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19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams (“JMET”) at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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STATUS (19):

PARTIAL COMPLIANCE

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution training and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and paragraphs 4.6, 4.7 and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert and the Rosas Monitors approved the training materials developed by the Department for the DeVRT on March 4, 2016.

The County's Fourth Self-Assessment reports that the Department has conducted 78 DeVRT courses, and has trained 1,290 existing Deputies, 1,024 new Deputies, and 166 "newly graduated Custody Assistants." It also reports that 234 Custody Assistants have received the eight hours of training in identifying and working with mentally ill prisoners as required by Paragraph 19(b).

As noted in the Monitor's previous reports, a number of the Deputies and Custody Assistants attended DeVRT classes before March 4, 2016, when the training materials developed by the Department for DeVRT were finally approved by the Monitor and the Rosas Monitors. These Deputies and Custody Assistants will be required to attend an additional eight-hour training course after the Department completes the initial 32-hour training of existing staff.6

While the Monitor’s auditors have received training records for new deputies and Custody Assistants, they have not received a detailed list of the individuals required to take the training in order to determine whether the Department achieved (and has since maintained) Substantial Compliance as of October 1, 2015, which is the date that the Department’s Initial Self-Assessment reported that this provision was “[r]eady for monitoring.”

Substantial Compliance will be achieved when 85% of the existing deputies and Custody Assistants in Custody Operations as of July 1, 2015, have received the required training, and 95% of the new deputies and Custody Assistants hired after that date have received the training, and those Deputies and Custody Assistants who attended DeVRT classes before March 4, 2016, receive the additional required DeVRT training in the first refresher course.

6 The Fourth Self-Assessment does not indicate how many Deputies and Custody Assistants attended the classes before March 4, 2016.
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20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

NOT CURRENTLY SUBJECT TO MONITORING

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the DeVRT curriculum for the Department’s De-escalation and Verbal Resolution Training (“DeVRT”), which provides for 32 hours of Crisis Intervention and Conflict Resolution training that meets the requirements of Paragraph 20 of the Settlement Agreement. This training of Deputies assigned to the North County Correctional Facility (“NCCF”), the Pitchess Detention Center (“PDC”), and the non-Mental Health Housing Units in Century Regional Detention Facility (“CRDF”) is not required to commence before the next reporting period, which began on July 1, 2017.

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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at PDC East and South (verified))
SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 at NCCF, PDC North and IRC (verified))
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017, at TTCF (verified))
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through December 31, 2016, (verified), and through March 31, 2017, at CRDF (unverified))
SUBSTANTIAL COMPLIANCE (as of July 1, 2016 through December 31, 2016 (verified) and through March 31, 31, 2017 at MCJ (unverified))
The Compliance Measures provide that the Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required CPR and first aid certifications for 12 consecutive months.
The Monitor’s auditors have now verified that PDC South and PDC East were in Substantial Compliance as of October 1, 2015, through September 30, 2016, and that NCCF, PDC North and IRC were in Substantial Compliance as of January 1, 2016, through December 31, 2016. Accordingly, pursuant to paragraph 111 of the Settlement Agreement, PDC South, PDC East, PDC North, NCCF, and IRC are no longer subject to monitoring for Substantial Compliance with Paragraph 21.
The County's Augmented Fourth Self-Assessment reports that the Department has been able to maintain Substantial Compliance at TTCF as of April 1, 2016, through March 31, 2017. These results have been verified by the Monitor's auditors and TTCF is no longer subject to monitoring for Substantial Compliance with Paragraph 21.
Finally, the Augmented Fourth Self-Assessment reports that the Department has achieved Substantial Compliance at MCJ as of July 1, 2016, through March 31, 2017, and maintained Substantial Compliance for twelve consecutive months at CRDF through March 31, 2017. These results are still subject to verification by the Monitor's auditors, who have requested additional information from the County.
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22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017)
The Justice Data Interface Controller (“JDIC”) message the Department has been using since June 29, 2016, is sufficient to establish Substantial Compliance with Paragraph 22. The Monitor has confirmed that the Department continued to maintain Substantial Compliance in the first and second quarters of 2017, and, as a result, Paragraph 22 is no longer subject to monitoring under Paragraph 111 of the Settlement Agreement.
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23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: PARTIAL COMPLIANCE
The Monitor has verified, with the advice of the Subject Matter Expert, that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department reports that it inspected all of the housing units by January 14, 2016, and it has provided the Monitor with completed checklists documenting the inspections.
The County has modified and updated its Suicide Hazard Mitigation plan to address the comments of the Monitor and the Mental Health Subject Matter Expert. Although the plan addresses critical issues such as fixtures, parts of it consist of analysis or discussion rather than specific remedies with completion dates. Recognizing that the plan is not static, the Substantial Compliance finding in the Monitor's Third Report was subject to the caveat that the plan must be updated at least six weeks before this Fourth Report is due and again six weeks before the Fifth Report is due, showing the status and completion of items in the plan.
On July 17, 2017, the Department submitted the required updated Suicide Hazard Mitigation Plan, but it is inadequate in several respects. For every uncompleted item listed in the Plan that requires some work,7 the "Start Date" is "TBD;" that is "To Be Determined." There also are several entries noting that the Department requires input from the Mental Health Subject Matter Expert without indicating what information is needed, and there are several entries dated 3/16/17 stating that the item "[r]equires funding and approval from Custody Admin, FPB, and FSB," without indicating whether anything has been done in the last four months to obtain the funding. It is difficult to determine from the Plan when, if ever, the open items will be addressed by the Department.
7 There are a several items designated "No Action" or "N/A" because the Department determined that "no further action [is] required."
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24. The County and the Sheriff will review and inspect housing areas on at least an annual basis to identify suicide hazards.
STATUS: PARTIAL COMPLIANCE CDM 3-06/020.00 FACILITIES INSPECTIONS requires Custody Support Services (CSS) to “review and inspect housing areas on a least an annual basis to identify suicide hazards.” The Monitor and Subject Matter reviewed a revised annual suicide hazard inspection tool that was submitted by the Department on December 13, 2016, and approved it with the caveat that, in order to achieve Substantial Compliance, the sample sizes of randomly selected cells must be large enough to ensure that the cells are representative of each housing type at a facility. Further, if a problem is found in the randomly selected cells, a complete inspection or remediation of the area or setting should then be conducted. An updated tool was submitted by the Department on February 9, 2017; it also was approved with the same caveats. The County's Fourth Self-Assessment reports that the Department has used the inspection tool to inspect TTCF and PDC North,8 and it is currently working to determine "the proper sample size of cells to ensure proper representation of each housing type at each facility." As noted by the Mental Health Subject Matter Expert, the "right sample size is not an easy thing to establish. . . .The smaller the number of cells of any one type, the greater the percentage of cells that needs to be inspected to ensure that the inspected sample is representative."
8 It also recently used the tool to inspect PDC South on June 19, 2017.
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: NON-COMPLIANCE The Proposed Revision of the Station Jail Manual9 requires that any arrestee who “displays obvious suicidal ideation or exhibits unusual behavior that clearly manifest[s] self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, such inmates . . . shall be under unobstructed visual observation or in a suicidal restraint location with safety checks every 15 minutes.” The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent to determine compliance with Paragraph 25 of the Agreement. The County’s Fourth Self-Assessment reports that the Department concluded that only 23% and 26% -- "rather than the required 95%" -- of the records reviewed by the Department for the Fourth Quarter of 2016 and the First Quarter of 2017 reflect the information required to establish Substantial Compliance with Paragraph 25. The Self-Assessment also reports that the Department is conducting training at station jails regarding the required documentation and "anticipate[s] a marked improvement in the next reporting period."
9 The status of the proposed revision to the Station Jail Manual is not clear.
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to “review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of 100 randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC.” Substantial Compliance requires that (1) 95% of the forms “include the required mental health information” and (2) 90% of the prisoners having urgent or emergent needs were “seen by a QMHP within four hours.” The County’s posted results for the one randomly selected week in the Fourth Quarter of 2016 reflect that 93% of the screening forms reviewed had the required mental health information, and 55% of the prisoners were seen by a QMHP within four hours. The posted results for the First Quarter of 2017, reflect that 92% of the forms had the required information and 69% of the prisoners were seen within four hours.
The Mental Health Subject Matter Expert and the clinicians retained by the Monitor reviewed the "qualitative aspects of the intake process and subsequent documentation" to look for "inconsistencies and errors in intake documentation" and whether urgent or emergent mental health conditions were missed at intake. The Mental Health Subject Matter Expert concluded that "[i]n general, the intake process seems to be working well to detect urgent and emergent cases," with some "failure[s] to resolve inconsistencies and some deficiencies in detecting important conditions at the nursing second triage.” The Subject Matter Expert and his team "found that 94% of emergent or urgent cases were detected [at intake]," but he is concerned that the County's methodology does not identify "false negatives."
The Monitor and Mental Health Subject Matter Expert have walked through the intake process at IRC and CRDF on several occasions. The Subject Matter Expert has expressed a concern that the County needs to ensure that all inmates who have mental health needs are evaluated in private by the QMHP. If this cannot be done in the clinic in IRC because of security concerns about an aggressive or agitated male inmate, he should be transferred immediately to the HOH intake area in 172 in TTCF and evaluated privately by a QMHP in that area. Similarly, if a female inmate cannot be privately evaluated in 1200 in CRDF, she should be transferred immediately to HOH and evaluated in that area.
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review the records of “randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC” to determine compliance with this provision. The County’s Fourth Self-Assessment reports that in the fourth quarter of 2016, Qualified Medical Personnel or trained custody staff filled out a Medical/Mental Health Screening Questionnaire for 99 of the 100 randomly selected prisoners within 12 hours of their arrivals in the jails, and that the required documents were available to QMHPs who assessed the 32 inmates identified as having mental health needs. In the first quarter of 2017, the required forms were filled out for all 100 of the prisoners within 12 hours and the required documentation was available to the QMHP's who assessed the 28 inmates identified as having mental health needs. The Monitor's auditors have verified the County’s reported results for the fourth quarter of 2016 and the first quarter of 2017.
Qualitative assessment by the Mental Health Subject Matter Expert and the clinicians confirmed the results reported by the County. They found "that 95% of the intake documentation was complete and available [and] 95% of routine cases were detected." "[I]n a minority of cases," however, there were "poor quality assessments that missed mental health conditions," which "appears to reflect the need for clinical supervision and remediation more than a systems problem." The Subject Matter Expert is also concerned that the County's methodology does not identify "false negatives."
In order to satisfy the requirements of Paragraph 27, inmates must be privately screened. The windows in the intake-triage area where the Medical/Mental Health Screening Questionnaire is administered at CRDF are not sufficiently private to satisfy this requirement. Inmates are often seated in close proximity to each other and Custody personnel take supplies from the closets behind the windows while inmates are at the windows. The lack of privacy also exists in IRC in the area where the questionnaire is administered for male inmates.
The Monitor and Mental Health Subject Matter Expert have discussed with the County several options for reconfiguring the areas in front of the intake windows so that the process will be sufficiently private to satisfy the requirements Paragraph 27.
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28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.
STATUS: PARTIAL COMPLIANCE The Compliance Measures require the Department to review the records of randomly selected prisoners at CRDF and IRC who have urgent or emergent mental health needs to determine whether they were expedited through the booking process. The County’s Fourth Self-Assessment reports that the County "continue[s] to have difficulty capturing the data at this time." The results for IRC for the fourth quarter of 2016 and the first quarter of 2017 (at 65% and 81%) are somewhat below the 85% threshold for expediting inmates through the booking process, but during unannounced visits, all inmates having urgent or emergent needs were under unobstructed visual observation and checked every 15 minutes as required by paragraph 28. The results of CRDF (at 40% and 16%) are considerably below the 85% threshold.10 Notwithstanding the lack of quantitative results, the Monitor and Mental Health Subject Matter Expert believe that the County has achieved Partial Compliance based upon what they have observed at CRDF and IRC. As the Fourth Self-Assessment correctly notes, "the Department regularly screens, identifies, and expedites inmates with emergent or urgent mental health needs."
10 There were no inmates at CRDF who required observation under Paragraph 28 during unannounced visits by CCSB.
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29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.
STATUS: PARTIAL COMPLIANCE The Compliance Measures require the Department to review randomly selected records of the prisoners identified in the intake nursing assessment as having nonemergent mental health needs to determine if the Department completed mental health assessment for 85% of the prisoners within the required time periods. The County’s Fourth Self-Assessment reports that in the fourth quarter of 2016 and the first quarter of 2017 the Department completed mental health assessments for 64% and 63% of the inmates within the required time periods. This is sufficient to achieve Partial Compliance.11
11 The Fourth Self-Assessment reports that the County has encountered "challenges with meeting the required timing standards when inmates are sent to court after intake but before they received their mental health assessment. The County's compliance rate will improve if the 'clock' contemplated in this Provision is 'paused' when the inmate goes to court." Subject to discussions with DOJ and the County, the Monitor and the Mental Health Subject Matter Expert do not object to pausing the 24-hour (72-hour) clock during periods in which inmates are not physically in IRC or CRDF as long as it does not "further delay inmates' access to psychotropic medication," which is a concern that has been expressed by DOJ. The Mental Health Subject Matter Expert does not believe that this will have "much impact on the timeliness of receiving medications as it will only extend the period by a matter of (at most) a half day."
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30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through March 31, 2017 (unverified))
The Compliance Measures require the Department to review randomly selected initial mental health assessments and report on (1) the percentage of assessments that have all of the information required by Paragraph 30, and (2) whether the housing recommendations were followed.
The County's Fourth Self-Assessment reports that 96% of the housing assignments reviewed in the fourth quarter of 2016 followed the housing recommendations in the initial treatment plans, which exceeds the 95% threshold for Substantial Compliance, and that 87% of the initial mental health assessments had the information required by Paragraph 30, which exceeds the 85% threshold. The Monitor's auditors determined, however, that only 76% of the assessments had the required information. The Self-Assessments reports 100% of housing assignments and 93% of the initial assessments complied with the requirements of Paragraph 30 in the first quarter of 2017. These results are subject to verification by the Monitor's auditors.
The Mental Health Subject Matter Expert and the clinicians evaluated a random sample of mental health assessments to determine if there was an initial treatment plan and the identification of immediate issues, and also "whether the determination of immediate issues was reasonable in light of available information." They also evaluated "whether the initial treatment plan covered the elements required by existing County policy, which goes beyond the content of the formal compliance measure." They found that 90% of the cases had an initial treatment plan and identified immediate issues. They also found that the determination of the immediate issues "was reasonable" in 80% of the cases, which is sufficient to support a finding of Substantial Compliance in light of the quantitative results.12
12 The Mental Health Subject Matter Expert and the clinicians also found that all but one of the cases "failed to meet County policy regarding discharge planning."
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31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk; (b) hoarding medications; and (c) prior suicide attempts.
STATUS: PARTIAL COMPLIANCE The Compliance Measures require the Department to review randomly selected electronic medical records for prisoners in certain at-risk groups to determine if the required mental health alerts are in 85% of the records reviewed, which is the threshold for Substantial Compliance. The County’s Fourth Self-Assessment reports that for TTCF, 90% of the records reviewed contained the required mental health alerts in the fourth quarter of 2016, and 78% for the records contained the alerts in the first quarter of 2017. For CRDF, the results were 80% for the fourth quarter of 2016 and 66% for the first quarter of 2017, which is below the required 85%. While the alerts for inmates who showed "suicidal ideation" exceeded the 85% threshold at both facilities, alerts for inmates who were removed from Risk Precaution status and alerts for inmates identified as hoarding medicines fell below the threshold at both facilities.13 The County's Fourth Self-Assessment reports that the County has established working groups to address these issues. The Monitor and Mental Health Subject Matter Expert note that there may be a problem with the County's methodology in relying only on nurses' notes rather than also using the results of cell searches to identify hoarding of medicine.
13 The Mental Health Subject Matter Expert concurs with the County's Self-Assessment that it needs "to improve consistency in evaluating inmates for placement on Risk Precaution so that this designation is used in the most clinically appropriate and useful way."
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32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require the County to review the electronic medical records of all prisoners who had a serious suicide attempt in the prior quarter. The County's Third Self-Assessment reported that 100% of the electronic medical records of prisoners who had a serious suicide attempt in the second, third, and fourth quarters of 2016 reflect the suicide attempts and that the information was entered into the record within one day of the attempt. The results exceed the 95% and 85% thresholds for Substantial Compliance.14
The Department’s reported results through the fourth quarter of 2016 have been verified by the Monitor’s auditors. In addition, under the Monitor's supervision, the Monitor's staff reviewed the Department's documentation and confirmed that the County was in Substantial Compliance in this reporting period.
The Mental Health Subject Matter Expert and the clinicians used an alternative methodology and confirmed the Department's results, finding that 95% of the cases were identified in the electronic medical record within one day of the attempt. They noted, however, that the documentation to determine "the nature of the suicide attempt, primarily its potential lethality, the presence of suicidality, and the presence of a reckless disregard for the prisoner's own safety" was adequate only 80% of the time.
The Subject Matter Expert has expressed concerns about the County's methodology for determining if a suicide attempt is serious, which is an issue for several of the provisions that are subject to monitoring. With respect to Paragraph 32, however, this is not an issue because all suicide attempts, which necessarily include serious suicide attempts, were entered into the records within one day of the attempt. Accordingly, the County has maintained Substantial Compliance for twelve consecutive months with Paragraph 32,15 and this provision is no longer subject to monitoring pursuant to Paragraph 111 of the Agreement.
14 "In an abundance of caution," the Department provided results for the first quarter of 2017, which again showed 100% of the suicide attempts were entered in the records within one day of the attempt. 15The County previously reported Substantial Compliance in the first quarter of 2016.
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33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:
(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;
(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;
(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and
(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through March 31, 2017 (subject to verification and qualitative review))
The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected prisoners from each clinician’s caseload. The County has provided the required tool, and previously reported Substantial Compliance for the third quarter of 2016. The County's Augmented Forth Self-Assessment reports "that 100% -- 15% more than the required 85% -- of the mental health supervisors complied with the requirements of this provision for both Fourth Quarter 2016 and First Quarter 2017." The results are still subject to verification by the Monitor's auditors, which will include verifying that the supervisors' reviews of the clinicians include the content required by Paragraph 33(b). In addition, the Monitor has asked the Subject Matter Expert to assess the quality of the reviews for compliance with the requirements of Paragraphs 33(b), (c), and (d).
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34. The County and the Sheriff will conduct discharge planning and linkage to community mental health providers and aftercare services for all prisoners with serious mental illness as follows:
(a) For prisoners who are in Jail seven days or less, a preliminary treatment plan, including discharge information, will be developed.
(b) For prisoners who are in Jail more than seven days, a QMHP will also make available:
(i) for prisoners who are receiving psychotropic medications, a 30-day prescription for those medications will be offered either through the release planning process, through referral to a re-entry resource center, or through referral to an appropriate community provider, unless clinically contraindicated;
(ii) in-person consultation to address housing, mental health/medical/substance abuse treatment, income/benefits establishment, and family/community/social supports. This consultation will also identify specific actions to be taken and identify individuals responsible for each action;
(iii) if the prisoner has an intense need for assistance, as described in DMH policies, the prisoner will further be provided direct linkage to an Institution for Mental Disease ("IMD"), IMD-Step-down facility, or appropriately licensed hospital;
(iv) if the prisoner has a moderate need for assistance, as described in DMH policies, and as clinically appropriate to the needs of the prisoner, the prisoner will be offered enrollment in Full Service Partnership or similar program, placement in an Adult Residential Facility (“Board and Care”) or other residential treatment facility, and direct assistance accessing community resources; and
(v) if the prisoner has minimal needs for assistance, as described in DMH policies, the prisoner will be offered referrals to routine services as appropriate, such as General Relief, Social Security, community mental health clinics, substance abuse programs, and/or outpatient care/support groups.
(c) The County will provide a re-entry resource center with QMHPs available to all prisoners where they may obtain information about available mental health services and other community resources.
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STATUS (34):

STAYED PENDING LITIGATION

Paragraph 34 is the subject of on-going litigation as a result of a First Amended Complaint in Intervention challenging the provisions relating to discharge planning. The County’s Fourth Self-Assessment reports that the litigation “has not been resolved” and, “[a]ccordingly, the Department has stayed its collection of compliance data with respect to this provision.”

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35. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team (“JMET”) member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: NON-COMPLIANCE The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral (“BOMHR”) records for prisoners referred by custody staff to a QMHP or JMET member for “routine” mental health care to determine the timeliness of the referrals. The Monitor and Mental Health Subject Matter Expert believe that it will be a challenge for the County to determine when Custody personnel identify inmates who have a potential need for routine mental health care. The Department has changed its BOMHR form to "help [it] capture more accurate data," and it also developed "an electronic version of the BOMHR." It is likely going to take some time before the Department achieves Substantial Compliance with this provision.
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36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected records of prisoners newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; and provide a staffing schedule for on-call services. The County's Fourth Self-Assessment reports that 60% of the prisoners identified in the two randomly selected weeks in the fourth quarter of 2016 received an assessment by a QMHP within four hours, and only 43% of the prisoners received a timely assessment by a QMHP in the first quarter of 2017. These results are well-below the 95% threshold and down from the 87% reported in the third quarter of 2016. The Mental Health Subject Matter has expressed a concern that it is "not clear how [the County is] detecting adverse triggering event[s]," which "must be sufficient for detecting false negatives" and determining the "time of referral."
During tours of TTCF and CRDF, the Monitor and Subject Matter Expert visited housing areas to observe where prisoners with adverse triggering events are housed pending a QMHP evaluation.
The process of observing prisoners following adverse triggering events at CRDF now satisfies Paragraph 36. As at TTCF, benches have been installed next to the officers’ stations in housing areas at CRDF. Custody staff reported that prisoners who experience triggering events are handcuffed to the benches and under constant visual observation until the QMHPs arrive to meet with the prisoners. Staff also indicated that the clinicians are called immediately when prisoners experience triggering events.
DOJ and the County have now agreed that instead of unannounced quarterly visits,16 "the Department will randomly select five BOMHRS" from a randomly selected date, "review videos to determine how the inmate was being observed while waiting for the QMHP," and "produce screen shots and movement records as part of their selfassessment. The County reports that four of the five selected prisoners (80%) at CRDF and three of the five selected prisoners (60%) at TTCF were on the videos "under
16 Since triggering events are random and variable, there were often no inmates to observe during the unannounced visits.
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unobstructed visual observation pending assessment." All of these prisoners were seen by QMHP within four hours.
The Fourth Self-Assessment reports that the County achieved 100% compliance with a staffing schedule that provides on-call services 24 hours a day, 7 days a week, pursuant to Compliance Measure 36.2.
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37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral ("BOMHR") Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: NON-COMPLIANCE The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter, review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner and incident reports for self-injurious behavior by prisoners appearing in the selected courts, and determine if these incidents are reflected in BOMHR forms completed by the Court Services Division staff in the selected courts. The County’s Fourth Self-Assessment reports that significant problems with the use and completion of the BOMHR form by the Court Services Division continued through the first quarter of 2017. Only 10% of the incidents covered by Paragraph 37 were reflected on BOMHRs in the fourth quarter of 2016 and only 33% were reflected on BOMHRs in the first quarter of 2017. These results are far below the 90% threshold for Substantial Compliance. The Self-Assessment reports that CCSB has conducted "road shows" to remind Court Services Division deputies of their obligations to fill out BOMHRs as required by Paragraph 37. The Monitor expects to conduct random checks of courthouse lock-ups to determine where these prisoners are housed and if they are "under unobstructed visual observation or subject to 15-minute checks."
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38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision. Substantial Compliance requires that (a) 90% of the required weekly cell-by-cell checks were completed; and (b) 85% of the out-of-cell interviews requested were granted, absent documented justification for denial of the request.
The County's reported results consistently showed that in 2016, 100% of the weekly cell-by-cell checks were completed at all the facilities to which this provision applies (CRDF, MCJ, NCCF, PDC North, and TTCF) and that, with the exception of MCJ in the second quarter, 100% of the out-of-cell interviews were granted at the facilities in both quarters. At MCJ 95% of the interviews were granted in the second quarter. These results were verified by the Monitor's auditors.
Accordingly, pursuant to paragraph 111 of the Settlement Agreement, the County is no longer subject to monitoring for Substantial Compliance with Paragraph 38.
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39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their requests to custody staff or other prisoners.
STATUS: PARTIAL COMPLIANCE
During tours of the jail facilities in the Fourth Reporting Period, the Monitor observed that the new healthcare referral forms for prisoners requesting medical or mental health care and envelopes were available either in the modules or at the deputies' stations adjacent to these housing areas, and prisoners are able to ask staff for the forms and envelopes if they do not have access to the box or it is empty. In some areas in Men's Central Jail where the inmates are in single cells in rows (e.g., for K-10 inmates), the forms are in boxes outside of the rows and must be obtained from the deputies and Custody Assistants assigned to the areas.
Based upon a review of the County’s policies and procedures, multiple tours of the facilities, interviews, and the County’s Semi-Annual Report, the Monitor is satisfied that the Department has adequate processes and procedures for inmates to make confidential self-referrals for mental health care.
Substantial Compliance requires the Department to (a) verify that housing areas have the required forms and (b) review randomly selected self-referrals for mental health care from prisoners to confirm that (i) the referrals “were forwarded to DMH” by the Department, and (ii) that “DMH documented the timeliness and nature of DMH's response to the self-referrals[.]” The thresholds for Substantial Compliance are that 90% of the self-referrals must be forwarded by the Department to the Department of Health Services – Custody Health Services (DHS-CHS) and 90% must contain the required documentation of DHS-CHS's response.
The County's Fourth Self-Assessment reports that it achieved Substantial Compliance with Compliance Measure 39.4(a) at PDC North, PDC South, PDC East, CRDF, MCJ, and TTCF in the fourth quarter of 2016 and Partial Compliance at NCCF in that quarter. The Self-Assessment also reports Substantial Compliance at all facilities in the first quarter of 2017. The posted results show that more than 85% of the housing areas in all of the facilities other than NCCF had the self-referral forms required by Compliance Measure 39.4(a) in the fourth quarter of 2016 and in all of the facilities including NCCF in the first quarter of 2017.
The County's Semi-Annual Report for Paragraph 39 reports that in the fourth quarter of 2016, 100% of the self-referrals forms from CRDF, TTCF, MCJ, and NCCF were forwarded by the Department to DHS-CHS as required by Compliance Measure 39.4(b), and DHS-CHS documented the timeliness and nature of its response in 95% of those referrals, as required by Compliance Measure 39.4(c). As noted in the Monitor's Third Report, there are instances when the County is counting a visit with the mental health professional before a self-referral request, which is not appropriate where the visit did not address the substance of the request. Further, there are some instances in which
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the documented response does not address the content of the request. The Augmented Self-Assessment concludes "that it was unable to assess this
provision at PDC East, PDC South, PDC North, and NCCF" because "[t]here were no self-referrals for mental health care" from these "facilities during the randomly selected weeks." Given the populations at South and East, it is not likely that there will be many requests for mental health care at those facilities, but results from North need to be included in future self-assessments because North now has two mental health modules with plans to expand to four modules. Results from NCCF should also be included given the nature and size of its inmate population. The Department should expand the universe by randomly selecting additional weeks if necessary. Also, absent extenuating circumstances, DHS-CHS must respond to self-referrals within seven days.
The County's Semi-Annual Report indicates that preliminary results for the first quarter of 2017 show that 79% of the self-referrals at CRDF and 71% of the self-referrals at MCJ were responded to by DHS-CHS within seven days. The Augmented Fourth Self-Assessment reports, however, that "71% -- rather than the required 90% -- of the time DHS-CHS documented the timeliness and nature of DMH's response to the selfreferrals received from [CRDF]" and only 2% of the self-referrals received from MCJ documented the timeliness and nature of the response. According to the County, this discrepancy is because the Semi-Annual Report is based on the nurses' time stamps, while the Augmented Fourth Self-Assessment is based upon mental health's time stamps. It "attributes this to a training issue and anticipates marked improvement in the Third Quarter assessment." The Mental Health Subject Matter Expert notes that most of the patients whose cases he reviewed were seen by someone from mental health within seven days.
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40. The County and the Sheriff will ensure a QMHP will be available on-site, by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires DHS-CHS (1) to provide the Monitor with oncall schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week, and (2) randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify that a QMHP responded to all referrals, and 90% of the referrals within four hours. The County’s Fourth SelfAssessment reports that in the fourth quarter of 2016, a QMHP responded to 95% of referrals and 72% were within four hours. The results for the first quarter of 2017 show that a QMHP responded 100% of the time and 68% were within four hours. Future results reporting Substantial Compliance will be subject to a qualitative assessment that the QMHP provided “clinically appropriate mental health crisis intervention services” as required by Paragraph 40.
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41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. The County’s Second and Third Self-Assessments reported that there were four prisoners (a) who were on suicide watch in the randomly selected months and (b) who were discharged from FIP before the end of the quarters. The Self-Assessments also reported that the step-down protocols required by Paragraph 41 were followed for these four patients. The County's Fourth Self-Assessment reports that all of the FIP patients on suicide watch during the Fourth Reporting Period either remained on suicide watch at the end of the period or they "did not remain in the system (they were transferred to prison), and therefore did not go through the protocols."
The Monitor is of the view that there is no basis for concluding that the County has or has not met the requirements of the sub-parts of Paragraph 41 in the Fourth Reporting Period since the predicate for the County's obligations have not occurred since the third quarter of 2016. The Mental Health Subject Matter also has expressed concern about evaluating whether the County has implemented "step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch" as required by Paragraph 41 based upon the very limited number of cases. He noted the importance of the step-down protocols, which require "cooperation between custody and [mental health] and careful [mental health] assessment to restore property and privileges (to the extent permitted by the patient's custody level) while balancing safety and minimizing restrictions."
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The Mental Health Subject Matter Expert questions whether the County is counting all prisoners on suicide watch and notes that the County's self-assessment “seems to limit the pool of patients to those who were in restraints or on direct constant observation,” and may not include patients “formally placed on any form of suicide watch/protection status: safety gown, checks, restraint, or constant observation.” He is of the view that "anybody placed in any form of suicide protection should be subject to stepdown in accordance with [the provisions of DMH policy 70.7.]"
The Mental Health Subject Matter Expert also indicates that the County should be, but is not, "assessing whether the policy is being followed and that sequential stepdowns are being utilized appropriately." He reviewed the four cases involving patients released from FIP after being on Suicide Watch in the earlier periods, and he found that “[a]ll four remained on some form of suicide restrictions that were generally the same as the restrictions in FIP." He also found that the documentation was "insufficient to show what intermediate steps were taken between these highly restrictive measures and the discontinuation of suicide watch,”17 and thus he could not determine whether the stepdown processes were implemented as required by this provision.”
The Monitor plans to meet with the parties and the Mental Health Subject Matter Expert to discuss revisions to the Compliance Measures that will increase the number of inmates subject to the step-down protocols of Paragraph 41 and ensure that the County's implementation of step-down protocols for FIP patients on suicide watch "ameliorate the impact of the restrictions" and have the necessary "level of precautions based upon individual assessment[s]" of the patients.
17 The Subject Matter Expert noted that in reviewing records for other provision there “was clear evidence of the implementation of sequential restoration of privileges and property consistent with policy 70.7 and in accordance with Paragraph 41.
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42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement “step-down” procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: PARTIAL COMPLIANCE (at CRDF)
NON-COMPLIANCE (at TTCF)
Substantial Compliance requires the Department to review the medical records of prisoners in HOH on risk precautions for one randomly selected month each quarter, and to report on the implementation of the step-down protocols and the results of the medical records review. The County’s Fourth Self-Assessment reports that for the fourth quarter of 2016 at CRDF, “81% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures” and “81% -- instead of the required 85% -- of the records reflected that stepdown procedures were implemented per the QMHP assessment, where applicable.” For this quarter at TTCF, “23% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures” and "the Department did not have records that reflected that step-down procedures were implemented per the QMHP assessment, where applicable, and therefore was unable to assess Compliance Measure 42-4(c).”
The County’s Fourth Self-Assessment also reports that for the first quarter of 2017 at CRDF, “67% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures” and “33% -- instead of the required 85% -- of the records reflected that stepdown procedures were implemented per the QMHP assessment, where applicable.” For the first quarter at TTCF, “6% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down
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procedures” and “0% -- instead of the required 85% -- of the records reflected that stepdown procedures were implemented per the QMHP assessment, where applicable.”18 As noted by the Mental Health Subject Matter Expert, "[t]o qualify as step-down from Risk Precautions, the record must reflect that a QMHP assessed the nature of the patient's risk and made a determination [of the level of care/housing] on the basis of that individualized assessment of risk."
To address these poor results, the Fourth Self-Assessment reports that: "DMH-CHS has determined that the challenges with compliance
for 42-4(b) and (c) are the result of documentation and practice issues. To this end, training efforts began in May 2017. The Compliance and Population Management (“CPM”) Program Head began meeting with the supervisors at TTCF and CRDF to provide feedback and to review the issues related to RP Step Down procedures with more of a focus on training efforts. A workgroup with staff from both CRDF and TTCF began meeting in June 2017 to address training and documentation process with staff in both programs."
18 The Mental Health Subject Matter Expert notes that the County's results "may be an issue of interpretation of what 'step-down' entails." He is of the view that "cases where patients were removed from R[isk] P[recaution]" and a QMHP discussed the relationship of the "restoration of privilege and/or property" to the "danger to self" should count "as step-down measures."
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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 42 of 107 Page ID #:2767
43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
STATUS: PARTIAL COMPLIANCE
In response to comments by the Monitor and DOJ, the Department submitted proposed revisions to its discipline policies on May 30, 2017. After consulting with the Subject Matter Experts, the Monitor provided his written comments to the Department on June 29, 2017. The DOJ provided its comments to the Department the same day. Approval of the revised policies by the Monitor and Subject Matter Experts will satisfy the requirements of Compliance Measure 43.9(a).
The County previously reported to the Monitor and DOJ that it has “stopped the practice of moving inmates with mental illness to [disciplinary] housing.” The Department reports that "no inmates with mental illness had lost behavioral credits for disciplinary reasons" in the first quarter of 2017, which addresses Compliance Measure 43.9(e).
The Department has collected data for the first quarter of 2017 for the
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Compliance Measures 43.9(c) and (d), which require that QMHPs meet with prisoners receiving psychotropic medication who are transferred from disciplinary housing and also walk through each disciplinary housing unit at least once a week.19 It has not, however, been able to provide any conclusions regarding Compliance Measures 43.9(b), which requires custody staff to consult with a QMHP prior to transferring prisoners from mental health housing to disciplinary housing.
The Mental Health Subject Matter Expert and the clinicians reviewed medical records to determine "whether each [inmate] was seen or consulted on time by a QMHP, whether the QMHP considered a higher level of mental health housing, whether the QMHP provided recommendations regarding restrictions being clinically contraindicated, whether the QMHP evaluation was based on the mental health condition of the prisoner as required, [and] whether the recommendations were followed."
As summarized by the Mental Health Subject Matter Expert, "the QMHPs are not consistently involved in evaluating those [inmates] in MOH and HOH prior to the imposition of discipline. When done, the QMHP assessments rarely considered the potential impact of different forms of discipline on the mental health condition of the patient." When there were "assessments with recommendations," the recommendations were almost always followed.
19 The results varied among the facilities. For example, QMHPs walked through disciplinary housing 20% of the time at NCCF, 60% of the time at MCJ, 80% at TTCF and 100% at CRDF and PDC North, and they met with prisoners receiving psychotropic medications who were transferred to disciplinary housing 56% of the time at TTCF, 57% of the time at MCJ, and 60% of the time at CRDF. There were no results for this at PDC North or NCCF.
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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 44 of 107 Page ID #:2769
44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County has maintained Substantial Compliance with Paragraph 44 of the Agreement since January 1, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 44 is no longer subject to monitoring.
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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 45 of 107 Page ID #:2770

45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016, at CRDF, NCCF, PDC EAST, PDC SOUTH, and TTCF (verified))

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016, at MCJ and PDC North (verified))

The County has maintained Substantial Compliance with Paragraph 45 for twelve consecutive months at all facilities. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 45 is no longer subject to monitoring.

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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 46 of 107 Page ID #:2771
46. The County and the Sheriff will immediately interrupt, and if necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to review the documentation from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment. The County reports that "the Department is unable to collect the universe of incidents when an inmate threatened self-injurious behavior" as opposed to when an inmate exhibited such behavior. The County's Fourth Self-Assessment reports that for the fourth quarter of 2016, “85% -- rather than the required 95% -- of the records reviewed . . . reflected that appropriate aid and (when necessary) immediate interruption of self-injurious behavior was provided by the Department.”
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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 47 of 107 Page ID #:2772
47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: PARTIAL COMPLIANCE
The County’s Fourth Self-Assessment sets forth what the County has done to implement each of the paragraphs of the Settlement Agreement and provides a summary of “changes in mental health staffing at the County's custody facilities.” As of September 1, 2016, "44 positions were funded and allocated to mental health, bringing the total number of employees to 410." As of June 15, 2017, "Mental Health has a total of 29 vacancies," and DHS "anticipates adding 80 positions after July 1, [2017]." – essentially completing the transition of DMH and the upcoming transition of the Medical Services Bureau to DHS, and the mental health staffing levels assigned to the Custody facilities under the new County-wide organization. The County's Augmented Fourth SelfAssessment reports that "CHS is working with the County's Chief Executive Office to authorize 80 new positions in the next year."
For purposes of Paragraph 47, "Critical Incidents" include inmate deaths, inmate suicides, serious suicide attempts, assaults on staff by inmates in mental health housing units or on mental health caseloads resulting in serious injuries to staff, and Category 3 uses of force (or a statement that no such incidents occurred). The County’s Augmented Fourth Self-Assessment reports that the County "is still working on compiling this list" of critical incidents that "must be evaluated to determine whether staffing levels were a factor in that critical incident and/or non-compliance."
Notwithstanding the lack of information about the critical incidents, the Monitor believes that the County has achieved Partial Compliance with Paragraph 47 because the Fourth Self-Assessment and the Augmented Fourth Self-Assessment report "the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement" and describe "the barriers to implementation" of specific paragraphs.
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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 48 of 107 Page ID #:2773
48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations (“CCR”) Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The Department’s revised CDM 5-11/020.00 SANITATION issued on July 6, 2015, requires each facility to “have a written housekeeping, sanitation and inspection plan.” The Department has provided Unit Orders for each facility that, for example, “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility.” As required by the Compliance Measures, the Department provided the most recent Local Detention Health Inspection Report pursuant to California Health & Safety Code Section 101045 and Corrective Action Plans for each facility. The Monitor, after consultation with the Subject Matter Expert, certified in the Initial Report that the Department’s plans satisfy the requirements of CCR Title 15, §1280 and had been implemented as of January 1, 2016.
The County maintained Substantial Compliance with Paragraph 48 of the Agreement at all facilities for twelve consecutive months from January 1, 2016 through December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, this provision is no longer subject to monitoring.
During the Fourth Reporting Period, the Monitor and Subject Matters Experts visited the facilities on a number of occasions to assess compliance with other provisions of the Settlement Agreement, and again observed that the Department had maintained “an acceptable level of cleanliness, sanitation, repair and safety” in each facility.
The most significant problems remain in the HOH units in TTCF when severely mentally ill inmates refuse to come out of their cells so that the cells can be cleaned of trash, debris, food, and sometimes human waste that has accumulated over a number of days. Overall, however, the common areas in the facilities were generally clean and relatively few of the cells had an undue buildup of trash and debris.
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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 49 of 107 Page ID #:2774
49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016, through February 28, 2017)
CDM 4-07/020, effective January 26, 2016, requires Unit Commanders to establish plans for their facilities that address the requirements of Paragraph 49. Unit Orders for each facility have been issued, for example, to “establish policy and procedures for maintaining an acceptable level of cleanliness, sanitation, repair and safety through the facility.” Unit Orders address procedures for handling maintenance requests and the eUDAL and Maximo automated systems are used to track such requests while on-site. The Unit Orders indicate that the Facilities Services Bureau (“FSB”) is to be notified when there is mold, and it will be responsible for treating the problem. The Department submitted a memorandum from FSB, dated February 3, 2016, indicating what steps FSB takes to treat the problem.
Each facility has a written maintenance plan for responding to routine and emergency needs and for addressing small and large mold infestations (minor mold infestations are handled by facility staff and inmate work crews and large mold infestations are reported to FSB for handling). Each facility also has a maintenance coordinator who serves as the point person between the facility, maintenance contractors and Internal Services Departments, as well as the coordinator for inmate work crews.
On February 7 and 8, 2017, and again on May 31, and June 1, 2017, the Monitor and the Use of Force Subject Matter Expert inspected each of the facilities (other than CRDF to assess the Department’s compliance with Paragraph 49. On April 5, and June 8, 2017, the Monitor inspected CRDF. During the inspections the Monitor and Subject Matter Expert again found that the lighting systems, heating, ventilation and cooling systems in each facility were “adequately maintained and installed.”
The County maintained Substantial Compliance with Paragraph 49 of the Agreement at all facilities for twelve consecutive months from March 1, 2016 through February 28, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, this provision is no longer subject to monitoring.
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50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016, at all facilities other than PDC South and PDC East (verified))

SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017, at PDC South and PDC East (verified))

On February 7 and 8, 2017, and again on May 31, and June 1, 2017, the Monitor and the Use of Force Subject Matter Expert inspected each of the facilities (other than CRDF), and on April 5, 2017, and June 8, 2017, the Monitor inspected CRDF. There was no indication of any pest control problems in the housing units, the medical units, kitchen, food storage areas, or elsewhere in the facilities.

Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with a copy of a contract with an outside vendor for regular pest control services at each jail facility and, on a quarterly basis, a schedule of the pest control activities at each facility in the previous quarter; a pest control compliance checklist of the pest control activities taken at each facility in the previous quarter; documentation from the outside vendor reflecting visits to each jail facility and the work performed during the visits; and a copy of the most recent report by the County Department of Public Health concerning pest control in the jail facilities.

The County's Fourth Self-Assessment reports that the Department has achieved Substantial Compliance for twelve consecutive months at all facilities, other than at PDC South and East, through the fourth quarter of 2016, and at PDC South and East through the first quarter of 2017. The results provided by the County have been verified by the Monitor's auditors, and Paragraph 50 is no longer subject to monitoring.

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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 51 of 107 Page ID #:2776

51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 for all facilities other than CRDF (verified))

SUBSTANTIAL COMPLIANCE (as of July 1, 2016 through June 30, 2017 at CRDF (verified))

The Monitor and Subject Matter Expert have randomly inspected control booths and officers’ stations and verified that the kits were readily available and regularly provided to the prisoners at all of the facilities.

The Fourth Self-Assessment reports Substantial Compliance for all facilities except CRDF for twelve consecutive months through December 31, 2016 and at CRDF for twelve consecutive months through June 30, 2017. The results at all the facilities have been verified by the Monitor's auditors, and Paragraph 51 is no longer subject to monitoring.

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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 52 of 107 Page ID #:2777
52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: PARTIAL COMPLIANCE
The Department's ALLOWABLE INMATE PROPERTY policies – CDM 5/06.010.05 for male inmates and CDM 5/06.010.10 for female inmates – require that property restrictions for inmates in mental health housing be determined by “a mental health professional after a clinical assessment has been conducted.” DMH 70.7 requires the same level of property restrictions where two inmates are housed in the same cell in HOH.
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52.20
During the most recent tours of TTCF and CRDF in June 2017, the Monitor and the DOJ representative noted that the property of inmates in the HOH units generally matched the allowable property reflected on the door signs, which was some improvement from earlier tours in the Fourth Reporting Period.
20 The parties and the Monitor have agreed that the Department will randomly select and review the medical records of all inmates, up to a maximum of 100 prisoners, who were placed in HOH during each month in a quarter (and not already assigned to HOH).
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The County’s Fourth Self-Assessment reports that it has not achieved Substantial Compliance at either TTCF or CRDF, which are the only facilities with an HOH. For the first quarter of 2017, the County reports that 89% and 91% of the inmates initially placed in HOH at TTCF and CRDF, rather than the required 95%, were provided the property required by Paragraph 52, and that 98% of the inmates placed in HOH “for more than 24 hours” at both TTCF and CRDF had “allowable property as recommended by a QMHP[.]”
The Mental Health Subject Matter Expert and the clinicians assessed the results reported by the Department and "qualitatively evaluated whether the restrictions were based on an analysis of relevant risks and whether patients had access to unrestricted allowable property." They found that "a QMHP provided an assessment” in 63% of the cases and saw the patient within 24 hours 72% of the time. The recommendations were followed approximately one-half the time, and "allowable property was based on relevant risks" only 28% of the time.
The County's Fourth Self-Assessment reports the results for Compliance Measures 52.5(b) and 52.5(e), but again it does not include results for 52.5(c) and (d), which are required to establish Substantial Compliance. The County needs to provide evidence of a formal assessment by a QMHP of what property is allowed; the placement of a door sign is not enough to establish either the timeliness or the sufficiency of the assessment. It must also show how it determines if a QMHP made an assessment.
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53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to audit the records of prisoners who were eligible and rejected or disqualified for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone. The County reports that in the fourth quarter of 2016, and the first quarter of 2017, 85% and 50% respectively of the mentally ill prisoners who were eligible for and denied work were not denied the work because of their mental health condition or a prescription for medication alone, which is below the 90% threshold for Substantial Compliance. The Mental Health Subject Matter Expert agrees that inmates who meet the P4 mental health level of care (the most severely impaired) may be excluded because they are not capable of participating or benefitting from these programs, but this should be the only population that is excluded from this provision.
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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 55 of 107 Page ID #:2780

54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through March 31, 2016 (unverified); as of April 1, 2016, through December 31, 2016 (verified))

Substantial Compliance requires the Department to audit the records of a maximum of 100 randomly selected prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. The County’s Fourth SelfAssessment reports that it has achieved Substantial Compliance for the fourth quarter of 2016. The reported results for the second, third, and fourth quarters of 2016 have been verified by the Monitor's auditors, but the results for the first quarter of 2016 have not been verified. If verified, Paragraph 54 will no longer be subject to monitoring.

There is a concern that the Compliance Measure may not adequately address the Substantive Provision. As noted by the Mental Health Subject Matter Expert, the randomly selected population "does not pre-select for patients on [mental health] rolls or on medication, so it is possible that all cases reviewed had no mental health problem that might have resulted in a denial." In the event that the 100 randomly selected prisoners did not include any prisoners with mental health problems, a finding that none of the prisoners were denied privileges and programing because of their mental health status would not show that the Department is complying with the requirements of Paragraph 54. In response to the Monitor's request for comments on how to address this issue, both parties expressed a willingness to discuss a possible revision of the Compliance Measures.

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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 56 of 107 Page ID #:2781

55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through March 31, 2017 (verified), and through June 30, 2017, at TTCF (unverified))

SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through June 30, 2017 at CRDF (unverified))

SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through June 30, 2017 at MCJ and PDC North (unverified))

Sections 3.5.2.3 and 3.5.3.2 of DMH Policy 70.2.1, effective February 4, 2016, require “relevant custody, medical and mental health staff” to meet in accordance with the requirements of Paragraph 55. The Monitor and a DOJ representative attended a daily HOH meeting at CRDF on June 8, 2017, which included custody, medical, and mental health personnel who appeared to be very knowledgeable about the condition and issues of individual HOH inmates. The Mental Health Subject Matter Expert also attended a number of meetings for HOH and MOH units at both CRDF and TTCF, which were well attended and thorough, and the staff actively participated.
On July 11, 2017, the Department provided semi-annual reports for each of the facilities with HOH and/or MOH units "verifying the coordination and communication at the staff meetings" at these units during the first six months of 2017 as required by Compliance Measures 55.4 and 55.6(c). The County's Fourth Self-Assessment reports that the Department has achieved Substantial Compliance as of the fourth quarter 2016 at CRDF and TTCF with Compliance Measures 55.3, 55.6(a) and 55.6(b). The Augmented Fourth Self-Assessment reports that it has achieved Substantial Compliance at MCJ as of the first quarter 2017, and all applicable facilities (which includes PDC North) for the second quarter of 2017. All of the Substantial Compliance results are subject to verification by the Monitor's auditors.

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Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 57 of 107 Page ID #:2782

56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through June 30, 2016 (verified), through September 30, 2016 (unverified), and through December 31, 2016 (verified))

Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH; and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing.

The County’s Fourth Self-Assessment reports that it has achieved Substantial Compliance for the fourth quarter of 2016 based upon (i) medical records reflecting the required medical and/or mental health approvals 100% of the time, and (ii) 96% of the prisoners who were the subject of a suicide notification were clinically assessed, and their post-incident housing was approved, by clinical staff. These reported results have been verified by the Monitor's auditors, but the previously reported results for the third quarter of 2016, are still subject to verification by the Monitor's auditors. If verified, Paragraph 56 will no longer be subject to monitoring.

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57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57):

SUBSTANTIAL COMPLIANCE (as of January 1, 2017 through March 31, 2017 at MCJ and PDC North (unverified))

PARTIAL COMPLIANCE (at TTCF and CRDF)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit in two randomly selected weeks to determine if the safety checks were staggered and conducted as required by Paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit for one randomly selected week to determine if a QMHP approved the new mental health housing assignments as required by Paragraph 57(e).

The County’s Fourth Self-Assessment reports that it has achieved Substantial Compliance in the first quarter of 2017 in the MOH units at MCJ (the "Hope Dorm") and at PDC North, where 96.7% and 99.4% of the safety checks were in compliance, and Partial Compliance in the HOH and MOH units at TTCF and CRDF, where 87.8% and 80.1% were in compliance. The Self-Assessment also reports that a QMHP approved 98% of the new mental health housing assignments for all facilities. These results are subject to verification by the Monitor's auditors, which will include verifying that the safety checks were staggered as required by Paragraph 57(c). As DOJ correctly notes, "Title 15 checks routinely separated by the same length of time do not comply with [the] requirement that the safety check be staggered."

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58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells; (b) At least every 30 minutes in dormitory-style housing units where the unit
does not provide for unobstructed direct supervision of prisoners from a security control room; (c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes; (d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing; (e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner; (f) Custody staff will document their checks in a format that does not have pre-printed times; (g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and (h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
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STATUS (58):

SUBSTANTIAL COMPLIANCE (as of January 1, 2016 through December 31, 2016 at PDC South, and PDC North (verified))

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through September 30, 2016, (verified), and through December 31, 2016 (unverified) at PDC East)

PARTIAL COMPLIANCE (at TTCF, CRDF, IRC, MCJ, and NCCF)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by Paragraph 58. The County’s Fourth Self-Assessment reports that the Department has achieved Substantial Compliance at PDC South, PDC North, and PDC East for twelve consecutive months as of December 31, 2016. These results at PDC South and North have been verified by the Monitor's auditors through December 31, 2016, and the results at PDC East have been verified through September 30, 2016, but are subject to verification through December 31, 2016. Based upon these results, Paragraph 58 is no longer subject to monitoring at PDC North and PDC South. If the results at PDC East through December 31, 2016 are verified by the Monitor's auditors, Paragraph 58 will no longer be subject to monitoring at PDC East as well.

Based upon a review of the County's data, which is generally in the 80% range, the Monitor has concluded that the County has achieved Partial Compliance at the remaining facilities.

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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through March 31, 2017 at PDC North, East, and South, and MCJ, (verified))

PARTIAL COMPLIANCE (at CRDF, TTCF, and NCCF)

Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if the supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. In response to the Monitor's comments, the Department's e-UDAL forms were modified to include a specific notation that the Supervisor verified that the safety checks were conducted.

The County's Fourth Self-Assessment reports that the Department achieved Substantial Compliance at PDC East, North, and South and MCJ in the first quarter of 2017. These results have been verified by the Monitor's auditors. The Monitor has also determined that the Department achieved Partial Compliance at the remaining facilities during that quarter.

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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
Compliance Measures 60.2 and 60.3(b) require the County to prepare semi-annual reports setting forth (a) any identified clinical issues in the areas identified in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods.
The County submitted "CHS Semi-Annual Report on Quality Improvement/Assurance" to the Monitor on July 18, 2017. The report is broken into two parts: 1) a description of the existing Continuous Quality Improvement ("CQI") Program and 2) the plans of Dr. Jonathan Liu, the Director of Quality & Performance Improvement, for "a robust quality improvement program for [Correctional Health Services] that permeates through all levels of staff and across all service lines," including mental health services. The Mental Health Subject Matter Expert observes that the report "is solid work. Once in place, the County will have the backbone of a sound QA/QI program."
The first part of the report describes the functions of various committees, programs, projects, and meetings that comprise the existing CQI process under the responsibility of the Correctional Health Services-Mental Health Services ("CHS-MHS") Compliance and Population Management Program. The second part of the report is a description of the goals of, and progress towards, the core components of Dr. Liu's plans in the following areas: 1) Quality and Safety Knowledge; 2) Availability of Real-Time Data; 3) Quality Improvement Methodology; 4) Project Tracking; and 5) Patient Safety Culture.
Although the report generally describes the County's current CQI efforts21 and its progress in developing a "robust quality improvement program,"22 it does not set forth any clinical issues that mental health personnel have identified as placing prisoners at significant risk, describe any corrective actions and systemic improvements to address such issues, or assess the effectiveness of any such steps as required by Compliance Measures 60.2 and 60.3(b) described above.
21 For example, it describes the process of the Critical Incident Review Committee ("CIRC") in reviewing suicides and serious suicide attempts, the tracking of Corrective Action Plans ("CAP") through the Joint Quality Improvement Program, and the functions of various other projects, committees, and work groups. 22 The Mental Health Subject Matter Expert comments that the report reflects "all the right sorts of approaches," and recommends that the program "more explicitly include measures of care and access to care[.]"
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts:
(i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints;
(c) Psychotropic medications;
(d) Access to care, timeliness of service, and utilization of the Forensic Inpatient Unit; and
(e) Elements of documentation and use of medical records.
STATUS: NON-COMPLIANCE
Substantial Compliance requires that the County’s semi-annual reports to (a) review, collect, and aggregate data in the areas set forth in paragraph 61; (b) recommend corrective actions and systemic improvements in those areas; and (c) assess the effectiveness of actions and improvements in prior reporting periods.
The "CHS Semi-Annual Report on Quality Improvement/Assurance" that the County submitted to the Monitor on July 18, 2017, describes the existing CQI Program and the plans to develop "a robust quality improvement program" for Correctional Health Services. This Report does not, however, “(i) review, collect, and aggregate data in the areas set forth in paragraph 61; (ii) recommend corrective actions and systematic improvements in those areas; [or] assess the effectiveness of actions and improvements in prior reporting periods" as required by Compliance Measure 61-3(b).
The Department's Response to Monitor's Draft Conclusion (61) sets forth a summary of CHS's Quality Improvement Program, including how data is collected on self-directed violence (SDV) in the jails by CHS and CCSB and the reviews of the SDV incidents by QMHP's (to determine the seriousness of the incidents based upon a Centers for Disease Control Risk Rating Score), Mental Health Supervisors (to determine if incidents meet the criteria for referrals to the Critical Incident Review Committee ("CIRC"), the CIRC (to review serious suicide attempts), the Joint Quality Improvement Committee ("JQIC") (to track and review the progress of corrective action plans), and the
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Suicide Prevention Advisory Committee ("to review known system issues and recommend coordinated approached to improving suicide prevention"). While this is a helpful summary of the quality improvement program, it does not address any of the requirements of Compliance Measure 61-3(b).
The Monitor and the Mental Health Subject Matter Expert recognize that the County is continually working to enhance and improve its quality improvement program and that it has made "substantial strides." It may be, as reported by the County, that the QI program tracks data, recommends improvements, and asses the effectiveness of the recommendations, but that information is not set forth in the either the CHS Semi-Annual Report on Quality Improvement/Assurance or the Department's Response to Monitor's Draft Conclusion (61) as required by Compliance Measure 61-3(b).
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the County's semi-annual Self-Assessments to set forth (a) the “development of corrective action plans to address the most recent recommendations of the quality improvement program;” and (b) the “implementation and tracking of corrective action plans to address recommendations of the program in prior quarters.” As noted above, the "CHS Semi-Annual Report on Quality Improvement/Assurance" that the County submitted to the Monitor on July 18, 2017, describes the existing CQI Program and the plans to develop "a robust quality improvement program" for Correctional Health Services. It generally describes the tracking and reviewing of CAPs at monthly CIRC meetings; the "discussion of systemic issues and improvements" at monthly meetings of the Joint Quality Improvement Program; and the Longitudinal Improvement Project to "track projects, especially corrective action items identified during Death Reviews and the CIRC process." The report, however, fails to describe the development, implementation and tracking of specific corrective action plans to address specific recommendations. As noted by the Mental Health Subject Matter Expert, the list of CAPs that the County provided, while "consistent with the spirit" of Paragraph 62, needs "to be folded into the CQI program proper."
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63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.

STATUS: NON-COMPLIANCE (at TTCF and CRDF)

The Compliance Measures require that the County's Self-Assessment set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period; (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. As the Mental Health Subject Matter Expert has noted, this analysis must be from an "identified fixed capacity rather than expanding beds day-to-day." In addition, for two random weeks, the Department is required to review the count sheets documenting the number of occupied and available beds in the MOH and HOH units at TTCF and CRDF. Substantial Compliance requires “the immediate availability of HOH and MOH beds at TTCF and CRDF 95% of the time.”

The County reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the fourth quarter of 2016 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 100% 85%

The County also reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the first quarter of 2017 are as follows:

TTCF CRDF24

MOH 100% 92%

HOH 100%23
85%

23 The County's Fourth Self-Assessment for TTCF indicates that it "did not properly capture HOH bed availability for purposes of this provision." The Department's Response to Monitor's Draft Conclusion (63) states that "there are concerns with the accuracy of the data collected by the upgraded technology at TCCF [sic], which are being addressed." Accordingly, the Monitor is unclear on how to evaluate the County’s reported results for TTCF. 24 Although the posted Self-Assessment for CRDF reports 92% for MOH and 85% for HOH, the summary tables in that Self-Assessment reflect the slightly higher percentages set forth above. The Monitor’s view is that the higher percentages are correct because the County satisfies the requirements of Compliance Measure 63.3 when a bed is available for every HOH or MOH inmate. Nevertheless, the Monitor has concerns about the MOH data for CRDF for the two randomly selected weeks in the first quarter of 2017.

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On August 15, 2017, the County submitted Semi-Annual Reports for the Fourth Reporting Period for both TTCF and CRDF setting forth the average daily populations in HOH and MOH units at CRDF and at TTCF, the average number of beds, the average number of step-downs per week,25 and the number of days in which there beds were available in HOH or MOH housing at CRDF and MOH housing at TTCF. The County also reported on the immediate availability of beds (that is, more beds than prisoners) during the entire reporting period as required by the Compliance Measure 63.3 as follows:

TTCF CRDF

MOH 97.23%
.5%

HOH 100% 78.45%

The Monitor is of the view that the Department has not achieved Partial Compliance at either CRDF or TTCF because the Department has expressed concerns about the accuracy of the data reported for HOH prisoners at TTCF and the Monitor has concerns about the data for MOH prisoners at CRDF. See notes 24, 25, supra.

Although the number of MOH beds is consistent with the number of beds in the randomly selected weeks in the fourth quarter of 2016 and the average number of beds in the Fourth Reporting Period, the number of MOH prisoners in those two weeks is significantly below the number of MOH prisoners in the two weeks in the fourth quarter of 2016 and the average number of MOH prisoners in each month in the Fourth Reporting Period. 25 Data for the months of May and June was not provided for this element.
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64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in an initial 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed.
On July 14, 2017, the County submitted to the Monitor a Plan Regarding Availability of Licensed Inpatient Mental Health Care (Long Term and Short Term Plans) to provide "an update regarding the County's current efforts to meet the needs of the acutely mentally ill." The County is working to "divert some of the most acute psychiatric patients in custody to inpatient care at a new [inpatient psychiatric] unit at Olive-View-UCLA Medical Center," which will open with 18 beds by the end of 2017.
The Plan also describes various "Other Programmatic Enhancements to Decrease Need for Licensed Inpatient Mental Health Care," including involuntary medication of inmates who are incompetent to stand trial, out of custody alternatives for Misdemeanor Incompetent to Stand Trial ("MIST") inmates and other mentally ill inmates, and the use of a Sterile Pod to house "patients who are at a high risk of self-harm due to accessibility to particular items such as razors or sharp objects."
The Plan also reports on efforts to address the need for additional FIP beds during the Fourth Reporting Period. On April 10, 2017, CHS added 15 beds in the CTC "dedicated to those with acute mental health needs." To reduce the number of patients who need to be housed in the FIP unit, an additional FIP step down housing unit for 24 patients has been added beginning July 1, 2017. This reflects the success of the existing FIP step down unit in reducing the likelihood of a return to the FIP unit and "providing an enhanced therapeutic environment for those who are on the list waiting to be admitted to the FIP."26
26 This is consistent with the observations of the Monitor and Mental Health Subject Matter Expert on site visits to TTCF.
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As stated in the Fourth Self-Assessment, the short-term and long-term "plans communicate the County's dual strategy to increase both inpatient beds and the resources necessary to obviate the need for these beds. The thought is that with increased services that address the underlying mental health needs (both through appropriate medication and clinical treatment) the need for inpatient services will decline." Future reports from the County should report on the effectiveness of the measures in the updated Plan, including any reductions in the number of patients on the FIP waiting list and who are incompetent to stand trial.
While the updated Plan addresses what the County is doing in the short-term to address the availability of the licensed inpatient mental health care for prisoners, neither the Fourth Self-Assessment nor the updated Plan projects how many beds will be required over the long-term (several years), which the Mental Health Subject Matter Expert indicates "is desperately needed."27 As he previously noted, the plans must have a reasonable basis for projecting need in order to establish Substantial Compliance with Paragraph 64.
27 The County's Augmented Fourth Self-Assessment notes that "the County continues to work towards addressing [this issue] regarding the methodology used to assess the number of in-patient beds required in both the long and short term."
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the County's Self-Assessments to set forth the (1) the results of weekly medication Administration Audits documenting the visual observation of the administration of medication during the quarter; (2) unauthorized medications found as a result of cell searches during the reporting period; and (3) incidents involving confirmed prescription drug overdoses. The reported results are subject to the Monitor’s conclusions, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner.
The County’s Fourth Self-Assessment is somewhat confusing. It first reports the "County's Conclusion" that the Department has achieved Partial Compliance with this provision in the fourth quarter of 2016 and the first quarter of 2017, but then states that the "County's Self-Assessment for the Fourth Quarter 2016 and First Quarter 2017 for this Provision reflect that the Department has achieved 'Substantial Compliance' with this provision."
Regardless of the County's conclusion, the Monitor finds the County to be in Non-Compliance. Once again, medication was found during a significant number of cell or module searches during the first quarter of 2017,28 which causes the Monitor and Subject Matter Expert to question how medications are being administered so as “to prevent misuse, hording, and overdose” as required by Paragraph 65.
During this Reporting Period, the Monitor and a DOJ representative observed pill calls at TTCF and CRDF that appeared at first to be sufficiently rigorous in conducting mouth checks to prevent the possibility of misuse, hoarding and overdose.
The Monitor nevertheless had doubts about whether the pill calls he observed reflected the "usual" pill calls at TTCF and CRDF, and also about the accuracy of the reported results. Based upon information that was provided by an inmate at TTCF that what Monitor had observed was not a "normal" pill call, the Monitor requested videos of pill calls at TTCF and at CRDF at the same time on other days. The pill calls shown on the videos provided by the Department were not at all similar to the pill calls the Monitor observed at these facilities, and they were not sufficiently rigorous to prevent misuse or hoarding of medication. The videos show inmates walking away from the nurse's station before (or without) swallowing the pills; nurses and custody staff failing to ensure that the pills were swallowed, and the custody staff failing to provide the required security.
28 45 unknown medications were found during 144 unannounced searches at CRDF, 1,228 medications were found during 118 searches at TTCF, 765 medications during 450 searches at MCJ, and 171 medications during 757 searches at NCCF. As noted above, the results of these searches should be used to determine whether hoarding alerts are being initiated timely.
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The County's posted Self-Assessment reports that "the overall compliance rate of documenting weekly medication visually for Q1 is 100%." Having reviewed videos of pill calls, the Monitor questions how the auditors could possibly have found 100% "Program Compliance,"29 in each month of the first quarter at each facility.
In its Augmented Fourth Self-Assessment, the County acknowledges that there are "ongoing issues regarding reporting and compliance with this provision, and is actively pursuing improvements on both fronts."
29 This includes 100% for "Nurse Ensure Med Ingest," "Security Provided," and "Custody Ensure Med Ingest." This is not what the Monitor saw on the videos.
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66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with a Serious Mental Illness ("SMI") to assess whether they have remained on an active mental health caseload, been offered structured mental health treatment, and been seen by a QMHP at least monthly, regardless of whether they refuse medications. For the first quarter of 2017, the County posted results show that only 34% of prisoners in HOH, 14% in MOH, and 33% of the prisoners with serious mental illness who reside in other housing areas were "offered clinically appropriate mental health treatment and were seen by a QMHP at least once a month." The Mental Health Subject Matter Expert and the clinicians "found virtually no evidence of treatment that qualified as structured or clinically appropriate;" "[F]requent prisoner moves and the resultant inability to maintain a course of treatment. . . limit the County's ability to meet this measure;" and "custody continues to determine group participation, precluding clinicians' ability to direct patients to appropriate services."
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings;
(c) the use of clinically appropriate interventions with such prisoners to encourage medication compliance;
(d) consideration of the need to transfer non-compliant prisoners to higher levels of mental health housing; and
(e) individualized consideration of the appropriateness of seeking court orders for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a).
STATUS: NON-COMPLIANCE
Substantial Compliance requires the County to review the electronic medical records of prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records reflect the documentation and consideration of the matters required by Paragraph 67. The Fourth Self-Assessment reports that the Department "continues to experience challenges implementing and assessing compliance with this provision” and “is pursuing a technolog[ical] solution.”
The Mental Health Subject Matter Expert and the clinicians reviewed 13 cases and found that in "46% of the cases, there was consideration of a transfer to a higher level of mental health housing;" in 23% of the cases, "clinically appropriate measures to encourage compliance were employed;" and in "14% of [the seven] cases where there was evidence of grave disability or danger to self or others,” the "record demonstrate[d] consideration of involuntary medications or transfer to FIP." They determined that in most cases where such considerations were in the record, the "consideration of transfer to a higher level of care or involuntary medications was reasonable." They noted, however, that “patients are not consistently being seen" and, when seen, the "assessment frequently does not address the issues specified in the [compliance] measures."
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016, at MCJ, NCCF, PDC East, PDC South, and PDC North (verified))

SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through March 31, 2017 (verified) and through June 30, 2017 (unverified) at CRDF)

SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through March 31, 2017 (verified) and through June 30, 2017 (unverified) at TTCF)

Substantial Compliance requires Self-Assessments to include a summary of searches conducted in the second quarter of the last reporting period and the first quarter of the current reporting period and to randomly select and review 25 Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units. The County’s Fourth Self-Assessment reports that the Department has maintained Substantial Compliance at CRDF through the first quarter of 2017 where 96% of the modules were searched and 100% of the HOH cells were visually inspected as required by Paragraph 68. Further, it achieved Substantial Compliance during this quarter at TTCF, where 100% of the modules were searched and 96% of the HOH cells were visually inspected.

The County's Augmented Fourth Assessment reports that the Department has maintained Substantial Compliance at CRDF through the second quarter of 2017, where 90% of the modules were searched and 100% of the HOH cells were visually inspected. It also achieved Substantial Compliance during this quarter at TTCF, where 96% of the modules were searched and 100% of the HOH cells were visually inspected.30 The Substantial Compliance results through March 31, 2017, have been verified by the Monitor's auditors, but the results through June 30, 2017, have not been verified.

The County previously maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC South, and PDC North and these facilities are no longer subject to monitoring for compliance with Paragraph 68.

30 Notwithstanding the Department's Substantial Compliance with the requirements of Paragraph 68 with respect to contraband searches, the extent of the hoarding discovered during the searches is a matter of concern. See n. 25, supra.
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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved,31 and documented, and that the results of medical welfare checks on restrained prisoners were also documented. The County’s Fourth Self-Assessment reports that for the fourth quarter of 2016, “78% -- rather than the required 95% -- of electronic medical records reviewed. . .reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required by this provision.” The Fourth Self-Assessment also reports that the County has been monitoring the requirement of an "individualized face to face follow-up assessment by a psychiatrist. . . within 24 hours," and found that "all but one" was completed as required by the provision.
The County’s Augmented Fourth Self-Assessment reports that, for the first quarter of 2017, “73% -- rather than the required 95% -- of electronic medical records reviewed . . . reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required by this provision.” 32
The Mental Health Subject Matter Expert and the clinicians assessed "whether a psychiatrist timely approved the restraints and performed an assessment, whether a QMHP was present at the time of the restraint, and whether [other] monitoring requirements were met." They found that the psychiatric assessments were "usually timely and sound," but that "it was sometimes difficult to determine whether a QMHP was present at the time of the restraint" and they could not "find the information [they] needed to determine compliance with monitoring requirements." They did not, however, find evidence that "a QMHP was not present in any cases;" there was "abundant evidence of checking being done and logs being utilized;" and "most episodes of restraint were very brief with most less than two hours."
31 Per agreement of the parties, with the concurrence of the Monitor and Subject Matter Expert, “a nonpsychiatrist physician can order medical/clinical restraints as long as it is for medical reasons.” 32 The Mental Health Expert is of the opinion that the County's policies place excessive requirements and should be revised "to bring them in line with accepted standards" regarding monitoring of inmates in restraints.
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through June 30, 2017)
CDM 7-03/000.05 FIXED RESTRAINTS, effective August 31, 2016; CDM 703/000.15 SECURITY RESTRAINTS IN MENTAL HEALTH HOUSING, effective August 31, 2016; CDM 7-03/010.00 WAIST-CHAIN PROCEDURES, effective August 31, 2016; and CDM 7-01/240.00 HANDLING INSUBORDINATE, RECALCITRANT, HOSTILE OR AGGRESSIVE INMATES address the requirements of Paragraph 70. The Department provided confirmation that these provisions were published in the Custody Division Manual and that Custody Support Services sent notice to Custody Operations managers on September 1, 2016.
The Mental Health Subject Matter Expert reviewed force packages from HOH or MOH settings to assess the Department's compliance with paragraph 70(d). Of seven force packages evidencing an inmate having a mental health crisis, six showed "mental health involvement either during or upon prompt referral. This amounts to 85.7% having appropriate referrals." They also observed that in a number of cases where the inmate was not in a crisis, mental health was still involved in the incident.
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71. The County and the Sheriff will ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.

STATUS:

SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through December 31, 2016 (verified) and through March 31, 2017 (unverified))

Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71. The County’s Fourth Self-Assessment reports that “100% -- 10% over the required 90% -- of electronic medical records reviewed . . . reflected that, for inmates placed in clinical restraints, the inmates received therapeutic services as required by this provision” in the fourth quarter of 2016, and 90% of the inmates received the services in the first quarter of 2017. These reported results for the first quarter of 2017 have not been verified by the Monitor's auditors.

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72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2017 through June 30, 2017) (subject to qualitative assessment))

Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings that review incidents of serious self-injurious behavior in the reporting period.

There were two suicides during the Fourth Reporting Period, and the Monitor attended the suicide review meetings during that period, which addressed the requirements of Paragraph 72.

The Fourth Self-Assessment reports that "DHS-CHS has strengthened the selfdirected violence analysis process which identifies 'serious' and otherwise appropriate incidents of self-directed violence for review at the CIRC meetings conducted in accordance with this provision. Through this process, the CHS compliance team evaluates all incidents of self-directed violence during the past quarter." The Mental Health Subject Matter Expert notes that this "may assuage my concern about identifying self-injurious behavior depending on how they are case-finding the universe in the first place[.]"

The County's posted Self-Assessment results for the Fourth Reporting Period reflect that the Department has achieved Substantial Compliance in that both suicides and all 15 serious suicide attempts were reviewed to determine whether there were any staff violations or any improvements were warranted as required by Paragraph 72. The Mental Health Subject Matter Expert is of the view that "[f]or the cases [the County] reviewed and posted, . . .they are meeting the requirements of this measure." The Substantial Compliance conclusion is, however, still subject to an analysis of the County's methodology by the Subject Matter Expert and clinicians to ensure that the County is "reliably detecting serious suicide attempts." In addition, the Monitor will assess "whether the County is adequately reviewing potential non-custody staff misconduct" as requested by DOJ.

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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicide during the reporting period. The County’s Fourth Self-Assessment reports that the County "cannot yet capture incidents involving threats of self-injurious behavior" as opposed to "incidents of selfinjurious behavior." It also reports that for the fourth quarter of 2016,"64% -- rather than the required 90% -- of reports reviewed have all of the information required by paragraph 73 of the Settlement Agreement" and that "100% -- equal to the required standard of 100% -- of incidents involving an apparent or suspected suicide were reported to the Inspector General[.]" The County’s Augmented Fourth Self-Assessment reports that for the first quarter of 2017, only "38% -- rather than the required 90% -- of reports reviewed have all of the information required by paragraph 73 of the Settlement Agreement" and that "100% -equal to the required standard of 100% -- of incidents involving an apparent or suspected suicide were reported to the Inspector General[.]"
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74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through June 30, 2017)
Substantial Compliance requires the Department to provide the Monitor with an Executive Suicide Death Review reflecting the results of the Department’s investigation of any suicide in the Jails within six months of the suicide. The review must reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded.
There was one suicide during the Third Reporting Period for which the Executive Inmate Death Review was due in the Fourth Reporting Period. The suicide occurred on November 18, 2016, and the Executive Inmate Death Review was timely submitted to the Monitor on May 18, 2017. The Executive Inmate Death Review included a Homicide Report prepared by the Detective Division of the Homicide Bureau that reports the steps taken to preserve all of the evidence; lists the interviews of persons involved in, or who witnessed, the incident; and notes if the interviews were recorded. The Homicide Report satisfies the requirements of Paragraph 74.
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75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires (a) DMH to review documentation of randomly selected suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (b) that the Department and DMH reviewed the relevant information known at that time and the status of any corrective actions taken, and they considered the need for additional corrective action if necessary; and (c) that the information is reflected in the Department's database for tracking and statistical analysis.
The County's Augmented Fourth Self-Assessment reports that for the fourth quarter of 2016, "90% -- 5% more than the required 85% -- of documents reviewed showed DMH staff considered the inmate's mental health status and need for immediate corrective action;" that "100% -- 5% more than the required 95% -- of suicide attempts are reflected in the Department's database;" and "50% -- rather than the required 95% of the suicide attempts [determined to be serious] were reviewed" by "management and command-level personnel" from Custody, mental health, and medical.
The results posted for the first quarter of 2017 reflect that 91% of documents reviewed showed DMH staff considered the inmate's mental health status and need for
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immediate corrective action; 100% of the suicide attempts are reflected in the Department's database; and 100% of the serious suicide attempts were reviewed by management and command-level personnel. Although these percentages meet the quantitative thresholds for Substantial Compliance, there is no evidence of tracking and statistical analysis.
The Monitor also has concerns about the qualitative aspects of the County's reviews of serious suicide attempts. The Mental Health Subject Matter Expert and the clinicians reviewed 12 cases to qualitatively assess the reviews of serious suicide attempts required by paragraph 75. They "noted that [corrective action plans] were rarely recommended, despite frequent evidence of problems in clinical management being noted in the review. There were also instances where identified systems problems were not converted into CAPs." They found that "[i]n only 9/24 = 38% of cases did we agree with the County' decision whether a CAP was indicated."
The Mental Health Subject Matter Expert also expressed a concern "that the County is not detecting all cases of serious suicide attempts." As pointed out by DOJ, only three of 245 suicide attempts in the first quarter of 2017 were determined to be sufficiently serious to require review by the CIRC.
In the Department's Response to Monitor's Draft Conclusion (75), the County "challenges" the Mental Health Subject Matter Expert's assertion "in light of the process used to identify and assess incidents of self-directed violence (SDV)" described in the Department's Response to Monitor's Draft Conclusion (61). The Mental Health Subject Matter Expert's concern is, however, that "[w]hile the County is likely detecting all cases of serious self-harm," it is "not clear" that the County is "actually categorizing all serious self-harm attempts as serious." The Mental Health Subject Matter Expert and the clinicians "found numerous instances [in patient charts] of self-harm that were detected but where the information in the related progress notes was insufficient to determine whether the self-harm was serious."
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76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through June 30, 2017)

There were two suicides during the Fourth Reporting Period. The first suicide occurred at TTCF on March 9, 2017. An initial Death Review was held within two working days of the death on March 13, 2017, and the seven-day review was held on March 20, 2017. The Monitor attended both meetings, which included command-level personnel from the Department and DHS and reviewed the information known about the suicide and corrective or preventive actions taken or required by Paragraph 76. The 30day death review, which the Monitor attended, was held on April 12, 2017.

The second suicide occurred at the Crescenta Valley station jail on May 25, 2017. An initial Death Review was held within two working days of the death on May 30, 2017, and the seven-day review was held on June 6, 2017. The Monitor attended both meetings, which again included command-level personnel from the Department and DHS and reviewed the information known about the suicide and corrective or preventive actions taken or required by Paragraph 76. The 30-day death review occurred on July 10, 2017, and a 60-day review occurred on August 30, 2017.

Paragraph 76(c) requires the County to provide a “final written report regarding the suicide” within six months of a suicide that addresses the 10 subparts of subparagraph (c). On May 18, 2017, the County timely provided an Executive Inmate Death Review report for the suicide that occurred at TTCF on November 18, 2016. The Review included the required supplemental reports from [or interviews of] the deputies who first discovered the inmate and the deputies who participated in the rescue attempt of the inmate, including deputies who first responded and deputies who subsequently participated in, or helped with, life-saving efforts. The Monitor, the Mental Health Subject Matter Expert, and one of the clinicians reviewed the report and concluded that it meets the requirements in the ten subparts of paragraph 76(c). As noted by the Mental Health Subject Matter Expert, the reports "are generally thorough and [the County] is clearly taking the process seriously."

On July 17, 2017, the County submitted to the monitor a Semi-Annual Summary Report for Apparent or Suspected Suicides during the Fourth Reporting Period that summarizes the discussions at each of the required death reviews for the two suicides that occurred in the Fourth Reporting Period and the resulting corrective action plans.

The Mental Health Subject Matter Expert and the clinicians evaluated all deaths in the jails during the Fourth Reporting Period "to determine whether apparent and suspected suicides were being reliably detected" and whether "there is a clear and bona fide documented effort to cleave to the terms of [Paragraph] 76." They "found that the county reliably detected all apparent and suspected suicides." They also noted that "the County would benefit greatly by greater integration of medical, mental health, and custody input in these complex cases that touch on elements of the function of each."

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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
On July 17, 2017, the County submitted a Semi-Annual Report of CCSB Activities during the Fourth Reporting Period. The report summarizes each of the Suicide Reviews and CIRC reviews of serious suicide attempts during the Fourth Reporting Period, listing the issues raised and corrective actions considered. It includes sections on each of the subparts of Paragraph 77. The section on "Patterns and trends and statistical analysis of suicides and serious suicide attempts in the jails" reports on crosssectional data during this most recent reporting period, but it does not include any trend or statistical analysis of changes over time. The section on "Analysis of staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts" notes when a classification issue was identified during a CIRC meeting and an Administrative Investigation was opened. Other than concluding that "staffing levels had no bearing" on the incidents, even though there were 29 mental health staffing vacancies as of June 15, 2017, it does not analyze the impact of any of these other issues on these incidents.
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of June 1, 2016, through May 31, 2017)
Section 4.13 of DMH 70.7, effective July 7, 2016, requires DMH and LASD to “maintain a county-level Suicide Prevention Advisory Committee” open to representatives of the entities identified in Paragraph 78. A fourth meeting of the Suicide Prevention Advisory Committee was held on May 18, 2017, which the Monitor attended.
Substantial Compliance requires (1) the Committee to meet twice per year and (2) “recommend coordinated approaches to suicide prevention in the Jails.” At the fourth meeting of the Suicide Prevention Advisory Committee, Dr. Tim Belavich from DHSCHS discussed various initiatives to address systems issues and coordinated approaches to suicide prevention in the jails. This was a comprehensive meeting and there was significant input from other members of the Committee. As with the meetings on May 11, 2016, and November 10, 2016, this meeting achieved the objectives of Paragraph 78.
The County has maintained Substantial Compliance with paragraph 78 for twelve consecutive months, and this provision is no longer subject to monitoring.
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; provide a description of the medication support services available for prisoners who are not in mental health housing and who are receiving psychotropic medications; and randomly select and review electronic medical records of prisoners who reside outside of mental health housing and receive psychotropic medications to confirm that medication support services were provided to these prisoners.
The County’s Fourth Self-Assessment reports that in the fourth quarter of 2016, 82% of the prisoners who reside outside of mental health housing and were receiving psychotropic medications were “provided medication support services,” which is below the 85% threshold required by Compliance Measure 79.5(d) for Substantial Compliance. For the first quarter of 2017, 76% of such prisoners were provided the support services. The Mental Health Subject Matter Expert observes that on this requirement, "the County is doing fairly well," and found that "80% were getting sound support services.
The County's Fourth Self-Assessment does not address Compliance Measures 79.1(a)-(c) and 70.5(b), which require the County to maintain records of "therapeutically appropriate" visits and programming by QMHPs. Further, it does not indicate how often the medication support services are provided to the patients in the sample.
As noted in the Monitor's Third Report, a finding of Substantial Compliance with Paragraph 79(a) is, subject to a determination by the Monitor, after consultation with the
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Subject Matter Expert, “that the treatments are clinically appropriate.” The Mental Health Subject Matter Expert notes that the provision requiring "therapeutically appropriate" treatment to inmates in HOH and MOH units "is not ripe for several reasons. The County is not yet conducting treatment according to a treatment plan and is rarely offering structured treatment . . . . Until the County is able to render structured treatment based on sound treatment methods according to a treatment plan, it will not be possible to meet the treatment components of the agreement."
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business workday. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

NON-COMPLIANCE

Paragraph 80 requires that 100% of the prisoners in HOH receive "ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week" "no later than 18 months after the Effective Date [July 1, 2015]." The parties have agreed that up to five hours of the structured time can consist of education or work programs, but at least five hours of the time must be therapeutic.

The County's Augmented Fourth Self-Assessment reports that "72.6% combined for CRDF and TTCF – rather than the required 100% -- of prisoners residing in HOH were offered the required out-of-cell time by Custody staff" and that "17.2% -- rather than the required 100% -- of prisoners residing in HOH were offered the required out-ofcell time by DMH staff." The Mental Health Subject Matter Expert continues "to have serious concerns about how the County is tracking out of cell time" because it counts as out-of-cell time "large numbers of hours when the inmate was not in fact out of his or her cell," categorizing it as "refused/ineligible." While there may be exceptional circumstances in which an inmate cannot be taken out of his or her cell without jeopardizing the safety of staff or other inmates, this should not be a routine justification for not providing the actual out-of-cell time required by Paragraph 80. The County is also counting time to court as unstructured recreational time, which is not appropriate.

The Department's Response to Monitor's Draft Conclusion (80) reports that "the County is working to identify new technology that will assist with compliance with this Provision" so that time to court will not be counted as unstructured recreational time.

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81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
Policies approved by the Rosas Monitors and adopted by the Department in the First Reporting Period implemented the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
In the Second Reporting Period, the Rosas Monitors approved policies to implement the following provisions of the Rosas Implementation Plan: Paragraphs 6.16.20 (grievance system); Paragraph 8.2 (combining “Complaints of Retaliation”). They also approved revised policies to implement Paragraphs 13.1-13.2 (discipline for PREA violations, dishonesty, and failure to report force incidents).
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 of the Rosas Implementation Plan reflect training requirements that were supposed to be, but were not, completed by December 31, 2016. This is due in part to the delays that have occurred in the review and approval of the Department's use of force and investigations training program. The Monitor does not believe that it is essential for the training to have been completed by the end of 2016 as long as the Department continues to meet the required thresholds for new deputies until it achieves the thresholds for existing deputies. At that time, virtually all of the personnel in the jails will have received the required training in either the Jail Operations Continuum or in-service training.
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Paragraphs 4.10 and 9.1 are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Finally, the Early Warning System to implement Paragraphs 19.1-19.3 will be completed in future reporting periods.
In the Fourth Reporting Period, the Monitor reviewed 18 randomly selected completed force packages for CRDF, NCCF, and PDC North, most of which were also reviewed by the Use of Force Subject Matter Expert. The Monitor concluded that the Department is complying with its policies regarding the use of force and documentation of force incidents at these facilities, and that the force investigations are thorough and complete. The Use of Force Subject Matter Expert concurs with this conclusion. As expressed by the Use of Force Subject Matter Expert, "the reports and packages are complete and comprehensive. Reviewing supervisors conduct critical analysis of the force incidents[.]"
With one exception, the Monitor and Use of Force Subject Matter Expert did not find any significant issues with either the force incidents or the force investigations in the force packages they reviewed. In one case, Custody personnel were dealing with a very abusive, hostile, and uncooperative inmate over an extended period of time late at night and in the early morning hours at CRDF. The staff made extensive efforts to gain the inmate's cooperation, when the inmate made a sudden move forward, the supervising sergeant ordered her to be sprayed even though the inmate was chained to the chair. Further, the sergeant who directed the use of force also conducted the force investigation in violation of Department policy. It was of concern that this violation was not noted by the commanders who reviewed the incident.
The Monitor and Use of Force Subject Matter Expert both noted that there is a significant time lag in completing force packages. During the Forth Reporting Period in the first six months of 2017, they were reviewing force incidents from the second and third quarters of 2016. This time lag should be addressed in the next reporting period by expediting the completion of force packages for force incidents beginning January 1, 2017.
The Monitor and Use of Force Subject Matter Expert were often unable to determine from the force packages whether the Department was in compliance with the provisions of the Rosas Implementation Plan relating to the timeliness of the use of force reports by Custody staff and where inmates are asked to be interviewed. These issues can be addressed by adding the time that the reports are prepared by the reporting deputy and issuing a directive that inmates are not to be asked whether they are willing to be interviewed when they are in the vicinity of other inmates.
All of the force incidents at CRDF and North reviewed by the Monitor and Subject Matter Expert were captured on fixed closed circuit television cameras at CRDF and North. Some parts of some force incidents at NCCF were captured with a handheld
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camera after the incident started. The Monitor strongly urges the Department to complete the installation of closed circuit television cameras at NCCF. Based upon numerous reviews of force packages at all of the facilities in the Los Angeles County jail system,33 it is apparent that the cameras significantly reduce the level of force used and enhance the quality of the investigations. Although the Department has until July 1, 2018, under the Paragraph 83 of the Settlement to install the cameras at NCCF, the Monitor urges the County to complete the installation as soon as possible.
During the Fourth Reporting Period, the Monitor met with the Inmate Grievance Teams at CRDF, NCCF, and PDC North (which also handles the grievances at PDC South). The teams at CRDF and NCCF have significantly improved their tracking of grievances at both facilities, but many grievances still take too long to resolve. The teams should be more proactive in identifying overdue grievances in the tracking systems and following-up with sergeants responsible for investigating these grievances. There are relatively few grievances at PDC North and South, and the Grievance Team does a good job monitoring the handling of those grievances.
The Monitor also met with the Division Inmate Grievance Coordinator who has oversight responsibility for the implementation of the new grievance system to discuss improvements to the tracking system that are being implemented throughout the Custody division. The Monitor anticipates continued improvement in the tracking of inmate grievances and that grievances will be handled more expeditiously in future reporting periods.
33 The Monitor also has reviewed numerous force packages at MCJ, IRC, and TTCF in his role as one of the three monitors in the Rosas case.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 15, 2016, through June 30, 2017)
The Rosas Monitors have approved a de-centralized inmate grievance system, which includes an Inmate Grievance Team co-located at Century Regional Detention Facility. The Department published its new grievance policies on July 15, 2016.
Under CDM 8-01/020.00 RESPONSIBILITIES, the Inmate Grievance Team is comprised of “a supervising deputy, a custody assistant and/or other appropriate professional staff” under the supervision of “at least one sworn supervisor of the minimum rank of sergeant who will serve as the Unit Inmate Grievance Coordinator and report to the Division Inmate Grievance Coordinator.”
CRDF has its own Inmate Grievance Team with the staffing required by CDM 801.020.00. The Monitor met with CRDF's Inmate Grievance Team during the Fourth Reporting Period and reviewed the operation of the grievance system at CRDF. As noted above, the team has a good system in place to track the status of inmate grievances, but should be more proactive in following up with investigative sergeants to complete overdue investigations.
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83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement (“Common Areas”), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.
STATUS: SUBSTANTIAL COMPLIANCE (as July 1, 2015, through June 30, 2016 at MCJ and IRC)
SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at TTCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31 2017, at CRDF)
NOT CURRENTLY SUBJECT TO MONITORING (REMAINING FACILITIES)
The Monitor and Subject Matter Experts toured TTCF, MCJ, IRC, and CRDF during the Fourth Reporting Period, and the Monitor confirmed that the closed circuit security cameras were operational in the Common Areas in these facilities. All or almost all of the cameras were operational at TTCF, IRC, and CRDF. At MCJ, 23 of the 885 cameras were off-line on the day of the tour, and another 18 needed adjustments or clearing. Although this was significantly more than at the other facilities, over 95% of the cameras were fully operational at MCJ.
The Monitor has previously verified that the County has maintained Substantial Compliance for twelve consecutive months with Compliance Measure 83.8(a) at MCJ, IRC, and TTCF by reviewing videos of force incidents in common areas to verify the accuracy of information on inventories provided by the Department. During the Fourth Reporting Period, the Monitor has verified that the County also maintained Substantial Compliance with this requirement at CRDF through March 31, 2017.
Paragraph 83 also requires the Department to provide evidence that all video recordings of force incidents were adequately stored and retained for a period of at least one year after the force incident occurs. The County's Fourth Self-Assessment reports that it has achieved Substantial Compliance for this measure at CRDF, IRC, MCJ and TTCF through the first quarter of 2017. This requirement of Paragraph 83 is still subject
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to monitoring at MCJ and IRC until June 30, 2017;34 at TTCF until September 30, 2017; and at CRDF until March 31, 2018. The Augmented Fourth Self-Assessment reports that it has maintained Substantial Compliance with this requirement in the second quarter of 2017 at CRDF, but there are no results for MCJ, IRC or TTCF.
34 The Monitor agrees that if the Department maintains Substantial Compliance at MCJ and IRC through the second quarter of 2017, this provision is no longer subject to monitoring at these facilities.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:
(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and
(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through March 31, 2017 (unverified))
Substantial Compliance under the Compliance Measures requires the Department to demonstrate that 95% of the investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies. Although Paragraph 84 requires the Department to implement policies for the "timely and thorough" investigation of force incidents, the subparagraphs and the Compliance Measures are focused on the timeliness of the completion of the investigations resulting in the imposition of discipline. The Monitor's determination of the Department's compliance with Paragraph 84 will be largely based upon the timeliness of the completion of the investigations, but the Monitor also has randomly selected and reviewed several internal investigations, which appeared to be very thorough and unbiased.
The County’s Fourth Self-Assessment reports that after having achieved Substantial Compliance in the first quarter of 2016, the Department did not achieve Substantial Compliance in the second quarter of 2016. This requires that the twelvemonth period for maintaining Substantial Compliance to start over with the next reporting period for which the Department achieved Substantial Compliance, which was the third quarter of 2016. The Self-Assessment reports that the Department has maintained Substantial Compliance from July 1, 2016, through March 31, 2017. These results are subject to verification by the Monitor's auditors.
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85. The County and the Sheriff will ensure that Internal Affairs Bureau management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training. The County's posted results show that 57.6% of the IAB investigators completed all three of the required courses as of March 31, 2017.
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86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 at MCJ and CRDF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through June 30, 2017 at PDC North)
SUBSTANTIAL COMPLIANCE (as of February 1, 2017, through June 30, 2017 at PDC South and PDC East)
SUBSTANTIAL COMPLIANCE (as of March 1, 2017 through June 30, 2017 at NCCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through June 30, 2017 at IRC)
NON-COMPLIANCE (at TTCF)
CDM 7-08/080 ACCOUNTABILITY OF SPECIALWEAPONS, effective October 14, 2016, requires each facility to have unit orders that “establish procedures for the storage, issuance, reissuance, accountability, maintenance, and periodic inventory of all weapons. . . stored at, or issued from, the facility,” which includes detailed requirements for the “Inventory, Control, and Accountability of Aerosol Chemical Agents.”
In addition to providing written policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment, Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with up-to-date Unit Orders for each jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons.
The Monitor and Use of Force Subject Matter Expert inspected the armory of each jail facility at PDC North, PDC South, PDC East, MCJ NCCF, and TTCCF on February 7 and 8, 2017, and again (including IRC, but not PDC East) on May 31 and June 1, 2017. On June 8, 2017, the Monitor inspected the armory at CRDF. All of these armories are well-organized and the weapons and ammunition are easy to locate and to inventory.
The inventory logs were checked daily in the MCJ, CRDF, IRC, and PDC North
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armories, weekly in the PDC South armory and regularly in the PDC East armory. 35 Each facility has reasonably up-to-date unit orders and all weapons were accounted for during recent inspections, with one exception at CRDF, where some weapons had been taken out of the armory for a training exercise, but not noted on a daily log.36 The Department submitted the required armory audit logs for all of the facilities for the first quarter of 2017.
The main armory at NCCF is checked daily and, except for one discrepancy (a deputy forgot to note on the inventory log that a Taser had been checked out) the inventories for the sub-armories matched the weapons in the sub-armories. In addition, a new unit order was effective on September 7, 2016.
The Monitor and Use of Force Subject Matter Expert noted significant problems with the armory at TTCF. They reviewed the inventory in the main armory during the am shift on their most recent visit, but it reflected that the same deputy had checked the armory on both the am shift and the pm shift that had not yet started. Further, there were some days when the armory was not checked during certain shifts (mostly early morning). They also observed that it was difficult to match weapons and inventories in the sub-armories. On a positive, note, the Unit Order for TTCF was revised at the end of the last reporting period.
35 Because PDC East is a fire camp with very few inmates, weapons in the armory are almost never used. 36 The supervisor in charge of the armory knew where the weapons were and the Monitor does not believe that this discrepancy takes CRDF out of Substantial Compliance.
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APPENDIX

NO. PROVISION

STATUS

18 Suicide Prevention Training Partial Compliance

19 Crisis Intervention &

Partial Compliance

Conflict Resolution Training

20 Training at NCCF, PDC and Not Currently Subject to

CRDF

Monitoring

21 CPR Certification

Substantial Compliance (NCCF, PDC East, North & South, CRDF, TTCF, IRC, & MCJ)

22 Use of Arresting and Booking Documents

Substantial Compliance

23 Suicide Hazard Mitigation Plans

Partial Compliance

24 Suicide Hazard Inspection Partial Compliance

25 Transportation of Suicidal Inmates

Non-Compliance

26 Identification and Evaluation Partial Compliance of Suicidal Inmates

27 Screening for Mental Health Partial Compliance Care and Suicide Risk

SUBSTANTIAL COMPLIANCE DATES
(10/1/15 – 9/30/16 PDC East, and South)1 (1/1/16 – 12/31/16 NCCF, PDC North, and IRC) (4/1/16 – 3/31/17 TTCF) (4/1/16 – 3/31/17 CRDF) (7/1/16 – 3/31/17) (MCJ) (7/1/16 – 6/30/17)

1 Substantial Compliance Dates in bold reflect that the Department has achieved Substantial Compliance for twelve consecutive months, the results were verified by the Monitor's auditors when required, and the County or designated facilities are no longer subject to monitoring of this provision pursuant to paragraph 111 of the Settlement agreement.

Case 2:15-cv-05903-DDP-JEM Document 131 Filed 09/01/17 Page 103 of 107 Page ID #:2828
APPENDIX

28 Expedited Booking of Suicidal Inmates

Partial Compliance

29 Mental Health Assessments Partial Compliance

30 Initial Treatment Plans

Substantial Compliance

31 Electronic Medical Records Partial Compliance Alerts

32 Electronic Medical Records Substantial Compliance – Suicide Attempts

33 Supervisor Reviews of

Substantial Compliance

Electronic Medical Records

34 Discharge Planning

Stayed Pending Litigation

35 Referral for Mental Health Care

Non-Compliance

36 Assessments After Triggering Events

Partial Compliance

37 Court Services Division Referrals

Non-Compliance

38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

39 Confidential Self-Referral Partial Compliance

40 Availability of QMHPs

Partial Compliance

41 FIP Step-Down Protocols Partial Compliance

42 HOH Step-Down Protocols Partial Compliance (CRDF) Non-Compliances (TTCF)

43 Disciplinary Policies

Partial Compliance

44 Protective Barriers

Substantial Compliance

(1/1/17 – 3/31/17) (1/1/16 – 12/31/16) (7/1/16 – 3/31/17)
(1/1/16 – 12/31/16)
(1/1/16 – 12/31/16)

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APPENDIX

45 Suicide Intervention and First Aid Kits

Substantial Compliance

46 Interruption of Self-Injurious Partial Compliance Behavior

47 Staffing Requirements

Partial Compliance

48 Housekeeping and Sanitation Substantial Compliance

49 Maintenance Plans

Substantial Compliance

(10/1/15 – 9/30/16 CRDF, NCCF, TTCF, PDC East & PDC South) (1/1/16 -- 12/31/16 MCJ & PDC North)
(1/1/16 – 12/31/16) (3/1/16 – 2/28/17)

50 Pest Control
51 Personal Care & Supplies
52 HOH Property Restrictions 53 Eligibility for Education,
Work and Programs 54 Privileges and Programs 55 Staff Meetings
56 Changes in Housing Assignments

Substantial Compliance
Substantial Compliance
Partial Compliance Partial Compliance Substantial Compliance Substantial Compliance (at CRDF, TTCF, PDC North, and MCJ) Substantial Compliance

(1/1/16 – 12/31//16 MCJ, NCCF, PDC North, TTCF, CRDF) (4/1/16 – 3/31/17 PDC South & East)
(1/1/16 – 6/ 30/16 all facilities other than CRDF) (7/1/16-6/30/17 CRDF)
(1/1/16 – 12/31/16)
(10/1/16 – 6/30/17 CRDF & TTCF) (4/1/17—6/30/17 MCJ and PDC North)
(1/1/16 – 12/31/16)

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APPENDIX

57 Inmate Safety Checks in Mental Housing

Substantial Compliance (at MCJ and PDC North) Partial Compliance (TTCF and CRDF)

(1/1/17 – 3/31/17 MCF & PDC North)

58 Inmate Safety Checks in Non-Mental Housing
59 Supervisor Rounds
60 Implementation of Quality Improvement Program
61 Requirements of Quality Improvement Program
62 Tracking of Corrective Action Plans
63 Sufficient HOH and MOH Housing
64 Plans for Availability of Inpatient Health Care
65 Administration of Psychotropic Medication
66 Active Mental Health Caseloads
67 Prisoner Refusals of Medication

Substantial Compliance (at PDC South, North and East) Partial Compliance (at TTCF, CRDF, IRC, MCJ and NCCF)

(1/1/16 – 12/31/16 PDC South, North) (1/1/16 – 12/31/16 PDC East)

Substantial Compliance (at PDC North, East, and South, and MCJ) Partial Compliance (at CRDF, TTCF, and NCCF)

(1/1/17 – 3/31/17 PDC North, East, and South, and MCJ

Partial Compliance

Non-Compliance

Partial Compliance

Non-Compliance

Partial Compliance

Non-Compliance

Non-Compliance

Non-Compliance

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APPENDIX

68 Contraband Searches 69 Clinical Restraints in CTC

Substantial Compliance (at MCJ; NCCF; PDC East, South and North; CRDF; and TTCF)

(1/1/16 – 12/31/16 MCJ, NCCF, PDC East, South and North) (10/1/16 – 6/30/17 CRDF) 1/17/17 – 6/30/17 at TTCF)

Partial Compliance

70 Security Restraints in HOH Substantial Compliance and MOH

71 Therapeutic Services for

Substantial Compliance

Inmates in Clinical Restraints

72 Administrative Reviews

Substantial Compliance

73 Reporting of Self-Injurious Partial Compliance Behavior and Threats

74 Law Enforcement Investigations of Suicides

Substantial Compliance

75 Management Reviews of Suicide Attempts

Partial Compliance

76 Management Reviews of Suicides

Substantial Compliance

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Substantial Compliance Committee

79 Therapeutic Services in Mental Health Housing

Non-Compliance

80 Out-of-Cell Time in HOH Non-Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

(9/1/16 – 6/30/17) (7/1/16 – 3/31/17) (1/1/17 – 6/30/17) (9/1/16 – 6/30/17)
(9/1/16 – 6/30/17)
(6/1/16 – 5/31/17)

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APPENDIX

82 Collection of Grievances at Substantial Compliance CRDF

(7/15/16 – 6/30/17)

83 Closed Circuit Cameras
84 Investigation of Staff Misconduct

Substantial Compliance (MCJ, TTCF, IRC, and CRDF) Not Currently Subject to Monitoring (Remaining Facilities)
Substantial Compliance

(7/1/15 – 6/30/16 MCJ & IRC)2 (10/1/15 – 9/30/16 TTCF) (4/1/16 – 3/31/17 at CRDF) (7/1/16 – 3/31/17)

85 Internal Affairs Bureau Training

Partial Compliance

86 Maintenance and Inventory Substantial Compliance (at MCJ, (4/1/16 – 3/31/17

of Security Equipment

CRDF, PDC North, PDC South MCJ and CRDF)

PDC East, NCCF, and IRC)

(10/1/16 – 6/30/17

Non Compliance (at TTCF)

PDC North)

(2/1/17 – 6/30/17

PDC South and East)

(3/1/17 – 6/30/17

NCCF)

(4/1/17 – 6/30/17

IRC)

2 Paragraph 83 also requires the Department to maintain video recording of force incidents for at least one year. This requirement is still subject to monitoring at MCJ and IRC until 6/30/17 and at TTCF until 9/30/17.

 
 Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 1 of 111 Page ID #:2843

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) rdrooyan@scheperkim.com

3 601 West Fifth Street, 12th Floor

4

Los Angeles, CA 90071-2025 Telephone: (213) 613-4655

5 Facsimile: (213) 613-4656

6 Email: rdrooyan@scheperkim.com

7 Monitor

8

9

UNITED STATES DISTRICT COURT

10

CENTRAL DISTRICT OF CALIFORNIA

11

WESTERN DIVISION

12

13 UNITED STATES OF AMERICA,

14

Plaintiff,

15 v.
16

17

COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF

18

JIM MCDONNELL, in his Official Capacity,

19

Defendants.

20

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR’S FIFTH REPORT

21

22

23

24

25

26

27

28

MONITOR'S FIFTH REPORT

CASE NO. 15-cv-05903 DDP (JEMx)

Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 2 of 111 Page ID #:2844

1

Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and the

4 Los Angeles County Sheriff during the six-month period from June 30, 2017, to

5 December 31, 2017, “to implement the Agreement and evaluating the extent to

6 which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

12

13 DATED: March 1, 2018

Respectfully submitted,

14

SCHEPER KIM & HARRIS LLP

15

RICHARD E. DROOYAN

16

17

18

By: /s/ Richard E. Drooyan Richard E. Drooyan

19

Monitor

20

21

22

23

24

25

26

27

28

- 1 -

CASE NO. 15-cv-05903 DDP (JEMx)

MONITOR’S FIFTH REPORT

Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 3 of 111 Page ID #:2845
MONITOR’S FIFTH REPORT
This Fifth Report sets forth the Monitor’s assessments of the implementation of the Settlement Agreement (the "Agreement") between the County of Los Angeles (the "County") and the United States Department of Justice ("DOJ") for the treatment of mentally ill inmates in the County’s jail facilities by the Los Angeles Sheriff’s Department (the "Department") and the County's Department of Health Services ("DHS").1 It covers the County's reported results for the period from July 1, 2017, through December 31, 2017 (the "Fifth Reporting Period").
As used herein, "Substantial Compliance" means that the County has "achieved compliance with the material components of the relevant provisions of this Agreement in accordance with the [agreed-upon Compliance Measures for assessing Substantial Compliance]," which it must maintain for twelve-consecutive months; "Partial Compliance" means that the County has achieved "compliance on some, but not all, of the material components of the relevant provision of this Agreement;" and "NonCompliance" means that the County has not met "most or all of the material components of the relevant provisions of this Agreement."
This Fifth Report is based upon the Monitor's review of the policies, procedures, and directives proposed and/or implemented by the Department and DHS in the Fifth Reporting Period; assessments and observations of the Subject Matter Experts; multiple tours of the jails by the Monitor and the Subject Matter Experts; the County’s SelfAssessment Status Report (the "Fifth Self-Assessment"), which was received on December 15, 2017; and the augmented Self-Assessment Status Report (the "augmented Fifth Self-Assessment"), which was received on January 17, 2018. It also takes into consideration the comments the Monitor received from the County and DOJ on the draft of this Report that was submitted to the parties on February 1, 2018.
During the Fifth Reporting Period, the Mental Health Subject Matter Expert, with the assistance of two clinicians retained by the Monitor, conducted additional qualitative assessments of the County's compliance with certain Substantive Provisions in the Settlement Agreement, and they again used different methodologies to test some of the County's reported results. The Monitor's determination of the County's compliance, with the advice of the Subject Matter Expert, is based upon the quantitative thresholds in the Compliance Measures (and any other applicable requirements in the Compliance Measures), unless the quality of the County's performance as determined by the qualitative assessment is plainly inadequate or the results reported by Subject Matter Expert vary significantly from the results reported by the Department.
During the Fifth Reporting period, the County established compliance with additional provisions of the Settlement Agreement, and made progress in addressing the significant challenges to achieving and maintaining Substantial Compliance with respect to quality improvement plans, therapeutic services, and out-of-cell time.
1 The Department of Health Services includes Correctional Health Services ("CHS"), which is responsible for Mental Health Services in the Los Angeles County jails.
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As in prior reports, this Fifth Report reflects the results of audits by the Monitor's auditors to verify results reported by the County. The Monitor has deemed the County to be in Substantial Compliance "as of" the beginning of the quarter reported by the County if the auditors have verified that the County has met the thresholds in the Compliance Measures. If the auditors were not able to verify the results reported by the County, the twelve-month period for maintaining Substantial Compliance will commence in a future period when the County's reported results are verified by the auditors. If the County maintains Substantial Compliance with a provision for twelve consecutive months, pursuant to Paragraph 111 of the Agreement, the Monitor and Subject Matter Experts will "no longer. . .assess or report on that provision" in future reporting periods.
Some of the Substantial Compliance results reported by the County in the Fifth Reporting Period have not been audited by the Monitor’s auditors and cannot be considered final until verified by the auditors. The County will not be deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the twelve-month compliance period if the results are not verified by the auditors.
Appendix A to this Fifth Report shows the status of each of the 69 provisions of the Agreement that are subject to monitoring and the twelve-month triggering dates where the County is deemed to be in Substantial Compliance. Appendix B shows the County's progress from the Initial Reporting Period through the Fifth Reporting Period in achieving Substantial Compliance and in maintaining Substantial Compliance for twelve consecutive months on provisions that are no longer subject to monitoring.
As has been the case since the beginning of the Initial Reporting Period, the County cooperated completely with the Monitor and the Subject Matter Experts during the Fifth Reporting Period. The Department, DHS, and County Counsel facilitated our visits and inmate interviews, answered our questions, and responded to our requests for documents and information. We appreciate their responsiveness, transparency, professionalism, and courtesy in handling our monitoring requests.
Richard Drooyan, Monitor March 1, 2018
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EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the County and the Department are in Substantial Compliance with 23 provisions, in Partial Compliance with 24 provisions, and in Non-Compliance with 7 provisions. In addition, there are ten provisions in which the Department is in Substantial Compliance at some facilities and in Partial Compliance or Non-Compliance at other facilities, and two provisions in which the Department is in Partial Compliance at some facilities and in Non-Compliance at other facilities. There is also one provision (Paragraph 34), that remains stayed pending litigation initiated by third party intervenors, one provision (Paragraph 41) that is Not Rated, and one provision (Paragraph 83) for which the Department is in Substantial Compliance at certain facilities and not currently subject to monitoring at other facilities. There are 34 provisions for which the County and the Department are in Substantial Compliance at some or all of the facilities.2
There are 15 provisions that are no longer subject to monitoring because the County and Department maintained Substantial Compliance for twelve consecutive months as required by Paragraph 111 of the Settlement Agreement. There are another five provisions for which some facilities are no longer subject to monitoring because those facilities maintained Substantial Compliance for the twelve consecutive months.3
As of the date of this Report, and subject to verification by the Monitor's auditors and qualitative assessments in some cases, the County and the Department are in Substantial Compliance at some or all of the facilities with the following provisions of the Settlement Agreement:
The County has provided documentation reflecting that the County has achieved Substantial Compliance at Men's Central Jail ("MCJ") and Pitchess Detention Center ("PDC") South as of October 1, 2017, at North County Correctional Facility ("NCCF") as of September 1, 2017, and at PDC East as of December 1, 2017 with Paragraph 18, which requires the training of Deputy Sheriffs and Custody Assistants on suicide prevention. The results are subject to verification by the Monitor's auditors.
The County has achieved Substantial Compliance at PDC East, PDC North, and NCCF as of August 1, 2017 and at PDC South as of October 1, 2017,with Paragraph 20, which requires the training of Deputy Sheriffs on Crisis Intervention and Conflict Resolution and on working with mentally ill prisoners. The County also has provided documentation reflecting that the County has achieved Substantial Compliance with Paragraph 20 as of August 1, 2017, at Century Regional Detention Facility ("CRDF").
2 Under Paragraph 111 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis. 3 The provisions that are no longer subject to monitoring at some are all of the facilities are highlighted in bold in Appendix A.
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The County has maintained Substantial Compliance for twelve consecutive months at PDC East, PDC South, PDC North, NCCF, the Inmate Reception Center ("IRC"), and Twin Towers Correctional Facility ("TTCF") with Paragraph 21, which requires Custody personnel to maintain CPR certifications. The County also has maintained Substantial Compliance for nine consecutive months at MCJ.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 22, which requires the County and the Sheriff to provide instructional material on the use of arresting and booking documents to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.
The County has achieved Substantial Compliance as of January 1, 2018, with Paragraph 23, which requires the Department conduct a systematic review of prisoner housing to reduce the risk of self-harm and to identify and address suicide hazards, and to develop plans to reasonably mitigate suicide hazards identified in the review.
The County has achieved Substantial Compliance as of October 1, 2017, with Paragraph 24, which requires the Department to conduct annual reviews and inspections of prisoner housing to identify suicide hazards.
The County has provided documentation reflecting that, as of April 1, 2017, through December 31, 2017, it achieved Substantial Compliance at IRC with Paragraph 28, which requires the Department to expedite inmates having urgent or emergent mental health needs through the booking process. The reported results are subject to verification by the Monitor’s auditors.
The County has provided documentation reflecting that, as of April 1, 2017, through December 31, 2017, it achieved Substantial Compliance with Paragraph 29, which requires mental health assessments of prisoners with non-emergent mental health needs within 24 hours of the intake nursing assessment. The reported results are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 32, which requires that a serious suicide attempt be entered in the prisoner’s electronic medical record in a timely manner.
The County has provided documentation reflecting that, as of July 1, 2016, through June 30, 2017, it achieved Substantial Compliance with Paragraph 33, which requires mental health supervisors to review electronic medical records on a quarterly basis to assess their accuracy. These results are subject to verification by the Monitor's auditors and a qualitative assessment by the Subject Matter Expert.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules to identify
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prisoners with mental illnesses and grant prisoner's requests for out-of-cell interviews.
The County has achieved Substantial Compliance as of April 1, 2017, through September 30, 2017, at PDC South with Paragraph 39, which requires the County to use a confidential self-referral system for prisoners to request mental health care. The County also has provided documentation reflecting that, as of July 1, 2017 through September 30, 2017, at PDC North, TTCF and NCCF, it achieved Substantial Compliance with Paragraph 39. The results are subject to verification by the Monitor's auditors and a qualitative assessment by the Subject Matter Expert.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 44, which requires the Department to install protective barriers in High Observation Housing and other mental health housing areas.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 45, which requires Suicide Prevention Kits and first-aid kits in control booths in all facilities.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 48, which requires the Department to have written housekeeping, sanitation, and inspection plans to ensure proper cleaning in accordance with California regulations.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 49, which requires the Department to have maintenance plans to respond to routine and emergency maintenance needs.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 50, which requires pest control in the jails.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 51, which requires the Department to ensure that all prisoners have access to basic hygiene supplies in accordance with state regulations.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 54, which requires the Department to ensure that prisoners not in mental health housing are "not denied privileges and programming based solely on their mental health status or prescription for psychotropic medication." Per agreement of the parties, the County is required to maintain Substantial Compliance under revised Compliance Measures for two additional quarters.
The County has provided documentation reflecting that it achieved Substantial Compliance as of October 1, 2016, through September 30, 2017, at CRDF with Paragraph 55, which requires custody, medical and mental health staff to meet daily in High Observation Housing and weekly in Moderate Observation Housing. The County also has provided documentation reflecting it achieved Substantial Compliance as of
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April 1, 2017, through September 30, 2017, at PDC North and MCJ with this paragraph. The reported results are subject to verification by the Monitor's auditors.
The County has provided documentation reflecting that it has maintained Substantial Compliance for twelve consecutive months with Paragraph 56, which requires custody, medical, and mental health staff to communicate regarding any change in a housing assignment following a suicide attempt or serious change in mental health condition. The reported results are subject to verification by the Monitor's auditors.
The County has maintained Substantial Compliance from July 1, 2017, through September 30, 2017, at MCJ with Paragraph 57, which requires safety checks in mental health housing.
The County has maintained Substantial Compliance for twelve consecutive months at PDC South, PDC North, and PDC East with Paragraph 58, which requires safety checks in non-mental health housing. The County also has maintained Substantial Compliance as of July 1, 2017 through September 30, 2017 at CRDF and TTCF with Paragraph 58.
The County has maintained Substantial Compliance from January 1, 2017, through September 30, 2017, at MCJ, PDC North, and PDC East, and from April 1, 2017 through September 30, 2017, at NCCF with Paragraph 59, which requires unannounced daily supervisory rounds to verify safety checks.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC North, and PDC South with Paragraph 68, which requires staggered contraband searches in housing units.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 71, which requires the County and the Sheriff to ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 72, which requires the Department to report on meetings to review suicides and incidents of serious self-injurious behavior. These results are subject to qualitative assessment by the Subject Matter Expert and clinicians.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 74, which requires the Department to have an objective law enforcement investigation of every suicide that occurs in the jails.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 76, which requires the Department to follow certain procedures whenever there is an apparent or suspected suicide.
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The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 78, which requires the Suicide Prevention Advisory Committee to meet twice a year.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 82, which requires the Department to co-locate personnel responsible for collecting prisoners' grievances at CRDF.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, IRC, TTCF, and CRDF with Paragraph 83, which requires it to install closed circuit security cameras throughout all of the common areas in the jails. Under the applicable Compliance Measures, the County needs to retain the videos from CRDF through March 31, 2018, to fully achieve Substantial Compliance at that facility.
The County has provided documentation showing that it has maintained Substantial Compliance as of July 1, 2017 through December 31, 2017, with Paragraph 84, which requires investigations of force incidents and administrative actions to be completed timely. The reported results are subject to verification by the Monitor's auditors.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, CRDF, and PDC North with Paragraph 86, which requires inventory policies and control of weapons. It has also maintained Substantial Compliance as of February 1, 2017, through December 31, 2017, at PDC South and PDC East, and as of March 1, 2017, through December 31, 2017 at NCCF, and as of April 1, 2017, through September 30, 2017, at IRC.
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18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016.
These trainings will include the following topics: (a) suicide prevention policies and procedures, including observation and
supervision of prisoners at risk for suicide or self-injurious behavior; (b) discussion of facility environments and staff interactions and why they
may contribute to suicidal behavior; (c) potential predisposing factors to suicide; (d) high-risk suicide periods and settings; (e) warning signs and symptoms of suicidal behavior; (f) case studies of recent suicides and serious suicide attempts; (g) emergency notification procedures; (h) mock demonstrations regarding the proper response to a suicide attempt,
including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance; (i) differentiating between suicidal and self-injurious behavior; and (j) the proper use of emergency equipment.
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STATUS (18):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (unverified) at MCJ and PDC South)

SUBSTANTIAL COMPLIANCE (as of September 1, 2017 (unverified) at NCCF)

SUBSTANTIAL COMPLIANCE (as of December 1, 2017 (unverified) at PDC East)

PARTIAL COMPLIANCE (at TTCF, CRDF, IRC, and PDC North)

The Monitor, in consultation with the Mental Health Subject Matter Expert, concluded in the First Reporting Period that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training ("DeVRT"), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015. On May 30, 2017, the Monitor, in consultation with the Subject Matter Expert, approved a revision to the two-hour course on suicide prevention for existing Deputy Sheriffs and Custody Assistants.

The County's Initial Self-Assessment Status Report delivered on December 14, 2015, reported that the Department commenced its suicide prevention training for new Deputy Sheriffs and Custody Assistants on July 1, 2015, and for existing Deputy Sheriffs and Custody Assistants before the Effective Date of the Settlement Agreement.

The County's Fifth Self-Assessment reports that "the Department has continuously provided the required training for new Deputies in the Jail Operations Continuum and new Custody Assistants in the Custody Assistants Academy" through September 30, 2017. It also reports that the Department achieved Substantial Compliance at MCJ, and PDC South as of October 1, 2017, at NCCF as of September 1, 2017,4 and Partial Compliance at the other facilities in the Third Quarter of 2017.5 The County's augmented Self-Assessment reports Substantial Compliance at PDC East as of November 1, 2017.6 These results are subject to verification by the Monitor's auditors.

4 This is the first day of the month after the Department reached the required 85% threshold. 5 The County's Self-Assessment reports Substantial Compliance at MCJ and PDC South as of September 2017 and at NCCF as of August 2017. The number of trained personnel in the posted Self-Assessment is, however, different than the numbers in the posted rosters for the course because, according to the County, "not all those on the posted rosters were assigned to the facilities after July 1, 2015." Further, there are different certification dates on different rosters, which the County indicates was "likely caused by miscommunications as to whether the 'date certified' or the date the course was taken was to be indicated." 6 All of the two-hour training of existing Deputy Sheriffs and Custody Assistants occurred after the revision of the suicide prevention course was approved by the Monitor on May 30, 2017.
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19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams ("JMET") at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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STATUS (19):

PARTIAL COMPLIANCE

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution training and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and paragraphs 4.6, 4.7 and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert and the Rosas Monitors approved the training materials developed by the Department for the DeVRT on March 4, 2016.

Substantial Compliance requires the County to show that 95% of the new deputies hired after July 1, 2015 and 85% of the existing deputies as of that date received the required DeVRT training. It also requires that 95% of the new Custody Assistants hired after that date and 85% of the existing Custody Assistants as of that date received the required training in working with mentally ill inmates.

The County's Fifth Self-Assessment reports that the Department achieved Substantial Compliance at all facilities for new Deputies and new Custody Assistants as of January 1, 2017 through June 30, 2017. The County's augmented Fifth SelfAssessment reports that the Department has continued to maintain Substantial Compliance at all facilities for new Deputies and new Custody Assistants through September 30, 2017. The Department trained 95% of the existing Deputy Sheriffs at TTCF by the end of the Third Quarter of 2017, but only 5% of the existing Custody Assistants. Similarly, the Department trained 100% of the existing deputies at IRC by the end of the Third Quarter, but only 2% of the existing Custody Assistants.

The Fifth Self-Assessment also reports that "effective October 1, 2017, the Department has completed its obligation under the Agreement as it relates to" existing Deputy Sheriffs in the Mental Housing Units at CRDF and existing Custody Assistants at CRDF "and is no longer subject to monitoring." Although the Department reached the 85% threshold for the training of "existing" deputies at CRDF in the Third Quarter of 2017, which has been verified by the Monitor's auditors, the results for Custody Assistants at CRDF were, as the County has acknowledged, based upon a misinterpretation of Paragraph 19(b). The 85% threshold for existing deputies at CRDF is based upon the number of deputies assigned to the Mental Health Units at CRDF as of July 1, 2015, but the threshold for existing Custody Assistants is based upon the total number of Custody Assistants assigned to any unit at CRDF as of July 1, 2015. The Department's posted results indicate that it is not counting Custody Assistants "who were not assigned to Mental Health Housing Units" at CRDF and, as a result, that there were no "Trainable CAs" at CRDF in the third quarter of 2017.7

7 The County did not report any results regarding the training of existing deputies or Custody Assistants assigned to MCJ or the Jail Mental Evaluation Teams ("JMET") at NCCF.
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20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

SUBSTANTIAL COMPLIANCE (as of August 1, 2017 (verified) at CRDF, PDC East, PDC North, and NCCF)

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (verified) at PDC South)

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the curriculum for the Department’s Deescalation and Verbal Resolution Training ("DeVRT"), which provides for 32 hours of Crisis Intervention and Conflict Resolution training that meets the requirements of Paragraph 20 of the Settlement Agreement.

Substantial Compliance requires that 85% of deputies at the designated facilities as of July 1, 2017, receive the required DeVRT training. The County reports that as of August 1, 2017, 85% of the deputies assigned to PDC East, 89% of the deputies assigned to PDC North, 85% of the deputies assigned to NCCF, and 91% of the deputies assigned to the non-mental housing units at CRDF, had received the required training, and as of October 1, 2017, 96% of the deputies assigned to PDC South had received the training. The results at CRDF, PDC East, PDC North, PDC South, and NCCF have been verified by the Monitor's auditors, and these facilities are no longer subject to monitoring.8

8 While the Department has achieved Substantial Compliance with the thresholds for the initial training of deputies at these facilities and Paragraph 20 is no longer subject to monitoring, the Monitor expects the Department to show that the Deputies have attended the required refresher courses through the duration of the Settlement Agreement.
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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at PDC East and South) SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at NCCF, PDC North and IRC) SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at TTCF) SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through December 31, 2017 (verified) at MCJ) NON-COMPLIANCE (at CRDF)9
The Compliance Measures provide that the Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required CPR and first aid certifications for 12 consecutive months.
Pursuant to paragraph 111 of the Settlement Agreement, PDC South, PDC East, PDC North, NCCF, IRC, and TTCF are no longer subject to monitoring for Substantial Compliance with Paragraph 21.
The County's Fifth Self-Assessment reports that the Department failed to achieve Substantial Compliance at MCJ in the Second Quarter of 2017 through August 2017, but achieved Substantial Compliance again in October 2017. These results have been verified by the Monitor's auditors.
9 The County's response to the Monitor's Draft Conclusions for Paragraph 21 withdrew "its conclusion of Substantial Compliance at CRDF for First Quarter of 2017."
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22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017)
The Justice Data Interface Controller ("JDIC") message the Department has been using since June 29, 2016, is sufficient to establish Substantial Compliance with Paragraph 22, and the County maintained Substantial Compliance for twelve consecutive through June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, the County was not subject to monitoring for Substantial Compliance with Paragraph 22 in the Fifth Reporting Period.
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23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2018)
The Monitor has verified, with the advice of the Subject Matter Expert, that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department reports that it inspected all of the housing units by January 14, 2016, and it has provided the Monitor with completed checklists documenting the inspections.
The County has modified and updated its Suicide Hazard Mitigation plan to address the comments of the Monitor and the Mental Health Subject Matter Expert. Although the plan addresses critical issues such as fixtures, parts of it consist of analysis or discussion rather than specific remedies with completion dates. Recognizing that the plan is not static, the Substantial Compliance finding in the Monitor's Third Report was subject to the caveat that the plan must be updated at least six weeks before the Fourth Report was due and again six weeks before the Fifth Report was due, showing the status and completion of items in the plan.
As noted in the Monitor's Fourth Report, the Department submitted an updated Suicide Hazard Mitigation Plan on July 17, 2017, but it was inadequate because the "Start Date" for uncompleted items is "To Be Determined;" the Department required input from the Mental Health Subject Matter Expert without indicating what information was needed; and several entries dated 3/16/17 state that the item "[r]equires funding and approval from Custody Admin, FPB, and FSB," without indicating whether anything has been done to obtain the funding.
The Department submitted the required updated Plan to the Monitor on January 18, 2018. This plan is significantly improved and, after consultation with the Mental Health Subject Matter Expert, the Monitor is of the opinion that the updated Plan satisfies the requirements of Paragraph 23. To maintain Substantial Compliance, the Department must submit an updated plan that satisfies the requirements of Paragraph 26 on or before the Monitor submits the draft of his Sixth Report.
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24. The County and the Sheriff will review and inspect housing areas on at least an annual basis to identify suicide hazards.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017) CDM 3-06/020.00 FACILITIES INSPECTIONS requires Custody Support Services (CSS) to "review and inspect housing areas on a least an annual basis to identify suicide hazards." The Monitor and Subject Matter reviewed a revised annual suicide hazard inspection tool that was submitted by the Department on December 13, 2016, and approved it with the caveat that, in order to achieve Substantial Compliance, the sample sizes of randomly selected cells must be large enough to ensure that the cells are representative of each housing type at a facility. Further, if a problem is found in the randomly selected cells, a complete inspection or remediation of the area or setting should then be conducted. An updated tool was submitted by the Department on February 9, 2017; it also was approved with the same caveats. The County's Fifth Self-Assessment reports that the Department has conducted an Annual Suicide Hazard Inspection at each of its jail facilities. The Monitor, after consultation with the Mental Health Subject Matter Expert, approves the sufficiency of these reports and is of the opinion that the County has achieved Substantial Compliance as of October 1, 2017. The Subject Matter Expert notes that the "inspections appear to be of high quality and scored objectively." The County will have maintained Substantial Compliance when it submits annual reports for each of its facilities for 2018 that are approved by the Monitor after consultation with the Mental Health Subject Matter Expert.
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: PARTIAL COMPLIANCE
The Proposed Revision of the Station Jail Manual10 requires that any arrestee who "displays obvious suicidal ideation or exhibits unusual behavior that clearly manifest[s] self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, such inmates . . . shall be under unobstructed visual observation or in a suicidal restraint location with safety checks every 15 minutes."
The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent to determine compliance with Paragraph 25 of the Agreement. The County’s Fifth Self-Assessment reports that 41% of the records reviewed for the Second Quarter of 2017, and 54.5% of the records reviewed for the Third Quarter of 2017 reflect the information required to establish Substantial Compliance with Paragraph 25. While short of the required 95%, this is an improvement over the two prior quarters, where the results were 23% and 26%.
On September 19, 2017, the Monitor visited five randomly selected station jails to observe where the inmates are housed pending transportation to IRC, CRDF, or a medical facility; to inspect for suicide hazards; and to interview Department personnel about the handling of suicidal inmates. The five station jails varied in size and configuration, which resulted in different procedures for housing and observing suicidal inmates. In two of the smaller jails, suicidal inmates are housed in booking cells near the entry to the jails with 15-minute safety checks by Department personnel. In one slightly larger jail, suicidal inmates are kept under unobstructed direct visual observation until they are transferred. In the two larger jails, suicidal inmates are housed in booking cells that are directly observed by the administrative Custody Assistant and are also subject to 15minute safety checks. Each of the facilities had closed circuit cameras in the booking cells, and each of the facilities that conducts 15-minute checks maintains a log of the checks. Custody personnel in each of the facilities were knowledgeable about the requirements of Paragraph 25. They all indicated that it is standard procedure to expedite the transfer of suicidal inmates to IRC, CRDF, or a medical facility. With one exception involving bunks in one facility, the Monitor did not see any apparent suicide hazards. In the one case, the Department was in the process of anchoring the bunks to the wall. Based upon these site visits, the Monitor is of the opinion that the Department has achieved Partial Compliance with Paragraph 25.
10 The County reports that the "proposed revision to the Station Jail Manual is expected to be published by or before the end of First Quarter 2018."
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to "review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of 100 randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC." Substantial Compliance requires that (1) 95% of the forms "include the required mental health information" and (2) 90% of the prisoners having urgent or emergent needs were "seen by a QMHP within four hours."
The County’s posted results for the one randomly selected week in the Second Quarter of 2017 reflect that 90% of the screening forms reviewed had the required mental health information, and 67% of the prisoners were seen by a QMHP within four hours.11 The posted results for the Third Quarter of 2017, reflect that 92% of the forms had the required information and 55% of the prisoners were seen within four hours.
As previously noted, the Mental Health Subject Matter Expert has expressed a concern that the County needs to ensure that all inmates who have mental health needs are evaluated in private by the QMHP. If this cannot be done in the clinic in IRC because of security concerns about an aggressive or agitated male inmate, he should be transferred immediately to the HOH intake area in TTCF and evaluated privately by a QMHP in that area. Similarly, if a female inmate cannot be privately evaluated in 1200 in CRDF, she should be transferred immediately to HOH and evaluated in that area.
11 The County's posted results state in a "Note to Monitor" that, for five of the 45 inmates with urgent or emergent mental health needs, "we are auditing ourselves as compliant due to the time-to-contact being minutes after the four hour requirement." There is, however, no grace period in either the Paragraph 26 or Compliance Measure 26-4(b). Further, in most of these cases, the evaluation was conducted more than just a few minutes after the inmate was "identified as having emergent or urgent mental health needs." For these reasons, only 55% -- rather than 67% -- of the inmates were seen by a QMHP within four hours in the Second Quarter of 2017.
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review the records of "randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC" to determine compliance with this provision. The County’s Fifth Self-Assessment reports that in the Second Quarter of 2017, Qualified Medical Personnel or trained custody staff filled out a Medical/Mental Health Screening Questionnaire for all of the 100 randomly selected prisoners within 12 hours of their arrivals in the jails, and that the required documents were available to QMHPs who assessed the 36 inmates identified as having mental health needs. In the Third Quarter of 2017, the required forms were filled out for all 100 of the prisoners within 12 hours and the required documentation was available to the QMHP's who assessed the 31 inmates identified as having mental health needs.12
In order to satisfy the requirements of Paragraph 27, inmates must be privately screened. The windows in the intake-triage area where the Medical/Mental Health Screening Questionnaire is administered at CRDF are not sufficiently private to satisfy this requirement. Inmates are often seated in close proximity to each other and Custody personnel take supplies from the closets behind the windows while inmates are at the windows. The lack of privacy also exists in IRC in the area where the questionnaire is administered for male inmates. The County's Fifth Self-Assessment reports that "the County has struggled to create a private location at IRC screenings" to address concerns expressed by the Monitor and Mental Health Subject Matter Expert. Although there is such a location at CRDF, the County has not demonstrated that it is being used to screen all female inmates booked into CRDF. The County reports that it "is currently working to consolidate the screening process during booking at both IRC and CRDF" and it "anticipates identifying a private screening area once the consolidation process is finalized. A pilot program is expected to begin in the Second Quarter 2018."
12 Qualitative assessment by the Mental Health Subject Matter Expert and the clinicians in the prior Reporting Period are consistent with the results reported by the County in the Fifth Reporting Period. They found "that 95% of the intake documentation was complete and available [and] 95% of routine cases were detected."
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28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.

STATUS:

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through September 30, 2017 (verified) and through December 31, 2017 (unverified) at IRC)

PARTIAL COMPLIANCE (at CRDF)

The Compliance Measures require the Department to review the records of randomly selected prisoners at CRDF and IRC who have urgent or emergent mental health needs to determine whether they were expedited through the booking process. The County’s Fifth Self-Assessment reports that for IRC for the Second, Third and Fourth Quarters of 2017 (at 86%, 85%, and 87%) are at or above the 85% threshold for expediting inmates through the booking process, and all inmates having urgent or emergent needs were under unobstructed visual observation and checked every 15 minutes during unannounced visits as required by Paragraph 28. The results at IRC for the Fourth Quarter 2017 are subject to verification by the Monitor's auditors.

The CRDF results for these quarters (77%, 37%, and 50%) are an improvement from the two prior quarters (40% and 16%), but still below the 85% threshold. During unannounced visits at CRDF all inmates having urgent/emergent needs were under unobstructed visual observation and checked every 15 minutes.

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29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through December 31, 2017 (unverified))
The Compliance Measures require the Department to review randomly selected records of the prisoners identified in the intake nursing assessment as having nonemergent mental health needs to determine if the Department completed mental health assessments for 85% of the prisoners within the required time periods.
The County’s Fifth Self-Assessment reports that in the Second Quarter of 2017 the Department completed mental health assessments for 86% of the inmates at CRDF and IRC within the required time periods, in the Third Quarter of 2017, it completed 90% of the assessments within the required time periods, and in the Fourth Quarter of 2017 it completed timely 93% of the assessments. These results are subject to verification by the Monitor's auditors.
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30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected initial mental health assessments and report on (1) the percentage of assessments that have (i) included an initial treatment plan that addresses housing recommendations and preliminary discharge information and (ii) identified any immediate issues and whether a more comprehensive evaluation was indicated; and (2) whether the housing recommendations were followed.
The County's Fifth Self-Assessment reports that 100% of the housing assignments reviewed in the Second Quarter of 2017 followed the housing recommendations in the initial treatment plans, which exceeds the 95% threshold for Substantial Compliance, but only 81% of the initial mental health assessments had the information required by Paragraph 30, which is below the 85% threshold for the initial assessment component. The Self-Assessment reports that 100% of housing assignments and 89% of the initial assessments complied with the requirements of Paragraph 30 in the Third Quarter of 2017, but the Monitor's auditors were unable to verify these results.13
The Mental Health Subject Matter Expert and the clinicians again evaluated "whether the determination of immediate issues [in random sample of mental health assessments] was reasonable in light of available information. . . [and] whether the initial treatment plan covered the elements required by existing County policy, which goes beyond the content of the formal compliance measure." They found that 83% of the cases "identified immediate issues," and that the determination of the immediate issues "was reasonable from a qualitative perspective" in 82% of the cases. The Subject Matter Expert reports that the "County has made substantial improvements to the initial mental health assessments. [The] qualitative assessments have shown [the County] to be near compliance percentages for the formal compliance measures except for discharge information."14 Based upon the qualitative assessment, the Monitor is of the view that the County has achieved Partial Compliance with Paragraph 30.
13 DOJ also expressed concerns that the source documents for some of the mental health assessments "the County reports as compliant do not contain the information required under [the] compliance measures[.]" 14 The Subject Matter Expert and clinicians also found that 68% of the cases had preliminary discharge information and 62% "met County policy requirements regarding discharge planning, a dramatic improvement from less than 10% on previous occasions." Discharge planning will eventually be addressed under Paragraph 34 of the Settlement Agreement.
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31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk;
(b) hoarding medications; and
(c) prior suicide attempts.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected electronic medical records for prisoners in certain at-risk groups to determine if the required mental health alerts are in 85% of the records reviewed, which is the threshold for Substantial Compliance, for prisoners who report suicidal thoughts during the intake process; were removed from risk precautions in the prior quarter; or were identified as hoarding medicine.
The County’s Fifth Self-Assessment reports that for TTCF, 76% of the records contained the required mental health alerts in the Second Quarter of 2017, and 95% for the records contained the alerts in the Third Quarter of 2017. In response to questions from the Monitor's auditors, the County reviewed the source documents and concluded that "it has only achieved partial compliance with regard to [Compliance Measure] 311(c) (hoarding) alerts due to issues identifying the entire hoarding population and a twomonth delay in entering one alert."15
For CRDF, the results were 78% for the Second Quarter of 2017 and 86% for the Third Quarter of 2017. Although the Third Quarter results at CRDF exceeded the 85% threshold, "no prisoners were identified as hoarders," and the County rated itself as "partially compliant" because of "on-going issues with defining and identifying hoarders."16
The County also reported results for MCJ, which had prisoners identified as hoarding medicine, where 50% of "the records reviewed contained the required mental health alerts[.]"
15 The Mental Health Subject Matter Expert observes that the measure "is difficult to verify, particularly the alerts for hoarding medicine," which are required by Paragraph 31(b), because the County's methodology "does not assure that hoarding detected by custody results in hoarding alerts." 16 The County reports that it is working to develop a "clear definition for 'hoarding,'" and a "more efficient system for nurses to report inmates who are prone to hoarding[.]"
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32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require that 95% of the electronic medical records of prisoners who had a serious suicide attempt reflect information regarding the attempt, and 85% of the records reflect that the information was entered into the record within one day of the attempt.
The County maintained Substantial Compliance with Paragraph 32 for twelve consecutive months as of December 31, 2016, and this provision was not subject to monitoring in the Fifth Reporting Period.
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33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:

(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;

(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;

(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and

(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.

STATUS:

SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (subject to verification and qualitative review))

The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected prisoners from each clinician’s caseload. The County has provided the required tool, and previously reported Substantial Compliance for the Third and Fourth Quarters of 2016, and the First Quarter of 2017.

The County's Augmented Fifth Self-Assessment reports "that 100% -- 15% more than the required 85% -- of the mental health supervisors complied with the requirements of this Provision for Second Quarter 2017."17 All of the results reported by the County in its Self-Assessments are subject to verification by the Monitor's auditors, which will include verifying that the supervisors' reviews of the clinicians include the content required by Paragraph 33(b). The Monitor has asked the Mental Health Subject Matter Expert to assess the quality of the reviews for compliance with the requirements of Paragraphs 33(b), (c), and (d).18

17 The County also reported the same results for the Third Quarter 2017. These results will be subject to verification by the Monitor's auditors if the results reported for the prior twelve months cannot be verified by the auditors and the Department is required to extend its Substantial Compliance into the Third Quarter of 2017. 18 The Monitor anticipate that the Subject Matter Expert will review the supervisors' reviews during the next reporting period.
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34. The County and the Sheriff will conduct discharge planning and linkage to community mental health providers and aftercare services for all prisoners with serious mental illness as follows:
(a) For prisoners who are in Jail seven days or less, a preliminary treatment plan, including discharge information, will be developed.
(b) For prisoners who are in Jail more than seven days, a QMHP will also make available:
(i) for prisoners who are receiving psychotropic medications, a 30-day prescription for those medications will be offered either through the release planning process, through referral to a re-entry resource center, or through referral to an appropriate community provider, unless clinically contraindicated;
(ii) in-person consultation to address housing, mental health/medical/substance abuse treatment, income/benefits establishment, and family/community/social supports. This consultation will also identify specific actions to be taken and identify individuals responsible for each action;
(iii) if the prisoner has an intense need for assistance, as described in DMH policies, the prisoner will further be provided direct linkage to an Institution for Mental Disease ("IMD"), IMD-Step-down facility, or appropriately licensed hospital;
(iv) if the prisoner has a moderate need for assistance, as described in DMH policies, and as clinically appropriate to the needs of the prisoner, the prisoner will be offered enrollment in Full Service Partnership or similar program, placement in an Adult Residential Facility ("Board and Care") or other residential treatment facility, and direct assistance accessing community resources; and
(v) if the prisoner has minimal needs for assistance, as described in DMH policies, the prisoner will be offered referrals to routine services as appropriate, such as General Relief, Social Security, community mental health clinics, substance abuse programs, and/or outpatient care/support groups.
(c) The County will provide a re-entry resource center with QMHPs available to all prisoners where they may obtain information about available mental health services and other community resources.
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STATUS (34):

STAYED PENDING LITIGATION

Paragraph 34 is the subject of on-going litigation as a result of a First Amended Complaint in Intervention challenging the provisions relating to discharge planning. The County’s Fifth Self-Assessment reports that the litigation "is on-going" and, "[a]ccordingly, the Department has stayed its collection of compliance data with respect to this [p]rovision."

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35. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team ("JMET") member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: NON-COMPLIANCE The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral ("BOMHR") records for prisoners referred by custody staff to a QMHP or JMET member for "routine" mental health care to determine the timeliness of the referrals. Substantial Compliance requires that "85% of the BOHMR forms reflect that the referral occurred before the end of the shift in which the potential need for mental health care is identified." Although the County appears to have made progress in capturing the data, it was able to locate timely completed BOMHR forms for only 44% and 36% of the randomly selected prisoners with a potential need for routine mental health needs who were referred for evaluation in the Second and Third quarters of 2017. The Department reports that it has developed an electronic version of the BOHMR, which was "implemented in all facilities as of November 6, 2017," which should facilitate the timely completion of the required BOHMRs.
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36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected records of prisoners newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; and provide a staffing schedule for on-call services. The County's Fifth Self-Assessment reports that 69% of the prisoners identified in the two randomly selected weeks in the Second Quarter of 2017 and 60% in the Third Quarter of 2017 received an assessment by a QMHP within four hours. These results are still below the 95% threshold, but an improvement from the Fourth Reporting Period. Almost all of the prisoners who did not receive an assessment by a QMHP within four hours were transported from NCCF in the north part of the County to IRC in the downtown jail complex.19
As previously noted, the process of observing prisoners following adverse triggering events at CRDF and TTCF satisfies Paragraph 36. Benches have been installed next to the officers’ stations in housing areas at both facilities, and prisoners who experience triggering events are handcuffed to the benches and under constant visual observation until the QMHPs arrive to meet with the prisoners.
DOJ and the County have agreed that, instead of unannounced quarterly visits, "the Department will randomly select five BOMHRS" from a randomly selected date, "review videos to determine how the inmate was being observed while waiting for the QMHP," and "produce screen shots and movement records as part of their selfassessment." The County reports that in the Second Quarter of 2017 all five selected prisoners at CRDF and four of the five at TTCF were on the videos "under unobstructed visual observation pending assessment." In the Third Quarter of 2017, two of the five prisoners at CRDF and four of the five at TTCF were under the required observation.
19 The Mental Health Subject Matter Expert notes that many cases may not be true emergencies because the inmates are using the threat of suicide "to secure exit from NCCF." He believes that it "might be reasonable to exclude" from the four-hour assessment requirement those inmates in general population at NCCF who are transferred to IRC as a result of threatening to commit suicide rather than engaging in selfinjurious behavior. The parties have agreed to exclude these NCCF inmates from the four-hour assessment requirement.
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The Fifth Self-Assessment reports that the County achieved 100% compliance with a staffing schedule that provides on-call services 24 hours a day, 7 days a week in both the Second and Third Quarters of 2017 pursuant to Compliance Measure 36.2.
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37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral ("BOMHR") Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: PARTIAL COMPLIANCE The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter, review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner and incident reports for self-injurious behavior by prisoners appearing in the selected courts, and determine if these incidents are reflected in BOMHR forms completed by the Court Services Division staff in the selected courts. The County’s Fifth Self-Assessment reports significant improvements with the use and completion of the BOMHR form by the Court Services Division in the Second and Third quarters of 2017. 93% of the incidents covered by Paragraph 37 in six randomly selected courts were reflected on BOMHRs in the Second Quarter of 2017 and 87% of the incidents in six other courts were reflected on BOMHRs in the Third Quarter of 2017. These results are far above the 10% and 33% results in the prior two quarters.20 The Monitor expects to conduct random checks of courthouse lock-ups to determine where these prisoners are housed and if they are "under unobstructed visual observation or subject to 15-minute checks."
20 Although Compliance Measure 37-2 requires the Department to "select different courts so that all 35 courts are selected at least once per year," only twenty-five of the Courts have lock-ups and handle defendants in custody.
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38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision.
The County's reported results, which were verified by the Monitor's auditors, showed that it had maintained Substantial Compliance with Paragraph 38 for twelve consecutive months as of December 31, 2016. Accordingly, pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 38 was not subject to monitoring in the Fifth Reporting Period.
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39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their requests to custody staff or other prisoners.

STATUS:

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through June 30, 2017 (verified) and through September 30, 2017 (unverified) at PDC South)

SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through September 30, 2017 (unverified) at TTCF, NCCF, and PDC North)

PARTIAL COMPLIANCE (at CRDF and MCJ)

During tours of the jail facilities in the Fifth Reporting Period, the Monitor and the Mental Health Subject Matter Expert observed that healthcare referral forms for prisoners requesting medical or mental health care and envelopes were available either in the modules or at the Deputies' stations adjacent to these housing areas, and prisoners are able to ask staff for the forms and envelopes if they do not have access to the box or it is empty. In some areas in Men's Central Jail where the inmates are in single cells in rows (e.g., for K-10 inmates), the forms are in boxes outside of the rows and must be obtained from the Deputies and Custody Assistants assigned to the areas.

Based upon a review of the County’s policies and procedures, multiple tours of the facilities, interviews, and the County’s Semi-Annual Report, the Monitor is satisfied that the Department has adequate processes and procedures for inmates to make confidential self-referrals for mental health care.

Substantial Compliance requires the Department to (a) verify that housing areas have the required forms and (b) review randomly selected self-referrals for mental health care from prisoners to confirm that (i) the referrals "were forwarded to DMH" by the Department, and (ii) that "DMH documented the timeliness and nature of DMH's response to the self-referrals[.]" The thresholds for Substantial Compliance are that 90% of the self-referrals must be forwarded by the Department to the Department of Health Services – Custody Health Services (DHS-CHS) and 90% must contain the required documentation of DHS-CHS's response.

The County's Fifth Self-Assessment reports that it achieved Substantial Compliance with Compliance Measure 39.4(a) in the Second and Third quarters of 2017 in that more than 85% of the housing areas in all of the facilities had the self-referral forms.

The County's Fifth Self-Assessment also reports that in the Second Quarter of 2017, 100% of the self-referrals forms from CRDF, PDC South, TTCF, and MCJ were forwarded by the Department to DHS-CHS as required by Compliance Measure 39.4(b), and DHS-CHS documented the timeliness and nature of its response in 98% of the CRDF

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referrals and 100% of the PDC South referrals, as required by Compliance Measure 39.4(c), but only 55% of the TTCF referrals and 9% of the MCJ referrals had the required documentation. The Self-Assessment also reports that "the County was unable to assess NCCF and PDC North during this quarter as there was no formal process in place during the random week selected to accurately document the timeliness and nature of CHS' response to the self-referrals, and it was unable to assess PDC East "as there were no referrals for mental health care received by the Department during the random week selected."
The County's Fifth Self-Assessment also reports that in the Third Quarter of 2017, 100% of the self-referrals forms from CRDF, PDC South, NCCF, and PDC North, 99% of the forms from TTCF, and 94% of the forms from MCJ were forwarded by the Department to DHS-CHS as required by Compliance Measure 39.4(b), and DHS-CHS documented the timeliness and nature of its response in 94% of the CRDF referrals, 99% of the TTCF referrals, 96% of the NCCF referrals, 100% of the PDC South referrals, and 100% of the PDC North referrals as required by Compliance Measure 39.4(c), but only 58% of the MCJ referrals. The Self-Assessment also reports that the County was unable to assess PDC East during this quarter because once again there were no referrals.21
As noted in prior reports, absent extenuating circumstances, Mental Health Services clinicians must respond to self-referrals within seven days. In many cases, however, the County is counting from when Mental Health Services receives the selfreferral from Medical Services rather than from when the inmate makes the self-referral. This would be reasonable if Medical Services promptly forwards the self-referral to Mental Health Services, but this is not always the case. For example, in one case an inmate made a self-referral on June 13, 2017, and the medical staff sent it to Mental Health Services on July 18, 2017. The County deemed Mental Health Services' response on July 20, 2017 to be timely because it was within seven days after it received the referral even though this was over a month after the inmate made the self-referral. The Mental Health Subject Matter Expert observes that this "is entirely unreasonable." When compliance is measured from the date the inmate submits the self-referral rather than the date the form is received by Mental Health Services, the Monitor's auditors determined that the County was not in Substantial Compliance at CRDF for the Second and Third Quarters of 2017.
The reported results for PDC South in the Second and Third Quarters of 2017 and for TTCF, NCCF, and PDC North in the Third Quarter of 2017 are subject to verification by the Monitors auditors, which will include an assessment of the timeliness of Mental Health Services' responses from the date of the inmate's self-referral.
21 This is not surprising, given the limited population at PDC East, which is a fire camp. The County should continue to determine if there are any referrals from PDC East in future reporting periods until all of the other facilities have maintained Substantial Compliance with Paragraph 39 for twelve consecutive months, at which time Paragraph 39 will no longer be subject to Monitoring.
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40. The County and the Sheriff will ensure a QMHP will be available on-site, by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the County (1) to provide the Monitor with oncall schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week, and (2) randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify that a QMHP responded to all referrals, and 90% of the referrals within four hours. The County’s Fifth SelfAssessment reports that a QMHP responded to 99% of referrals and 64% were within four hours in the Second Quarter of 2017. The results for the Third Quarter of 2017 show that a QMHP responded 100% of the time and 84% were within four hours. Future results reporting Substantial Compliance will be subject to a qualitative assessment that the QMHP provided "clinically appropriate mental health crisis intervention services" as required by Paragraph 40. During a May 2017 site visit, the Mental Health Subject Matter Expert and the clinicians "found that a QMHP responded in 28/29 cases (one case was not an urgent or emergent referral);" in 70% of the cases in which they could determine timeliness, a QMPH responded within four hours; and in 46% of the cases in which they could determine if the services were clinically appropriate, the services were adequate.
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41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: NOT RATED
Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. In the Fourth Reporting Period, the Monitor did not rate the County's compliance with Paragraph 41 because all of the FIP patients on suicide watch during the period either remained on suicide watch at the end of the period or they "did not remain in the system (they were transferred to prison), and therefore did not go through the protocols."
During the Fifth Reporting Period, the parties agreed to revisions to the Compliance Measures that will increase the number of inmates subject to the step-down protocols of Paragraph 41 and ensure that the County's implementation of step-down protocols for FIP patients on suicide watch "ameliorate the impact of the restrictions" and have the necessary "level of precautions based upon individual assessment[s]" of the patients. The revised Compliance Measures were reviewed by the Mental Health Subject Matter Expert. They will be effective as of January 1, 2018, so that the pool of patients in FIP who are subject to the step-down protocols will be sufficient to assess meaningfully the County's compliance with Paragraph 41 in the next Reporting Period.
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42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement "step-down" procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: PARTIAL COMPLIANCE (at CRDF)
NON-COMPLIANCE (at TTCF)
The County’s Fifth Self-Assessment reports that for the Second Quarter of 2017 at CRDF, 100% of the medical records reviewed reflected that "inmates in HOH and placed on risk precautions were assessed by a QMHP"; "73% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and "50% -- instead of the required 85% -of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 100%, 27%, and 0%.
For the Third Quarter of 2017 at CRDF, 100% of the records "reflected that inmates in HOH and placed on risk precautions were assessed by a QMHP"; 50% "of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and 83% "of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 100%, 22% and 0%.
Notwithstanding the poor quantitative results, the Mental Health Subject Matter Expert observed that the County is "doing a better job of self-assessment and that the clinicians, when they do invoke stepdown procedures, are doing much better at determining what level of services are needed and are also more appropriately considering what restrictions are needed (as reflected by door signs)." The Fifth Self-
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Assessment reports that a Risk Precaution workgroup developed a "standardized criteria for designation as requiring R[isk] P[recaution] [that] was approved by DHS-CHS management" and also mandatory training for staff, which began on November 17, 2017.22
22 DOJ has requested additional information about the "standardized criteria for designation."
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Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 42 of 111 Page ID #:2884
43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
STATUS: PARTIAL COMPLIANCE
In response to comments by the Monitor and DOJ, the Department submitted proposed revisions to its discipline policies on May 30, 2017. After consulting with the Subject Matter Experts, the Monitor provided his written comments to the Department on June 29, 2017. The DOJ provided its comments to the Department the same day. These revisions were not, however, finalized by the Department during the Fifth Reporting Period. The County's Fifth Self-Assessment reports that the Department is "currently finalizing revisions to policies related to discipline and the mentally ill," which should satisfy the requirements of Compliance Measure 43.9(a).
The Fifth Self-Assessment reports that the Department reported that "no inmates with mental illness had lost behavioral credits for disciplinary reasons during Second and Third Quarters, 2017, "which addresses Compliance Measure 43.9(e).
The County's Fifth Self-Assessment did not report any results for the other
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subparts of Compliance Measure 43.9, which require that (b) "custody staff consult with a QMHP" prior to transferring prisoners in mental health housing to disciplinary housing; (c) QMHPs meet with prisoners receiving psychotropic medication who are transferred from disciplinary housing; and (d) QMHPs walk through each disciplinary housing unit at least once a week. The County's posted results for Compliance Measure 43.9(b) state that the County "discovered systematic problems with QMHP discipline clearance for inmates in mental health housing." The posted results for Compliance Measure 43.9(c) were in the 80% range for each facility during that quarter, which was a significant improvement at MCJ and TTCF. The posted results for Compliance Measure 43.9(d) show that QMHPs walked through each of the facilities at least once a week in each facility during the randomly selected month in the Third Quarter of 2017.
The Fifth Self-Assessment reports that "the current practice regarding QMHP review of discipline for inmates in mental health housing locations is, when appropriate, a P2 inmate is transferred from dorm housing to cell-housing within mental health, and evaluated afterwards as to whether discipline can be imposed" and "[i]nmates who have been designated as P3 or P4 do not get moved from their housing assignments when they commit an infraction. The County does, however evaluate P3 inmates before any other discipline is imposed. Inmates designated as P4 are not disciplined."23 The SelfAssessment also reports that "the County has identified staffing levels as [a] factor in the County's failure to achieve substantial compliance with this Provision."
23 "P" levels indicate the seriousness of an inmate's mental illness, with P4 being inmates with the most severe mental illnesses.
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Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 44 of 111 Page ID #:2886
44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County has maintained Substantial Compliance with Paragraph 44 of the Agreement since January 1, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 44 was not subject to monitoring during the Fifth Reporting Period.
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45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at CRDF, NCCF, PDC EAST, PDC SOUTH, and TTCF)

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ and PDC North)

The County has maintained Substantial Compliance with Paragraph 45 for twelve consecutive months at all facilities as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 45 was not subject to monitoring during the Fifth Reporting Period.

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46. The County and the Sheriff will immediately interrupt, and if necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to review the documentation from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment. The Department has been unable to collect the universe of incidents when an inmate threatened self-injurious behavior as opposed to when an inmate exhibited such behavior. The County's Fifth Self-Assessment reports that, with the implementation of the electronic BOMHRs at all facilities as of November 6, 2017, the "Department anticipates providing data as to inmates who threaten self-injurious behavior by the First Quarter of 2018." The County's Fifth Self-Assessment reports that for the First Quarter of 2017, "72% -- rather than the required 95% -- of the records reviewed . . . reflected that appropriate aid and (when necessary) immediate interruption of self-injurious behavior was provided by the Department." In the Second Quarter of 2017, 80% of the records reflected that the appropriate aid and necessary interruption was provided by the Department. In the Third Quarter of 2017, 75% of the records reflected this information.24
24 The Mental Health Subject Matter Expert observes that the "challenging issue" is how to respond to selfinjurious behavior without reinforcing the behavior. He suggests considering a qualitative assessment of Paragraph 46 for this purpose.
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47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: PARTIAL COMPLIANCE The County’s Fifth Self-Assessment sets forth what the County has done to implement the paragraphs of the Settlement Agreement that were subject to monitoring in the Fifth Reporting Period. After discussions with the parties, the Monitor revised the Compliance Measures for Paragraph 47 to define "Critical Incidents" as "all inmate deaths, all serious suicide attempts, all Category 3 uses of force, and a random sample of 25%, but not more than 25 per quarter, of assaults on staff (excluding gassing) by inmates in mental health housing units or on mental health caseloads resulting in felony filings". The revised Compliance Measures have been approved by the parties and implemented by the Monitor, effective January 1, 2018. The County’s Fifth Self-Assessment reports that the County will provide a list of critical incidents" after the revised measures are implemented and "is working to develop the methodology to determine and assess whether staffing was a factor in any non-compliance with the Agreement, any critical incident, or the Department's handling of the incident."
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Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 48 of 111 Page ID #:2890
48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations ("CCR") Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County maintained Substantial Compliance with Paragraph 48 of the Agreement at all facilities for twelve consecutive months as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 48 was not subject to monitoring in the Fifth Reporting Period. Nevertheless, during inspections in the Fifth Reporting Period, the Monitor and Subject Matters Experts observed "an acceptable level of cleanliness, sanitation, repair and safety" in each facility.
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49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016, through February 28, 2017)
The County maintained Substantial Compliance with Paragraph 49 of the Agreement at all facilities for twelve consecutive months as of February 28, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 49 was not subject to monitoring during the Fifth Reporting Period. Nevertheless, during inspections in the Fifth Reporting Period, the Monitor and Subject Matter Expert noted that the lighting systems, heating, ventilation and cooling systems in each facility were "adequately maintained and installed."
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50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at all facilities other than PDC South and PDC East)

SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at PDC South and PDC East)

The County maintained Substantial Compliance with Paragraph 50 of the Agreement at all facilities for twelve consecutive months as of March 31, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 50 was not subject to monitoring during the Fifth Reporting Period.

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51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) for all facilities other than CRDF)

SUBSTANTIAL COMPLIANCE (as of July 1, 2016 through June 30, 2017 (verified) at CRDF)

The County maintained Substantial Compliance with Paragraph 51 of the Agreement at all facilities for twelve consecutive months as of June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 51 was not subject to monitoring during the Fifth Reporting Period.

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52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52. All of the Compliance Measures for Paragraph 52 have a 95% threshold for Substantial Compliance.
The County’s Fifth Self-Assessment reports that for the Second Quarter of 2017 at CRDF, 95% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 6% "of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP regarding allowable property;" 4% "of electronic medical records for inmates assigned to HOH reflect that property restrictions were based upon the clinical judgment of a QMHP;" and 100% of the inmates placed in HOH "for more than 24 hours" and had "allowable property as recommended by a QMHP[.]"
For the Third Quarter of 2017 at CRDF, the reported results were that 69% of the inmates initially placed in HOH were provided the property required by Paragraph 52, and 100% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]" The County was, however, "unable to determine the compliance rate" for the other two Compliance Measures.
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For the Second Quarter of 2017 at TTCF, the County reports that 87% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 14% "of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP regarding allowable property;" 0% "of electronic medical records for inmates assigned to HOH reflect that property restrictions were based upon the clinical judgment of a QMHP; and 99% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
For the Third Quarter of 2017 at TTCF, the results were 69% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 58% "of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP regarding allowable property,"25 and 94% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]" The County was, however, "unable to determine its compliance rate for electronic medical records for inmates assigned to HOH reflect[ing] that property restrictions were based upon the clinical judgment of a QMHP." Accordingly, the Mental Health Subject Matter Expert and one of the clinicians expressed concern that results reported for this Compliance Measure "may not reflect the involvement of a QMHP in determining property allowed, but rather the correspondence of the property observed in the cell compared with the property noted on the door sign."26
The County reports that it "recently updated and improved functionality of the door signs to assist with identifying allowable property for inmates in High Observation Housing," which is determined by the QMHPs, not Custody. During the most recent tours of the TTCF and CRDF, the Monitor, the Mental Health Subject Matter Expert, and the clinicians all noted continuing improvement in the matching of door signs with the allowable property.
25 DOJ notes that "the County's August 2017 tool for TTCF contain multiple QMHP meeting that do not correspond with the correct inmate, such that many QMHP meeting are recorded as untimely. If this were corrected, the County's compliance percentage for 3Q17 at TTCF would likely be higher." 26 The Mental Health Subject Matter Expert also notes that this "element is the most challenging to achieve and to properly audit as it requires some degree of clinical judgement to determine whether the restrictions were based on a clinical assessments, let alone determining whether the assessment was adequate."
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53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to audit the records of prisoners who were eligible and rejected or disqualified for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone. The County reports that in the Second and Third Quarters of 2017, 81% and 97% respectively of the mentally ill prisoners who were eligible for and denied work were not denied the work because of their mental health condition or a prescription for medication alone. In reviewing these results, the Monitor and Mental Health Subject Matter Expert expressed concerns about the Third Quarter results because there are no prisoners from CRDF who asked for or were denied programing in that quarter, even though there were a number of prisoners in both categories in the Second Quarter. The County has acknowledged "an issue with the documentation," and reports that it has "revised the documentation process at CRDF[.]" The Mental Health Subject Matter Expert agrees that inmates who meet the P4 mental health level of care (the most severely impaired) may be excluded because they are not capable of participating or benefitting from these programs, but this should be the only population that is excluded from this provision.
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54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016 through December 31, 2016 (verified))
Substantial Compliance requires the Department to audit the records of a maximum of 100 randomly selected prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. In the Third and Fourth Reporting Periods, the County reported that it achieved and maintained Substantial Compliance for twelve consecutive months in 2016. The results have been verified by the Monitor’s auditors.
The Mental Health Subject Matter Expert has expressed a concern that the randomly selected population "does not pre-select for patients on [mental health] rolls or on medication, so it is possible that all cases reviewed had no mental health problem that might have resulted in a denial." To address this concern, with the approval of the parties, the Monitor revised the Compliance Measures for Paragraph 54, effective January 1, 2018, to reflect an alternative pool of inmates proposed by the County. Because Monitor's auditors have verified that the County has maintained Substantial Compliance under the existing Compliance Measures, the County will only be required to maintain Substantial Compliance under the revised Compliance Measures for two additional quarters.
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55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2016 (unverified); as of January 1, 2017 through September 30, 2017 (verified) at CRDF)

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through June 30, 2017 (verified) and through September 30, 2017 (unverified) at MCJ)

SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through September 30, 2017 (verified) at PDC North)

PARTIAL COMPLIANCE (at TTCF)

During the Fifth Reporting Period, the Monitor and a DOJ representative attended a daily HOH meeting at CRDF, which included custody, medical, and mental health personnel who appeared to be very knowledgeable about the condition and issues of individual HOH inmates. The Mental Health Subject Matter Expert also attended a number of meetings for HOH and MOH units at both CRDF and TTCF, which were well attended, and the staff actively participated and addressed salient issues.

The County's Fifth Self-Assessment reports that the Department has maintained Substantial Compliance for twelve consecutive months through the Third Quarter of 2017 at CRDF and TTCF with Compliance Measures 55.3, 55.6(a) and 55.6(b), and at MCJ and PDC North for the second and third quarters of 2017. The results posted by the County show, however, that it failed to meet the 95% Substantial Compliance threshold under Compliance Measure 55.6(b) for the MOH meetings at TTCF for the third quarter of 2017.

On January 16, 2018, the Department provided its semi-annual reports "verifying the coordination and communication at the staff meetings" at each of the facilities with HOH and/or MOH units during the second six months of 2017 as required by Compliance Measures 55.2, 55.4 and 55.6(c).

The Substantial Compliance results for the Fourth Quarter of 2016 at CRDF and for the Third Quarter of 2017 at MCJ are subject to verification by the Monitor's auditors.

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56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through June 30, 2016 (verified), through September 30, 2016 (unverified), through December 31, 2016 (verified), and through June 30, 2017 (unverified))

Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH; and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing.

The County’s Fifth Self-Assessment reports that it has achieved Substantial Compliance for the First and Second quarters of 2017, which means that it has maintained Substantial Compliance for 18 consecutive months. Once the reported results for the Third Quarter of 2016 have been verified by the Monitor's auditors Paragraph 56 will no longer be subject to monitoring.

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57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57):

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through September 30, 2017 (verified) at MCJ)

PARTIAL COMPLIANCE (at TTCF, CRDF, and PDC North)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit in two randomly selected weeks to determine if the safety checks were staggered and conducted as required by Paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit for one randomly selected week to determine if a QMHP approved the new mental health housing assignments as required by Paragraph 57(e). The thresholds for achieving Substantial Compliance with these two Compliance Measures is 95%.

The County’s Fifth Self-Assessment reports that it has maintained Substantial
Compliance with Compliance Measure 57.5(b) in the Second and Third Quarters of 2017
in the MOH unit at MCJ (the "Hope Dorm") where 96.8% and 96.6% of the safety checks were in compliance.27 It also reports that it achieved Partial Compliance in the HOH and
MOH units at TTCF (93.6% and 93.9%) and CRDF (86% and 89.7%), and in the MOH units at PDC North (95% and 79.9%).28

The Self-Assessment also reports the County has maintained Substantial Compliance with Compliance Measure 57.5(c) in all facilities in the Second Quarter of 2017 where 99% of the new mental health housing assignments for were approved by a QMHP. In the Third Quarter of 2017, 99% of the new mental housing assignments at TTCF and CRDF and 100% of the assignments at MCJ were approved by a QMHP.29 The results for the Third Quarter of 2017 at MCJ have been verified by the Monitor's auditors. These results are consistent with the Subject Matter Expert's qualitative assessment.

The Monitor has concerns that deputies are more concerned about the timeliness, as opposed to the quality, of the cell checks in mental health housing, which have tighter 15- and 30-minute requirements. On videos the Monitor has reviewed, Deputies and Custody Assistants will sometimes scan the bar codes without stopping or looking into

27 DOJ has expressed concern that the checks in the Hope Dorm "may not truly be staggered because the checks are often separated consistently by intervals of almost exactly 25 minutes." The Monitor notes that there is some staggering of these checks and, as confirmed by the Mental Health Subject Matter Expert, significant variations are less important in the Hope Dorm because it is a direct observation dorm with Department personnel stationed inside the dorm 24 hours per day. 28 There are, however, no reported results for the Forensic In-Patient ("FIP") unit in the CTC. 29 In order to satisfy Compliance Measure 57.5(c), inmates must be moved expeditiously after a QMHP approves a new housing assignment. Although it is not realistic to expect the Department to move all inmates immediately, the transfers should be done within 48 hours of the QMHPs' approvals of new housing assignments. and placements in FIP should be as soon as possible. The Monitor's auditors determined that 100% of the inmates were moved by the Department within 48 hours of the QMHPs' approvals in the Third Quarter.
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cells. This is more prevalent in TTCF than in CRDF and MCJ, where deputies usually look in the cells during cell checks. In one troubling incident involving the death of an inmate at TTCF, videos show that Deputies and Custody Assistants walked by the inmate's cell without looking in his cell on two separate checks after it appears (from another video) that the inmate had fallen to the floor in his cell. The Mental Health Subject Matter Expert and clinicians observed similar variations in the quality of safety checks at CRDF and TTCF.
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58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells; (b) At least every 30 minutes in dormitory-style housing units where the unit
does not provide for unobstructed direct supervision of prisoners from a security control room; (c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes; (d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing; (e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner; (f) Custody staff will document their checks in a format that does not have pre-printed times; (g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and (h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
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STATUS (58):

SUBSTANTIAL COMPLIANCE (as of January 1, 2016 through December 31, 2016 (verified) at PDC South, PDC North, and PDC East)

SUBSTANTIAL COMPLIANCE ( as of July 1, 2017, through September 30, 2017 (verified) at CRDF and TTCF)

PARTIAL COMPLIANCE (at IRC, MCJ, and NCCF)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by Paragraph 58. The thresholds for achieving Substantial Compliance with this Compliance Measures is 90%.

The County maintained Substantial Compliance with Paragraph 58 for twelve consecutive months at PDC South, PDC North, and PDC East as of December 31, 2016. Pursuant to Paragraph 111, those facilities were not subject to monitoring in the Fifth Reporting Period.30

The County's Fifth Self-Assessment also reports that for the Second and Third
Quarters of 2017, the following percentages of safety checks were in compliance with Paragraph 58: CRDF (83.5% and 90.5%);31 TTCF (89.8% and 92.6%); MCJ (86.4% and 88.6%); NCCF (83.5% and 84.8% )32 and IRC (93% and 87.8%).

30 Based upon the County's reported results, in the last reporting period the Monitor found the County to be in Substantial Compliance at PDC East for the First Quarter of 2016. Following the submission of the Monitor's Fourth Report, the County posted revised results showing that the Department did not meet the 90% threshold for Substantial Compliance at PDC East in that quarter. However, the Monitor’s auditors concluded that the Department reached the threshold for Substantial Compliance at PDC East in that quarter. 31 Substantial Compliance requires achieving the 90% threshold based upon the aggregate data for the two randomly selected weeks. 32 DOJ has requested an update regarding the Department's "plans to stagger [the Title 15] checks at NCCF."
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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through September 30, 2017 (verified) at PDC North, PDC East, and MCJ)

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through September 30, 2017 (verified) at NCCF)

PARTIAL COMPLIANCE (at PDC South, TTCF, and CRDF)

Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if the supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. In response to the Monitor's comments, the Department's e-UDAL forms were modified to include a specific notation that the Supervisor verified that the safety checks were conducted.

The County's Fifth Self-Assessment reports that the Department achieved Substantial Compliance at CRDF and NCCF in the Second Quarter of 2017 and maintained Substantial Compliance at PDC East, PDC North, PDC South, and MCJ during that quarter. It also reports that it maintained Substantial Compliance at PDC East, PDC North, MCJ, and NCCF in the Third Quarter of 2017. The Substantial Compliance results have been verified by the Monitor's auditors. The Monitor has also determined that the Department achieved Partial Compliance at TTCF, PDC South, and CRDF.

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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
Compliance Measures 60.2 and 60.3(b) require the County to prepare semi-annual reports setting forth (a) any identified clinical issues in the areas identified in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods.
On December 8, 2017, the Monitor and the Mental Health Subject Matter Expert met with Dr. Jonathan Liu, the Director of Quality & Performance Improvement for Correctional Health Services, and members of the recently formed Mental Health Quality Improvement (QI) Redesign Workgroup. With input from the Mental Health Subject Matter Expert, this Workgroup is working "to create a high functioning model for QI which aligns with the greater DHS improvement program." At the meeting, Dr. Liu discussed the goals and plans of the working group, and the framework of the quality improvement plan. As stated by the Mental Health Subject Matter Expert, "CHS is clearly developing a sound QM system. It is based on well-established principles and methods of QM. They are taking appropriate and measured steps to implement their plan." Quality improvement remains a challenge for the County, however, given the different roles and responsibilities of CHS, which is responsible for both medical and mental health services, and the Department, which is responsible for the safety and security of the jails, staff, and inmates.
On January 18, 2018, the County submitted a CHS Semi-Annual Report on Quality Improvement/Assurance. It provides a high-level description of the re-design of the quality improvement program "to implement a coherent and cohesive QI program across all aspects of Correctional Health Services that coordinates seamlessly with LASD-Custody QI processes." It describes the Self-Directed Violence Analysis processes by which Custody Heath Services "evaluates all incidents of self-directed violence (SDV) to track relevant [categories of] data. . .and to determine if it is appropriate for presentation at [monthly Critical Incident Review Committee] CIRC meetings." Each incident of Self-Directed Violence is reviewed within two working days by the "CHS Compliance Team," which determines if the "risk rating" score warrants designating the SDV by the CIRC as a "critical incident" review. At the CIRC meetings, "issues are identified and discussed" and corrective action plans ("CAPs") are "identified and assigned." These issues and CAPs are monitored at monthly meetings of the Joint Quality Improvement Committee ("JQIC"). The Mental Health Subject Matter Expert notes that the "CHS mapping of provisions onto SDV demonstrates a sound understanding of how different elements of the associated compliance measures need to
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be viewed from a broader system-perspective that looks at how all the elements of a QM approach to SDV fit together and interact. It also provides a roadmap for where LASD and CHS need to share information regarding SDV."
The Semi-Annual Report includes a section with "Aggregate Data from 2017 Suicide Attempt Tracker," which breaks down incidents of SDV on a monthly basis by age, race/ethnicity, gender, facility, days in custody, method of attempt, and risk rating. There is also section with "Aggregate Data on CIRC's," which breaks down CIRC meetings by similar categories.
The report also provides a synopsis of each of the "29 individual case presentations" at the CIRC meetings during the Fifth Reporting Period and the issues identified during each review, the response to each issue, and the status of each issue. The Mental Health Subject Matter Expert finds that these synopses provide "a simple framework to understand and track progress for the county and a ready way to review and aggregate information obtained from CIRC and JQIC findings and plans." There is, however, only a limited discussion of "systemic improvements taken. . .to address" issues identified during the previous six months and assessments of "the effectiveness of steps taken. . . to address issues identified during earlier reporting periods."33
The Mental Health Subject Matter Expert's main concern is with the quality of the data analysis. Although CHS "intends to be able to perform [this sort of analysis] as the process matures," it is not there yet.
33 It would be helpful in future reports if there are separate sections on systemic improvements undertaken in the reporting period and an assessment of CAPs and plans undertaken in the prior period.
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts:
(i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints;
(c) Psychotropic medications;
(d) Access to care, timeliness of service, and utilization of the Forensic Inpatient Unit; and
(e) Elements of documentation and use of medical records.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County’s semi-annual reports to (a) review, collect, and aggregate data in the areas set forth in paragraph 61; (b) recommend corrective actions and systemic improvements in those areas; and (c) assess the effectiveness of actions and improvements in prior reporting periods.
The CHS Semi-Annual Report on Quality Improvement/Assurance collects and aggregates data in the areas in paragraph 61(a)(ii), (iii), and (v), but not in the other areas in 61(a) or the areas in 61(b) through 61(e).34 The Report does not, however, analyze the aggregated data, "recommend corrective actions and systemic improvements in [the] areas [set forth in paragraph 61,] or assess the effectiveness of actions and improvements in prior reporting periods." Following discussions with the Monitor, the County submitted a Supplemental Response that collects and aggregates data in each of the specific provisions of Paragraph 61. It also discusses clinical issues identified from the aggregate data, and corrective actions systemic improvements undertaken by CHS to address a number of these issues. After consulting with the Mental Health Subject Matter Expert, the Monitor finds the County has now achieved Partial Compliance with all of the provisions relating to the development of an effective quality improvement program.
34 The Semi-Annual Report of the Custody Compliance and Sustainability Bureau ("CCSB") provides aggregate data in the areas in 61(a)(ii), (v) and (vi).
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the County's semi-annual Self-Assessments to set forth (a) the "development of corrective action plans to address the most recent recommendations of the quality improvement program;" and (b) the "implementation and tracking of corrective action plans to address recommendations of the program in prior quarters." The CHS Semi-Annual Report on Quality Improvement/Assurance sets forth "responses" to issues identified in specific Self-Directed Violence incidents," but it does not separately set forth "recommendations of the quality improvement program" or describe or track corrective action plans to address such recommendations and there "are no CAPs based upon other QM findings such as an analysis of aggregate data." As noted by DOJ, "there is no discussion of cross-cutting issues, or analysis of repeating CAPs or systemic issues raised by related CAPs." The Semi-Annual Report on the activities of the Custody Compliance and Sustainability Bureau ("CCSB") describes the corrective action plans identified during the Executive Inmate Death Reviews of suicides that occurred in May and July of last year and the status of those CAPs as of January 2018, and also describes other corrective actions the Department has taken.
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63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.

STATUS: PARTIAL COMPLIANCE (at TTCF)

NON-COMPLIANCE (at CRDF)

The Compliance Measures require that the County's Self-Assessment set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period; (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. In addition, for two random weeks, the Department is required to review the count sheets documenting the number of occupied and available beds in the MOH and HOH units at TTCF and CRDF. Substantial Compliance requires "the immediate availability of HOH and MOH beds at TTCF and CRDF 95% of the time."

The County reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the Second Quarter of 2017 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 100% 21%

The County also reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the Third Quarter of 2017 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 100% 100%

On January 18, 2018, the County submitted Semi-Annual Reports for the Fourth Reporting Period for both TTCF and CRDF setting forth the average daily populations in HOH and MOH units at CRDF and at TTCF, the average number of beds, the average number of step-downs per week, and the number of days in which there beds were available in HOH or MOH housing at CRDF and MOH housing at TTCF. The County also reported on the immediate availability of beds (that is, more beds than prisoners) during the entire reporting period as required by the Compliance Measure 63.3 as follows:

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TTCF CRDF

MOH 100%
0

HOH 91.33% 57.6%

Notwithstanding concerns about the accuracy of the HOH data for TTCF,35 the Monitor is of the view that the Department has achieved partial compliance at TTCF given the other data set forth above.

35 The County's Semi-Annual Report states, however, that "[a]lthough the count sheets indicate there was availability in HOH 91.33% of the time during the second semi-annual period, the current technology does not properly capture the HOH bed availability for purposes of this provision."
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64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in an initial 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed.
On July 14, 2017, the County submitted to the Monitor a Plan Regarding Availability of Licensed Inpatient Mental Health Care (Long Term and Short Term Plans) to provide "an update regarding the County's current efforts to meet the needs of the acutely mentally ill." The County's Fifth Self-Assessment explains that "the County is pursuing a dual strategy to increase inpatient beds and the resources necessary to obviate the need for these beds. With increased services that address the underlying mental health needs (both through increased services and clinical treatment), and the County's strong effort to divert people from the jails the need for inpatient services will decline."
The County's augmented Fifth Self-Assessment reports that the plans to "open a new 18 bed inpatient psychiatric unit" at Olive View-UCLA has been delayed from the end of 2017 to July 1, 2018. It also reports that "an additional housing unit has been added" to the Mental Health Unit-Correctional Treatment Center Inpatient Step-Down Unit, "which increased the capacity to 64 beds."
As noted in the Monitor's Fourth Report, the County needs to "report on the effectiveness of the measures in the updated [plans], including any reductions in the number of patients on the FIP waiting list and who are incompetent to stand trial."
The County's Fifth Self-Assessment reports that the "FIP waitlist consists of 36 patients. Eleven of these individuals are taking medications on a voluntary basis and are, therefore, not prioritized for admission to FIP." Further, "the current average time from referral to admission is three to four days." Without more, this information is not sufficient to assess the effectiveness of the County's plans.
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The Monitor's Fourth Report also stated that the County's long-term "plans must have a reasonable basis for projecting need in order to establish Substantial Compliance with Paragraph 64." In response, the Fifth Self-Assessment states
To better gauge the need for inpatient mental health beds, the County created a Mental Health level of care system that designates patients into categories based on acuity and treatment needs. The County recently redefined the highest level of acuity (P4) as a designation for any inmate in mental health services who is considered to need an inpatient bed. The County is currently creating a tracking system to monitor the number of patients who meet this criteria on any given day. The County believes that by tracking this information across time it will have a stronger understanding of the number of inpatient mental health beds that are needed to serve this population. Clinicians were recently trained on this new designation and the County anticipates having the first set of data for the next report. While the "new level of care" designations and "tracking system" may provide a reasonable basis for projecting "the number of licensed inpatient mental health beds necessary to serve the inmate population," neither the updated Plan nor the Fifth SelfAssessment "describe the projected capacity required" or project how many beds will be required over the long term (several years).
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: NON-COMPLIANCE
Substantial Compliance requires that (1) the County's Self-Assessments set forth the (a) the results of weekly medication audits documenting the visual observation of the administration of medication during the quarter; (b) unauthorized medications found as a result of cell searches during the reporting period; and (c) incidents involving confirmed prescription drug overdoses; and that (2) "the Monitor concludes, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner 85% of the time."
During the Fifth Reporting Period, the Monitor and the Use of Force Subject Matter Expert observed a pill call at CRDF. The Monitor also obtained videos of pill calls in HOH units at TTCF and CRDF, the FIP Step-down unit at TTCF, and MOH units at CRDF on dates randomly selected by the Monitor. In the HOH units, deputies have to open tray slots for nurses to provide medication to inmates in their cells, and thus the deputies are close by when the medication is provided. Although the deputies usually looked into the cell before closing the tray slots, there were occasions when they appeared to close the tray slots without looking into the cell to verify that the inmate had swallowed the medication. There were also occasions when the deputies were distracted by other deputies, inmates, or television on in the unit, and they were not paying close enough attention to the administration of the medication. In the FIP step-down units in TTCF, the Monitor noted improvements from the previous quarter in that a deputy was nearby when the medication was administered by a nurse, but there were occasions when inmates turned away before swallowing the medication and neither the nurse nor the deputy verified that it had been swallowed. Similarly, in the MOH units at CRDF, the deputies were close by the nurse who dispensed the medication, but the deputies and the nurses sometimes failed to verify that the inmates had swallowed the medication before returning to their cells. Overall, there was improvement in the administration of the medication, but the deputies and nurses still need to be more rigorous in verifying that the inmates swallowing the medication "to prevent misuse, hoarding, and overdose."
In the County's posted Self-Assessment, the "County acknowledges ongoing issues regarding the reporting and compliance with [Compliance Measure 65-1(a)]" and it has found "inconsistencies. . .with the current auditing practice" for this measure. Once again, medication was found during a significant number of cell or module searches during the Third Quarter of 2017,36 which is similar to what that was found during the Fourth Reporting Period. There were also six confirmed drug overdoses during the Third Quarter of 2017.
36 During the Third Quarter of 2017, 69 unknown medications were found during 168 unannounced searches at CRDF, 1,360 medications were found during 124 searches at TTCF, 628 medications during 402 searches at MCJ, and 153 medications during 655 searches at NCCF and 45 medications during 224 searches at PDC North. There were no medications found during searches at PDC South and PDC East.
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66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with a Serious Mental Illness ("SMI") to assess whether they have remained on an active mental health caseload and that 95% of HOH prisoners, 90% of MOH prisoners, and 85% of other prisoners with a serious mental illness been offered "clinically appropriate structured mental health treatment" and been seen by a QMHP at least monthly, regardless of whether they refuse medications.
For the Second Quarter of 2017, the County posted results show that 20% of prisoners in HOH, 22% in MOH, and the two prisoners with serious mental illness who reside in other housing areas (100%) were "offered clinically appropriate structured mental health treatment and were seen by a QMHP at least once a month."37
For the Third Quarter of 2017 the posted results show that 18% of the prisoners in HOH, 22% in MOH, and 55% of the mentally ill prisoners who reside in other housing areas were offered the appropriate treatment and seen by a QMPH monthly.
The Fifth Self-Assessment reports, in part, that:
The County continues to focus its efforts on reducing clinician caseloads, which will allow time for clinicians to develop meaningful treatment plans and ensure these plans can be implemented. . . . [A]s part of the current staffing model, clinical Social Worker positions have been requested to deliver some of the structured group treatment to the patient population.
** **
To increase the quality of structured group treatment, in addition to utilizing clinical social workers as group leaders, the County has worked to obtain structured evidence-based curriculum for groups that include topics such as anger management, socialization, trauma-informed care and cognitive behavioral therapy. Additionally, the County has plans to
37 The Mental Health Subject Matter Expert reviewed the County's documentation and observed that it "is entirely unclear how they are arriving at these numbers." He believes that the "County would do well to consider how it intends to operationalize and then measure clinically appropriate structured mental health treatment as this measure has inherent qualitative elements making review challenging and needful of clinical expertise in the review process."
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develop a training department that will support clinician development so they have the skills necessary to provide these curriculum based groups. The Mental Health Subject Matter Expert previously "found virtually no evidence of treatment that qualified as structured or clinically appropriate." The County's reported results indicate that these problems continued in the Fifth Reporting Period. He notes, however, that the recent pilot program in HOH at TTCF "providing for progressive privileges based upon acuity and behavior. . .should allow the development of structured treatment that is clinically appropriate for the population."
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings; (c) the use of clinically appropriate interventions with such prisoners to
encourage medication compliance; (d) consideration of the need to transfer non-compliant prisoners to higher
levels of mental health housing; and (e) individualized consideration of the appropriateness of seeking court orders
for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a). STATUS: NON-COMPLIANCE Substantial Compliance requires the County to "review the electronic medical records of 25% of the prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records [of 85% of the prisoners] reflect the documentation and consideration of the matters required by the terms of Paragraph 67." The Fifth Self-Assessment reports that '[a]t this time, it is not possible to extract this information from the Powerchart system" and the County did not report any results for the Fifth Reporting Period.
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ, NCCF, PDC East, PDC South, and PDC North)

PARTIAL COMPLIANCE (at CRDF and TTCF)

Substantial Compliance requires Self-Assessments to include a summary of searches conducted in the Second quarter of the last reporting period and the first quarter of the current reporting period and to randomly select and review 25 Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units. The County’s posted Self-Assessments report that the Department has maintained Substantial Compliance at CRDF for twelve consecutive months through the Third Quarter of 2017 where 96% of the modules were searched and 100% of the HOH cells were visually inspected as required by Paragraph 68. Further, they report that the County maintained Substantial Compliance for twelve consecutive months through the end of 2017 at TTCF, where 100% of the modules were searched and 96% of the HOH cells were visually inspected in the Third Quarter and 96% of the modules were searched and 96% cells were visually inspected in the Fourth Quarter of 2017.38

The Monitor's auditors were unable to verify the Substantial Compliance results reported by the County for the inspection of the HOH cells at TTCF and CDRF. The County intends to provide additional support for a Substantial Compliance rating for these facilities. The Monitor will review the additional support with the auditors and assess whether to reinstate the Substantial Compliance rating for the Third Quarter of 2017 in the next report to the Court.

The County previously maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC South, and PDC North, which do not have HOH cells, and these facilities were not subject to monitoring for compliance with Paragraph 68 during the Fifth Reporting Period.

38 Notwithstanding the Department is in Substantial Compliance with the requirements of Paragraph 68 with respect to contraband searches, the extent of the hoarding discovered during the searches remains a matter of concern. See n. 31, p. 71, supra.
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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved within 24 hours,39 and documented, and that the results of medical welfare checks on restrained prisoners were also documented. The County’s Fifth SelfAssessment reports that for the Second Quarter of 2017, "73% -- rather than the required 95% -- of electronic medical records reviewed. . .reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required by this provision."
The County’s Fifth Self-Assessment also reports that, for the Third Quarter of 2017, 86% of the medical records reviewed "reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required by this [p]rovision."
The Mental Health Subject Matter Expert and the clinicians previously found that "it was sometimes difficult to determine whether a QMHP was present at the time of the restraint" and they could not "find the information [they] needed to determine compliance with monitoring requirements." In response to the Subject Matter Expert's recommendation, the County reports that "the Department is currently revising its policy related to monitoring inmates in restraints."
39 Per agreement of the parties, with the concurrence of the Monitor and Subject Matter Expert, "a nonpsychiatrist physician can order medical/clinical restraints as long as it is for medical reasons."
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: PARTIAL COMPLIANCE
The Mental Health Subject Matter Expert and DOJ have expressed concern about the Department's Substantial Compliance with paragraph 70(c) if all inmates in HOH are routinely handcuffed when they are out of their cells "in a housing pod at the same time." In response, the Department has developed a housing program "whereby each patient begins and ends their mental health treatment in the same module. . .[T]he HOH inmates enter in one pod and gradually step-down to the next pod, which allows more and more privileges as their behavior improves."40 The pilot program started in January 2018.
The Mental Health Subject Matter Expert is of the view that "the steps the County has taken to pilot the progressive stepdown system in TTCF is a welcome effort to address this issue. The patients are progressed from an intake pod to progressively less restrictive pods on the same floor, ending in a pod that mirrors MOH. . . . [T]his will also make it possible to provide treatment according to patient need rather than according to who is allowed out of the cell." The Monitor will observe this program during the next Reporting Period and consult with the Mental Health Subject Matter Expert before determining if this provision is no longer subject to Monitoring after six months (in light of the prior Substantial Compliance findings and the change in scope of Paragraph 70(d) or only after two full Reporting Periods.
40 The Monitor's Fourth Report found the County to be in Substantial Compliance (as of September 1, 2016 through June 30, 2017). Although the County does not agree that paragraph 70(c) requires individualized assessments of HOH inmates, who are often unpredictable and dangerous, the County agreed to establish a progressive stepdown program to address the concerns expressed by the Mental Health Subject Matter Expert and DOJ.
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71. The County and the Sheriff will ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (verified))
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71. The County’s Fifth Self-Assessment reports that "95% -- 5% over the required 90% -- of electronic medical records reviewed . . . reflected that, for inmates placed in clinical restraints, the inmates received therapeutic services as required by this [p]rovision" in the Second Quarter of 2017, and 97% of the inmates received the services in the Third Quarter of 2017.
These reported results have been verified by the Monitor's auditors. The County has maintained Substantial Compliance with Paragraph 71 for twelve consecutive months and pursuant to Paragraph 111 this provision is no longer be subject to monitoring.
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72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31 2017) (subject to qualitative assessments)

Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings that review incidents of serious self-injurious behavior in the reporting period.

The Fifth Self-Assessment reports that "DHS-CHS management continuously works to improve CIRC meeting to ensure they include all of the topic areas specified in measures 72(a) and (b)." The augmented Fifth Self-Assessment reports that during the Fifth Reporting Period 100% of the suicides and 96.5% (28 out of 29) incidents involving "serious self-injurious behavior" were reviewed to determine if they addressed these topic areas.41 Neither the posted audit source document nor the synopsis of each review in CHS' semi-annual report are, however, sufficient for the Monitor to assess, as requested by DOJ, "whether the County is adequately reviewing potential non-custody staff misconduct."42 Further, based upon an initial qualitative assessment, the Mental Health Subject Matter Expert has some concerns about the completeness of the documentation and the quality of the determinations. Accordingly, the Substantial Compliance finding is subject to additional qualitative assessments by the Monitor and the Mental Health Subject Matter Expert in the next reporting period.

The Monitor attended a CIRC meeting on December 7, 2017. Although the meeting covered the subjects required by Paragraph 72, the review was not integrated into a quality improvement plan that addresses systemic issues. The Mental Health Subject Matter Expert states that the "key is now feeding those results into the QM process."

41 The remaining incident will be reviewed at the February CIRC meeting. 42 The County will need to provide this information to enable the Monitor to determine if Paragraph 72 is no longer subject to monitoring.
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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicide during the reporting period.
The County’s Fifth Self-Assessment reports that for the Second Quarter of 2017, "27% -- rather than the required 90% -- of reports reviewed have all of the information required by paragraph 73 of the Settlement Agreement" and that "100% -- equal to the required standard of 100% -- of incidents involving an apparent or suspected suicide were reported to the Inspector General[.]"
The County’s Fifth Self-Assessment reports that for the Third Quarter of 2017, "39% -- rather than the required 90% -- of reports reviewed have all of the information required by paragraph 73 of the Settlement Agreement" and that "100% -- equal to the required standard of 100% -- of incidents involving an apparent or suspected suicide were reported to the Inspector General[.]"
The Fifth Self-Assessment also reports that the "Department has developed an electronic version of the BOMHR which was recently implemented in all the facilities." The Department "anticipates" the electronic BOMHR will improve the results in the future.
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74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)
Substantial Compliance requires the Department to provide the Monitor with an Executive Suicide Death Review reflecting the results of the Department’s investigation of any suicide in the Jails within six months of the suicide. The review must reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded.
There were two suicides during the Fourth Reporting Period for which the Executive Inmate Death Reviews were due in the Fifth Reporting Period. The first suicide occurred on March 9, 2017, and the Executive Inmate Death Review was timely submitted on September 8, 2017, but it did not include a Homicide Report prepared by the Detective Division of the Homicide Bureau. The Homicide Report was subsequently submitted to the Monitor on December 8, 2017 and reflects the steps taken to preserve all of the evidence; lists the interviews of persons involved in, or who witnessed, the incident; and notes if the interviews were recorded.43 The Homicide Report satisfies Paragraph 74.44
The second suicide occurred on May 25, 2017, and the Executive Inmate Death Review was timely submitted to the Monitor on November 22, 2017, but again did not include the Homicide Report. That Report was subsequently submitted to the Monitor on December 22, 2017, and supplemented on January 3, 2018. It reflects the steps taken to preserve all of the evidence, and lists the interviews of persons involved in, or who witnessed, the incident. The supplement provides the audio recordings of the interviews. As supplemented, the Homicide Report satisfied Paragraph 74.45
The Department has maintained Substantial Compliance with Paragraph 74 for over twelve consecutive months and this provision is no longer subject to monitoring.
43 The Compliance Measures do not require this information to be in the Executive Inmate Death Review or be submitted to the monitor within six months of the suicide. 44 The posted results reflect that 90% of the persons involved in. or who witnessed, the incident were interviewed. 45 The posted results reflect that all of the persons involved in, or who witnessed, the incident were interviewed.
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75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires (a) DMH to review documentation of randomly selected suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (b) that the Department and DMH reviewed the relevant information known at that time and the status of any corrective actions taken, and they considered the need for additional corrective action if necessary; and (c) that the information is reflected in the Department's database for tracking and statistical analysis.
The County's Fifth Self-Assessment reports that for Second Quarter of 2017, "93% -- 8% more than the required 85% -- of documents reviewed showed DMH staff considered the inmate's mental health status and need for immediate corrective action;" "100% -- 5% more than the required 95% -- of suicide attempts are reflected in the Department's database;" and "100% -- more than the required 95% of the suicide attempts" were reviewed by "management and command-level personnel" from Custody, mental health, and medical as required by Compliance Measure 75-5(b).
The results for the Third Quarter of 2017 reflect that 93% of documents reviewed showed DMH staff considered the inmate's mental health status and need for immediate
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corrective action; 100% of the suicide attempts are reflected in the Department's database; and 100% of the serious suicide attempts were reviewed by management and command-level personnel.
Although the results reported by the County meet the quantitative thresholds for Substantial Compliance, the County's Self-Assessment notes that the "County is aware of concerns with the reporting system, which is why [its] self-assessment reflects only Partial Compliance." The Mental Health Subject Matter Expert observes that the tracking of Corrective Action Plans remains a problem.
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76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)

There was one suicide during the Fifth Reporting Period, which occurred at TTCF on July 3, 2017. An initial Death Review was held within two working days of the death, which the Monitor attended. It included command-level personnel from the Department and DHS and reviewed the information known about the suicide and identified necessary corrective actions. The seven-day review was held on July 12, 2017 and the 30-day death review was held on August 8, 2017. The County's posted Self-Assessment reports that matters required by Paragraphs 76(a) and (b) and Compliance Measures 76.1, 76.2, and 76.6(a) were discussed at these meetings.

Paragraph 76(c) and Compliance Measure 76.6(b) require the County to provide a "final written report regarding the suicide" within six months of a suicide that addresses the 10 subparts of subparagraph (c).

On September 8, 2017, the County timely provided an Executive Inmate Death Review report for the suicide that occurred at TTCF on March 9, 2017. On November 22, 2017, the County timely provided an Executive Inmate Death Review for the suicide that occurred at the Crescenta Valley station jail on May 25, 2017.46 The Reviews did not include Homicide Reports or supplemental reports from all of the department personnel who first discovered the inmates or participated in the rescue attempt of the inmates, but did include logs reflecting the activities of the Homicide Bureau, which the parties agreed satisfied the requirements of paragraphs 76(c)(iii). The Homicide Reports that were subsequently received by the Monitor reflected the interviews of the department members who were involved in, or witnessed, the suicides, which the parties agreed satisfy the requirements of Paragraph 76(c)(i). The Monitor, the Mental Health Subject Matter Expert, and one of the clinicians reviewed the reports and concluded that they meet the requirements in the other nine subparts of paragraph 76(c).

During the Fifth Reporting Period, the Monitor received notices of all deaths in the jails, not just suicides, and attended one or more reviews for each of the non-suicide deaths in the reporting period. Based upon those reviews, the Monitor concluded that all of the non-suicide deaths were properly classified and none of those deaths were suicides.

The County has maintained Substantial Compliance with Paragraph 76 for twelve consecutive months and this provision is no longer subject to monitoring. The Monitor expects the County to continue to conduct the reviews required by Paragraph 76 for any suicides that occur in the jails for the duration of the Settlement Agreement and Monitor will attend these meetings when he is available.

46 On January 3, 2018, the Department timely provided the Executive Inmate Death Review for the suicide that occurred on July 3, 2017.
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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
Semi-Annual Report of CCSB Activities includes the following sections:
(a) "Administrative Review of Suicides." This summarizes the 24-hour, and 7-day reviews of the suicide that occurred on July 3, 2017 at TTCF,47 and the 30-day and (additional) 60-day reviews during the Fifth Reporting Period for the suicide that occurred on May 25, 2017 at Crescenta Valley station. It also cross-references CHS' semi-annual report, which summarizes the reviews of serious suicide attempts by the CIRC. The Monitor is satisfied that CCSB is ensuring that CHS and the Department are timely and thoroughly conducting administrative review of suicides and serious suicide attempts in the jails as required by Compliance Measure 77-2(a).
(b) "Patterns and trends and statistical analysis of suicides and serious suicide
47 Although the report did not summarize the August 8, 2017 30-day review of the July 3, 2017 suicide, minutes of that review were posted for Paragraph 76(2) and Compliance Measure 76-2.
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attempts in jails." This section again reports on cross-sectional data during the most recent reporting period and concludes that "these incidents occurred mostly between the hours of 1200-23, by ligature/hang[ing] made from clothing and or torn mattress. There appear to be no other patterns or trends from these incidents." The Mental Health Subject Matter Expert observes that the "quality of the analysis is marginal at best. . . ,[A]nalysis is not just a matter of reporting numbers – actual, formal analysis is needed that will sometimes require statistical evaluation."48
(c) "Corrective action taken by the department to mitigate suicide risks" section. This describes the corrective action plans taken by the Department in addition to the cross-referenced CAPs discussed at the suicide review meetings under the "Administrative Review of Suicides" section and the CAPs discussed by CIRC in its reviews of serious suicide attempts and other incidents involving self-directed violence. Taken together with CHS's Semi-Annual Report, this satisfies the requirements of Compliance Measures 77-2(c).
(d) "Technical issues provided to, or obtained for other administrative units within the Custody Division to address suicide-risk issues." This section describes the creation of the electronic BOMHR form "to improve tracking and ensure that each entity (e.g., custody, medical, mental health) completes the form. It also describes the roll-out and training of the use of the electronic form. It satisfies the requirements of Compliance Measure 77-2(d).
(e) "Analysis of staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts." This section reports that the Executive Review of the suicide that occurred during the Fifth Reporting Period concluded that "staffing levels had no bearing on the ability to discover the inmate in distress, or on the subsequent life saving measures." Although it does not analyze whether staffing levels had any bearing on the 29 incidents of serious suicide attempts/self-directed violence that were analyzed by the CIRC, the County notes that the CHS Semi-Annual Report indicates that the issue of staffing levels was raised in the CIRC meeting for seven of the incidents "when appropriate." It is not clear, however, what makes the issue appropriate for some incidents, but not others, and why it was not analyzed in every case.49 A sub-section reports that classification was not an issue for "for the inmate who committed suicide" during the Fifth Reporting Period and that it was an issue for an inmate who attempted suicide during the period. It also reports that the "Department has identified a trend of inmates who may engage in suicidal or self-injurious behaviors" that raise housing issues, and what steps the Department has taken to address these behaviors. Finally, a sub-section on Employee Performance
48 Even taking into consideration the "relevant data and analysis regarding suicides and serious attempts in jails" in the CHS Semi-Annual Report and the County's Supplemental Response to Provision 61, there needs to be a more formal analysis of the data. For example, as noted by DOJ, the charts and graphs "do not compare incident rates for one group with another, or show whether there were meaningful changes with a particular group over time." 49 For example, the CIRC meeting on October 12, 2017, identified "Was staffing an issue for this incident" in three of the four cases reviewed, but it is not clear why it was not reviewed in the fourth case or why the fourth case was different from the other cases.
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reports that "[d]uring each Executive Death Review and CIRC meeting, employee performance is examined," and an administrative investigation was opened regarding the Title 15 safety checks that were conducted immediately prior to the suicide on July 3, 2017.
(f) "Remedial measures, including policy revisions, re-training, or staff discipline, to address issues related to suicide and serious suicide attempts." This describes the remedial measures taken by Custody Division as a result of the May 25, 2017 suicide at the Crescenta Valley station, and notes than an administrative investigation was opened as a result of the July 3, 2017 suicide at TTCF. It does not, however, report on the results of either administrative investigation, notwithstanding that both investigations were opened more than six months before the report was submitted to the Monitor.
(g) "Summaries of meeting with DMH to develop, implement, and track corrective action plans." This section reports that "[c]orrective action plans are primarily discussed with CHS at CIRC meeting and secondarily discussed with CHS at JQIC [Joint Quality Improvement Committee] meetings." The CIRC meetings are summarized in the CHS semi-annual report, see pp. 62-3 , supra, and this section of the CCSB report summarizes the status of the corrective actions plans that were discussed by staff members from CHS, CCSB, and the involved jail facilities at the JQIC meetings. In most cases, the corrective action plans were completed before the JQIC meetings and most of the open items were placed on a tracker assigned to CHS
Paragraphs 60 and 62 of the Settlement Agreement, in particular, impose obligations on CCSB to work with CHS to "implement a quality improvement plan to identify and address clinical issues that place prisoners at significant risk of suicide and self-injurious behavior" and "develop, implement and track corrective action plans addressing recommendations of the quality improvement program." Further, as noted by the Mental Health Subject Matter Expert, "cooperation and sharing of information are necessary" to address many other provisions of the Settlement Agreement. He has not seen "evidence of an overarching Q[uality] M[anagement] approach at the Department."
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of June 1, 2016, through May 18, 2017)
Substantial Compliance requires (1) the Committee to meet twice per year and (2) "recommend coordinated approaches to suicide prevention in the Jails."
The County maintained Substantial Compliance with paragraph 78 for twelve consecutive months as of May 18, 2017, and this provision was not subject to monitoring in the Fifth Reporting Period.
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; provide a description of the medication support services available for prisoners who are not in mental health housing and who are receiving psychotropic medications; and randomly select and review electronic medical records of prisoners who reside outside of mental health housing and receive psychotropic medications to confirm that medication support services were provided to these prisoners.
The County’s Fifth Self-Assessment reports that in the Second Quarter of 2017, 67% of the prisoners who reside outside of mental health housing and were receiving psychotropic medications were "provided with medication support services," which is below the 85% threshold required by Compliance Measure 79.5(d) for Substantial Compliance. For the Third Quarter of 2017, 66% of such prisoners were provided the support services.
The County's Fifth Self-Assessment does not address Compliance Measures 79.1(a)-(c) and 79.5(b), which require the County to maintain records of "therapeutically appropriate" visits and programming by QMHPs.
As noted in the Monitor's Third and Fourth Reports, a finding of Substantial Compliance with Paragraph 79(a) is subject to a determination by the Monitor, after consultation with the Subject Matter Expert, "that the treatments are clinically appropriate." The County's Fifth Self-Assessment reports that it is continuing "to work to
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identify and overcome challenges to providing appropriate therapeutic treatment to patients in the jails. At present, the County is pursuing staffing solutions to bring down caseload sizes which remain a hindrance to providing consistent, quality therapeutic treatment and medication support services." The Mental Health Subject Matter Expert believes that the new pilot program in HOH at TTCF will facilitate clinically appropriate treatment.
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business workday. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

NON-COMPLIANCE

Paragraph 80 requires that, "no later than 18 months after the Effective Date [July 1, 2015]," 100% of the prisoners in HOH receive "ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week." The parties have agreed that up to five hours of the structured time can consist of education or work programs, but at least five hours of the time must be therapeutic.

The County's posted results for the Third Quarter of 2017 shows that 45% of the prisoners at CRDF and 79% of the prisoners at TTCF were offered 10 or more hours of unstructured, out-of-cell recreational time. The County did not, however, report on the percentage of prisoners who were offered 10 or more hours of structured therapeutic or programmatic time per week.

Further, the Department did not provide documentation relating to prisoners in HOH who refused to leave their cells during the period reviewed by the County. The Mental Health Subject Matter Expert previously expressed "serious concerns about how the County is tracking out of cell time" because it counts as out-of-cell time "large numbers of hours when the inmate was not in fact out of his or her cell," categorizing it as "refused/ineligible." The Mental Health Subject Matter Expert and the clinicians noted that "some hours are being double counted," and "group times are being counted for the whole time a patient is out of the cell" even if the group session has not begun or has ended.

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81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
Policies approved by the Rosas Monitors and adopted by the Department in the First Reporting Period implemented the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
In the Second Reporting Period, the Rosas Monitors approved policies to implement the following provisions of the Rosas Implementation Plan: Paragraphs 6.16.20 (grievance system); Paragraph 8.2 (combining "Complaints of Retaliation"). They also approved revised policies to implement Paragraphs 13.1-13.2 (discipline for PREA violations, dishonesty, and failure to report force incidents).
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 of the Rosas Implementation Plan reflect training requirements that were supposed to be, but were not, completed by December 31, 2016. This is due in part to the delays that have occurred in the review and approval of the Department's use of force and investigations training program. As previously noted, the Monitor does not believe that it is essential for the training to have been completed by the end of 2016 as long as the Department continues to meet the required thresholds for new deputies until it achieves the thresholds for existing deputies. At that time, virtually all of the personnel in the jails will have received the required training in either the Jail Operations Continuum or in-service training.
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Paragraphs 4.10 and 9.1 are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Finally, the Early Warning System to implement Paragraphs 19.1-19.3 will be completed in future reporting periods, at which time the Department can achieve Substantial Compliance with Paragraph 81 at CRDF and PDC North jail facilities.
In the Fifth Reporting Period, the Monitor reviewed 33 randomly selected completed force packages for CRDF, NCCF, and PDC North, some of which were also reviewed by the Use of Force Subject Matter Expert. Unfortunately, the Use of Force Subject Matter Expert tragically passed away in Los Angeles on November 3, 2017, after touring CRDF with the Monitor. During the tour the Monitor and the Use of Force Subject Matter Expert discussed the expert's views on the use of force by Department personnel at CRDF. The Monitor also reviewed the expert's notes on some of the force packages he reviewed, but the expert did not prepare a report reflecting his observations before he passed away. The Monitor concluded that the Department is complying with its policies regarding the use of force and documentation of force incidents at CRDF and PDC North jail facilities, and that the force investigations are thorough and complete. In some cases, however, the Monitor was unable to determine whether the Department was in compliance with policies pertaining to the timeliness of reports and the interviews of inmate witness. The Department intends to address this by including a checklist in force packages setting forth whether the use, reporting and investigation of the force complied with applicable provisions of the Rosas Implementation Plan.
The only issue noted by both the Monitor and the Subject Matter Expert was the Department's policy to use chemical spray in every cell extraction of mentally ill inmates, regardless of the inmate' criminal history, propensity for violence, and size. In some cases involving smaller female inmates refusing to come out of the cells for court or for transfers to medical facilities, the Monitor and Subject Matter Expert question whether it was necessary to use a chemical spray before entering the cell to extract the inmate. The Department should look at other force options in these cases and consider the use of chemical spray on a case-by-case basis rather than as a default policy.
During the Fifth Reporting Period, the Department took steps to expedite the completion of force packages so that all of the force packages reviewed by the Monitor and Subject Matter Expert pertained to force incidents in 2017. This was a significant improvement from the prior reporting periods.
All of the force incidents at CRDF and PDC North reviewed by the Monitor and Subject Matter Expert were captured on fixed closed circuit television cameras at CRDF and PDC North. Although the closed circuit camera televisions is not required to be fully operational at NCCF until July 1, 2018, all of the force incidents at NCCF reviewed by the Monitor during the Fifth Reporting Period were captured on the CCTV's that have been installed at NCCF.
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During the Fifth Reporting Period, the Monitor met with the Inmate Grievance Teams at CRDF and NCCF on November 2 and 28, 2017, respectively. At CRDF the grievance team has continued to improve the tracking of inmate grievances, and also made progress in reducing the back-log of overdue grievance investigations. As of November 2, 2017, when the Monitor and Subject Matter Expert visited CRDF, there were 59 open grievance investigations, of which 20 had been opened for more than 30 days. From reviewing some of the investigations, it appears that many open for more than 30 days should have been closed out for various reasons (e.g., misclassified as a grievance rather than a request, involved grievance about food that should have been resolved by Food Services).
The Monitor also noted a significant improvement in the tracking and handling of inmate grievances at NCCF during this period. The grievances are now tracked electronically by the NCCF Grievance Team, which provided the Monitor and the DOJ representative with a list detailing all of the outstanding grievances against staff. As of November 28, 2017, there were 35 open grievances, 19 against staff and 16 that did not involve staff. Twelve of the grievances against staff were open for more than 30 days, although several were simply waiting for a commander's review or signature. None of the non-staff grievances were open for more than 30 days. The staff at NCCF also reported that 99.2% of the requests have been completed and that most are handled immediately by the floor sergeants.
Finally, the Monitor also met with the Division Inmate Grievance Coordinator who has oversight responsibility for the implementation of the new grievance system to discuss improvements to the tracking system that are being implemented throughout the Custody division. He reported continued improvement in the tracking and expeditious handling of inmate grievances. Overall, the Monitor noted significant progress in the Department's handling of inmate grievances at CRDF and NCCF, and the continued efforts at PDC North to address the relatively few grievances from PDC North and PDC South.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 15, 2016, through December 31, 2017)
The Rosas Monitors have approved a de-centralized inmate grievance system, which includes an Inmate Grievance Team co-located at Century Regional Detention Facility. The Department published its new grievance policies on July 15, 2016.
CRDF has its own Inmate Grievance Team with the staffing required by CDM 801.020.00. The Monitor met with CRDF's Inmate Grievance Team during the Fifth Reporting Period and reviewed the operation of the grievance system at CRDF.
The County has maintained Substantial Compliance with Paragraph 82 for twelve consecutive months and, pursuant to Paragraph 111, this provision is no longer subject to monitoring.
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83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement ("Common Areas"), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.
STATUS: SUBSTANTIAL COMPLIANCE (as July 1, 2015, through June 30, 2016 at MCJ and IRC)
SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at TTCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31 2017 at CRDF)
NOT CURRENTLY SUBJECT TO MONITORING (REMAINING FACILITIES)
The Monitor and Use of Force Subject Matter Expert toured CRDF during the Fifth Reporting Period, and they confirmed that the closed circuit security cameras were operational in the Common Areas at that facility. The Department reported that all of the 534 cameras installed at CRDF were operational on the day of the visit.
The Monitor has previously verified that the County has maintained Substantial Compliance for twelve consecutive months with Compliance Measure 83.8(a) at MCJ, IRC, TTCF, and CRDF by reviewing videos of force incidents in common areas to verify the accuracy of information on inventories provided by the Department.
Paragraph 83 also requires the Department to provide evidence that all video recordings of force incidents were adequately stored and retained for a period of at least one year after the force incident occurs. The County's Fifth Self-Assessment reports that it has achieved Substantial Compliance for this measure at CRDF, IRC, MCJ and TTCF through the Third Quarter of 2017. CRDF is still subject to this requirement of Paragraph 83 until March 31, 2018.
The County has maintained Substantial Compliance with Paragraph 83 at IRC, MCJ, and TTCF for twelve consecutive months and, pursuant to Paragraph 111, it is no longer subject monitoring at these facilities.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:

(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and

(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.

STATUS:

SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through September 30, 2017 (verified) and through December 31, 2017 (unverified)

Substantial Compliance under the Compliance Measures requires the Department to demonstrate that 95% of the investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies. Although Paragraph 84 requires the Department to implement policies for the "timely and thorough" investigation of force incidents, the subparagraphs and the Compliance Measures are focused on the timeliness of the completion of the investigations resulting in the imposition of discipline. The Monitor's determination of the Department's compliance with Paragraph 84 will be largely based upon the timeliness of the completion of the investigations, but the Monitor also has randomly selected and reviewed several internal investigations, which appeared to be thorough and unbiased.

The County’s Fifth Self-Assessment reports that after having achieved Substantial Compliance in the Third Quarter of 2016 through the First Quarter of 2017, the Department did not achieve Substantial Compliance in the Second Quarter of 2017. This requires that the twelve-month period for maintaining Substantial Compliance to start over with the next reporting period for which the Department achieved Substantial Compliance, which was the Third Quarter of 2017. The reported results have been verified by the Monitor's auditors.

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85. The County and the Sheriff will ensure that Internal Affairs Bureau management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training. The County's posted results show that only 40% of the IAB investigators completed all three of the required courses as of September 30, 2017, which is a decrease of 17% since the First Quarter of 2017.
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86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 at MCJ and CRDF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2017 at PDC North)
SUBSTANTIAL COMPLIANCE (as of February 1, 2017, through December 31, 2017 at PDC South and PDC East)
SUBSTANTIAL COMPLIANCE (as of March 1, 2017 through December 31, 2017 at NCCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through September 30, 2017 at IRC)
PARTIAL COMPLIANCE (at TTCF)
CDM 7-08/080 ACCOUNTABILITY OF SPECIALWEAPONS, effective October 14, 2016, requires each facility to have unit orders that "establish procedures for the storage, issuance, reissuance, accountability, maintenance, and periodic inventory of all weapons. . . stored at, or issued from, the facility," which includes detailed requirements for the "Inventory, Control, and Accountability of Aerosol Chemical Agents."
In addition to providing written policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment, Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with up-to-date Unit Orders for each jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons.
The Monitor and Use of Force Subject Matter Expert inspected the armories at CRDF, TTCF, and IRC on November 2, 2017. The Monitor inspected the armories and sub-armories at NCCF, PDC North and PDC South on November 28, 2017, and checked the available inventory logs.
The inventory logs were checked daily in the CRDF, IRC, PDC North, and TTCF armories, and weekly in the PDC South armory. 50 The main armory and the subarmories at NCCF are checked daily and the inventories matched the weapons in the sub-
50 Because PDC East is a fire camp with very few inmates, weapons in the armory are almost never used.
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armories. Each of these facilities has reasonably up-to-date unit orders and all weapons were accounted for during recent inspections. The Department submitted the required armory audit logs for all of the facilities that were subject to monitoring for Second and Third Quarters of 2017.
The Department has maintain Substantial Compliance with Paragraph 86 for twelve consecutive months at MCJ, CRDF, and PDC North. Pursuant to Paragraph 111, the armory at MCJ was not subject to monitoring in the Fifth Reporting Period and the armories CRDF and PDC North are no longer subject to monitoring in future reporting periods. If PDC South, PDC East, and IRC maintain Substantial Compliance in the First Quarter of 2018, these facilities will no longer be subject to monitoring in future periods.
The Monitor and Use of Force Subject Matter Expert noted continuing problems in the armories at TTCF. They reviewed the daily inventory list in the main armory, which was generally accurate except the inventory list did not reflect the number of rounds for one item that was on the master inventory list, and deputies routinely (and erroneously) confirmed that the number of rounds matched the wrong number on the inventory sheet. The main armory appeared, however, to be otherwise in good condition, and it was easy to locate the weapons and rounds of ammunition in the armory.
Similar inventory problems existed in the sub-armories at TTCF, where the master inventory lists did not accurately reflect what was in the sub-armories. In addition, in filling out the daily inventory sheets, deputies failed to account for rounds on the master lists that were actually in the sub-armories. It was relatively easy to locate weapons and rounds in one of the two sub-armories, but the other sub-armory was not as well-organized and had unnecessary and unused equipment. While there has been improvements in the TTCF armory and sub-armories, it has not achieved Substantial Compliance like the armories at the other facilities.
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APPENDIX A

NO. PROVISION 18 Suicide Prevention Training

STATUS
Substantial Compliance (MCJ, NCCF, PDC South, & PDC East) Partial Compliance (TTCF, CRDF, IRC, & PDC North)

SUBSTANTIAL COMPLIANCE DATES (10/1/17 at MCJ & PDC South) (9/1/17 at NCCF) (12/1/17 at PDC East)

19 Crisis Intervention &

Partial Compliance

Conflict Resolution Training

20 Training at NCCF, PDC and Substantial Compliance (PDC

CRDF

East, PDC North, PDC South,

NCCF & CRDF)

(8/1/17 at PDC East, PDC North, NCCF & CRDF)1 10/1/17 at PDC South)

21 CPR Certification

Substantial Compliance (NCCF, PDC East, PDC North & PDC South, TTCF, IRC, & MCJ) Non-Compliance (CRDF)

(10/1/15 – 9/30/16 at PDC East & PDC South) (1/1/16 – 12/31/16 at NCCF, PDC North & IRC) (4/1/16 – 3/31/17 at TTCF) (10/1/16 – 12/31/17) (MCJ)

22 Use of Arresting and Booking Documents

Substantial Compliance

(7/1/16 – 6/30/17)

23 Suicide Hazard Mitigation Plans

Substantial Compliance

(1/1/18)

24 Suicide Hazard Inspection Substantial Compliance

(10/1/17)

25 Transportation of Suicidal Inmates (station jails)

Partial Compliance

1 Substantial Compliance Dates in bold reflect that the Department has achieved Substantial Compliance with the training requirements or maintained Substantial Compliance for twelve consecutive months with the other requirements; the results were verified by the Monitor's auditors when required; and the County or designated facilities are no longer subject to monitoring of this provision pursuant to paragraph 111 of the Settlement agreement.

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APPENDIX A

26 Identification and Evaluation Partial Compliance of Suicidal Inmates

27 Screening for Mental Health Partial Compliance Care and Suicide Risk

28 Expedited Booking of Suicidal Inmates

Substantial Compliance (IRC) Partial Compliance (CRDF)

29 Mental Health Assessments Substantial Compliance (of non-emergent mental health needs)

30 Initial Mental Health Assessments & Treatment Plans

Partial Compliance

31 Electronic Medical Records

Alerts

Partial Compliance

32 Electronic Medical Records Substantial Compliance – Suicide Attempts

33 Supervisor Reviews of

Substantial Compliance

Electronic Medical Records

34 Discharge Planning

Stayed Pending Litigation

35 Referral for Mental Health Care

Non-Compliance

36 Assessments After Triggering Events

Partial Compliance

37 Court Services Division Referrals

Partial Compliance

38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

(4/1/17 – 12/31/17 at IRC) (4/1/17 – 12/31/17)
(1/1/16 – 12/31/16) (7/1/16 – 6/30/17)
(1/1/16 – 12/31/16)

39 Confidential Self-Referral

Substantial Compliance (PDC South, PDC North, TTCF, & NCCF)

(4/1/17 – 9/30/17 at PDC South) (7/1/17 – 9/30/17 at

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APPENDIX A

40 Availability of QMHPs 41 FIP Step-Down Protocols 42 HOH Step-Down Protocols
43 Disciplinary Policies 44 Protective Barriers 45 Suicide Intervention and
First Aid Kits

Partial Compliance (MCJ & CRDF)
Partial Compliance
Not Rated
Partial Compliance (CRDF) Non-Compliance (TTCF)
Partial Compliance
Substantial Compliance
Substantial Compliance

46 Interruption of Self-Injurious Partial Compliance Behavior

47 Staffing Requirements

Partial Compliance

48 Housekeeping and Sanitation Substantial Compliance

49 Maintenance Plans

Substantial Compliance

TTCF, NCCF, & PDC North)
(1/1/16 – 12/31/16) (10/1/15 – 9/30/16 CRDF, NCCF, TTCF, PDC East & PDC South) (1/1/16 – 12/31/16 MCJ & PDC North)
(1/1/16 – 12/31/16) (3/1/16 – 2/28/17)

50 Pest Control

Substantial Compliance

51 Personal Care & Supplies Substantial Compliance

(1/1/16 – 12/31/16 MCJ, NCCF, PDC North, TTCF, CRDF) (4/1/16 – 3/31/17 PDC South & PDC East)
(1/1/16 – 12/31/16 MCJ, NCCF, PDC East, PDC North, PDC South, and TTCF) (7/1/16 – 6/30/17 CRDF)

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APPENDIX A

52 HOH Property Restrictions 53 Eligibility for Education,
Work and Programs 54 Privileges and Programs 55 Staff Meetings
56 Changes in Housing Assignments
57 Inmate Safety Checks in Mental Housing
58 Inmate Safety Checks in Non-Mental Housing
59 Supervisor Rounds
60 Implementation of Quality Improvement Program
61 Requirements of Quality Improvement Program
62 Tracking of Corrective Action Plans

Partial Compliance Partial Compliance

Substantial Compliance

(1/1/16 – 12/31/16)2

Substantial Compliance (CRDF, PDC North, & MCJ) Partial Compliance (TTCF)

(10/1/16 – 9/30/17 at CRDF) (4/1/17 – 9/30/17 at MCJ & PDC North)

Substantial Compliance

(1/1/16 – 6/30/17)

Substantial Compliance (MCJ) Partial Compliance (TTCF, CRDF & PDC North)

(7/1/17 – 9/30/17 MCJ)

Substantial Compliance (PDC South, PDC North, PDC East, CRDF & TTCF) Partial Compliance (IRC, MCJ & NCCF)

(1/1/16 – 12/31/16 at PDC South, PDC North & PDC East) (7/1/17 – 9/30/17 at CRDF & TTCF)

Substantial Compliance (at PDC North, PDC East, MCJ & NCCF) Partial Compliance (at CRDF, TTCF & PDC South)
Partial Compliance

(1/1/17 – 9/30/17 at PDC North, PDC East & MCJ) (4/1/17 – 9/30/17 at NCCF)

Partial Compliance

Partial Compliance

63 Sufficient HOH and MOH Housing

Partial Compliance (at TTCF) Non-Compliance (at CRDF)

2 Per agreement of the parties, the County must maintain Substantial Compliance for two additional quarters under the revised Compliance Measures.

Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 108 of 111 Page ID #:2950
APPENDIX A

64 Plans for Availability of Inpatient Health Care

Partial Compliance

65 Administration of Psychotropic Medication
66 Active Mental Health Caseloads
67 Prisoner Refusals of Medication
68 Contraband Searches
69 Clinical Restraints in CTC

Non-Compliance

Non-Compliance

Non-Compliance

Substantial Compliance (at MCJ, NCCF, PDC East, PDC South & PDC North, CRDF & TTCF)Partial Compliance (at CRDF & TTCF)

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC East, PDC South, & PDC North)

Partial Compliance

70 Security Restraints in HOH Partial Compliance and MOH

71 Therapeutic Services for

Substantial Compliance

Inmates in Clinical Restraints

72 Administrative Reviews

Substantial Compliance

73 Reporting of Self-Injurious Partial Compliance Behavior and Threats

74 Law Enforcement Investigations of Suicides

Substantial Compliance

(7/1/16 – 6/30/17) (1/1/17 – 12/31/17)3
(9/1/16 – 12/31/17)

75 Management Reviews of Suicide Attempts
76 Management Reviews of Suicides

Partial Compliance Substantial Compliance

(9/1/16 – 12/31/17)

3 This is subject to a qualitative assessment by the Monitor and Subject Matter Expert

Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 109 of 111 Page ID #:2951
APPENDIX A

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Substantial Compliance Committee

79 Therapeutic Services in Mental Health Housing

Non-Compliance

80 Out-of-Cell Time in HOH Non-Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

82 Collection of Grievances at Substantial Compliance CRDF

83 Closed Circuit Cameras

Substantial Compliance (MCJ, TTCF, IRC, & CRDF) Not Currently Subject to Monitoring (Remaining Facilities)

84 Investigation of Staff Misconduct

Substantial Compliance

85 Internal Affairs Bureau Training

Non- Compliance

(6/1/16 – 5/18/17)
(7/15/16 – 12/31/17)
(7/1/15 – 6/30/16 at MCJ & IRC) (10/1/15 – 9/30/16 TTCF) (4/1/16 – 3/31/17 at CRDF)4 (7/1/17 – 12/31/17)

86 Maintenance and Inventory Substantial Compliance (at MCJ, (4/1/16 – 3/31/17 at

of Security Equipment

CRDF, PDC North, PDC South MCJ & CRDF)

PDC East, NCCF & IRC)

(10/1/16 – 12/31/17 at

Partial Compliance (at TTCF) PDC North)

(2/1/17 – 12/31/17 at

4 Paragraph 83 also requires the Department to maintain video recording of force incidents for at least one year. This requirement is still subject to monitoring at CRDF until 3/31/18.

Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 110 of 111 Page ID #:2952
APPENDIX A
PDC South & PDC East) (3/1/17 – 12/31/17 at NCCF) (4/1/17 – 9/30/17 IRC)

Case 2:15-cv-05903-DDP-JEM Document 139 Filed 03/01/18 Page 111 of 111 Page ID #:2953
APPENDIX B

Substantial Partial

Non-

Substantial

Compliance Compliance1 Compliance Compliance

(Provisions)

(Facilities)

No Longer
Subject To Monitoring2

First3

5

16

104

Second 14

30

13

24

Third

22

27(1)

10

29

4(2)

Fourth 24

26(1)

10

29

10(2)

Fifth

23

24(2)

7

34

15(5)

1 The figure in parenthesis under Partial Compliance is the number of additional
provisions where some facilities were in Partial Compliance and other facilities were in Non-
Compliance. 2 The figure in parenthesis under No Longer Subject to Monitoring is the number of
additional provisions where some facilities are no longer subject to monitoring. 3 During the First Reporting Period, 43 provisions were not subject to monitoring. 4 This represents the number of provisions where the Department is in Substantial
Compliance at all or some of the facilities.

 
 Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 1 of 117 Page ID #:2956

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) 601 West Fifth Street, 12th Floor

3 Los Angeles, CA 90071-2025

4

Telephone: (213) 613-4655 Facsimile: (213) 613-4656

5 Email: rdrooyan@scheperkim.com

6 Monitor 7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

WESTERN DIVISION

11

12 UNITED STATES OF AMERICA,

13

Plaintiff,

14

15

v.

CASE NO. 15-cv-05903 DDP (JEMx) MONITOR’S SIXTH REPORT

16 COUNTY OF LOS ANGELES AND LOS ANGELES COUNTY SHERIFF
17 JIM MCDONNELL, in his Official Capacity,
18 Defendants.
19

20

21

22

23

24

25

26

27

28

MONITOR'S SIXTH REPORT

CASE NO. 15-cv-05903 DDP (JEMx)

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 2 of 117 Page ID #:2957

1

Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and the

4 Los Angeles County Sheriff during the six-month period from January 1, 2018,

5 through June 30, 2018, “to implement the Agreement and evaluating the extent to

6 which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

12

13 DATED: August 31, 2018

Respectfully submitted,

14

SCHEPER KIM & HARRIS LLP

15

RICHARD E. DROOYAN

16

17

18

By: /s/ Richard E. Drooyan Richard E. Drooyan

19

Monitor

20

21

22

23

24

25

26

27

28

- 1 -

CASE NO. 15-cv-05903 DDP (JEMx)

MONITOR’S SIXTH REPORT

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 3 of 117 Page ID #:2958
MONITOR’S SIXTH REPORT
This Sixth Report sets forth the Monitor’s assessments of the implementation of the Settlement Agreement (the "Agreement") between the County of Los Angeles (the "County") and the United States Department of Justice ("DOJ") for the treatment of mentally ill inmates in the County’s jail facilities by the Los Angeles Sheriff’s Department (the "Department") and the County's Department of Health Services ("DHS").1 It covers the County's reported results for the period from January 1, 2018, through June 30, 2018 (the "Sixth Reporting Period").
As used herein, "Substantial Compliance" means that the County has "achieved compliance with the material components of the relevant provisions of this Agreement in accordance with the [agreed-upon Compliance Measures for assessing Substantial Compliance]," which it must maintain for twelve-consecutive months; "Partial Compliance" means that the County has achieved "compliance on some, but not all, of the material components of the relevant provision of this Agreement;" and "NonCompliance" means that the County has not met "most or all of the material components of the relevant provisions of this Agreement."
This Sixth Report is based upon the Monitor's review of the policies, procedures, and directives proposed and/or implemented by the Department and Correctional Health Services ("CHS") in the Sixth Reporting Period; assessments and observations of the Subject Matter Expert; tours of the jails by the Monitor, the Subject Matter Expert, and the two clinicians retained by the Monitor; the County’s Self-Assessment Status Report (the "Sixth Self-Assessment"), which was received on June 15, 2018; and the augmented Self-Assessment Status Report (the "augmented Sixth Self-Assessment"), which was received on July 16, 2018, and results reported through that date. It also takes into consideration the comments the Monitor received from the County and DOJ on the draft of this Report that was submitted to the parties on August 1, 2018, and the County's responses to DOJ's comments.
During the Sixth Reporting Period, the Mental Health Subject Matter Expert, with the assistance of the clinicians, conducted additional qualitative assessments of the County's compliance with certain Substantive Provisions in the Settlement Agreement, and they again used different methodologies to test some of the County's reported results. The Monitor's determination of the County's compliance, with the advice of the Subject Matter Expert, is based upon the quantitative thresholds in the Compliance Measures (and any other applicable requirements in the Compliance Measures), unless the quality of the County's performance as determined by the qualitative assessment is plainly inadequate or the results reported by Subject Matter Expert vary significantly from the results reported by the Department.
During the Sixth Reporting period, the County established compliance with additional provisions of the Settlement Agreement, and made progress in addressing the
1 The Department of Health Services includes Correctional Health Services, which is responsible for Medical and Mental Health Services in the Los Angeles County jails.
1

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 4 of 117 Page ID #:2959
significant challenges to achieving and maintaining Substantial Compliance with respect to its quality improvement plans. It still faces those challenges with respect to therapeutic services and out-of-cell time, in particular. The County is also facing challenges in privately screening inmates at IRC and CRDF and timely identifying inmates with mental health needs. A pilot program intended to have nurses do all of the screenings in private appears to have unintended consequences of delaying the initial screenings and, consequently, the identification of inmates with mental health needs, including in some cases urgent or emergent mental health needs. The County is in the process of revamping the program to address this problem.
As in prior reports, this Sixth Report reflects the results of audits by the Monitor's auditors to verify results reported by the County. The Monitor has deemed the County to be in Substantial Compliance "as of" the beginning of the quarter reported by the County if the auditors have verified that the County has met the thresholds in the Compliance Measures. If the auditors were not able to verify the results reported by the County, the twelve-month period for maintaining Substantial Compliance will commence in a future period when the County's reported results are verified by the auditors. If the County maintains Substantial Compliance with a provision for twelve consecutive months, pursuant to Paragraph 111 of the Agreement, the Monitor and Subject Matter Experts will "no longer. . .assess or report on that provision" in future reporting periods.
Some of the Substantial Compliance results reported by the County in the Sixth Reporting Period have not been audited by the Monitor’s auditors and cannot be considered final until verified by the auditors. The County will not be deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the twelve-month compliance period if the results are not verified by the auditors.
Appendix A to this Sixth Report shows the status of each of the 69 provisions of the Agreement that are subject to monitoring and the twelve-month triggering dates where the County is deemed to be in Substantial Compliance. Appendix B shows the County's progress from the Initial Reporting Period through the Sixth Reporting Period in achieving Substantial Compliance and in maintaining Substantial Compliance for twelve consecutive months on provisions that are no longer subject to monitoring.
As has been the case since the beginning of the Initial Reporting Period, the County cooperated completely with the Monitor and the Subject Matter Experts during the Sixth Reporting Period. The Department, DHS, and County Counsel facilitated our visits and inmate interviews, answered our questions, and responded to our requests for documents and information. We appreciate their responsiveness, transparency, professionalism, and courtesy in handling our monitoring requests.
Richard Drooyan, Monitor August 31, 2018
2

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EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the County and the Department are in Substantial Compliance with 32 provisions, in Partial Compliance with 22 provisions, and in Non-Compliance with 7 provisions. In addition, there are 5 provisions in which the Department is in Substantial Compliance at some facilities and in Partial Compliance or Non-Compliance at other facilities. There is also one provision (Paragraph 34), that remains stayed pending litigation initiated by third party intervenors, one provision (Paragraph 41) that is Not Rated, and one provision (Paragraph 39) for which the Department is in Substantial Compliance at certain facilities, Partial Compliance at other facilities, and Not Rated at other facilities. There are 38 provisions for which the County and the Department are in Substantial Compliance at some or all of the facilities.2
There are 18 provisions that are no longer subject to monitoring because the County and Department maintained Substantial Compliance for twelve consecutive months as required by Paragraph 111 of the Settlement Agreement. There are another 9 provisions for which some facilities are no longer subject to monitoring because those facilities maintained Substantial Compliance for the required twelve consecutive months.3
As of the date of this Report, and subject to verification by the Monitor's auditors and qualitative assessments in some cases, the County and the Department are in Substantial Compliance at some or all of the facilities with the following provisions of the Settlement Agreement:
The County has provided documentation reflecting that the County has achieved Substantial Compliance at Men's Central Jail ("MCJ") and Pitchess Detention Center ("PDC") South as of October 1, 2017, at North County Correctional Facility ("NCCF") as of September 1, 2017, at PDC East as of December 1, 2017, at Twin Towers Correctional Facility ("TTCF"), the Inmate Reception Center ("IRC") and PDC North as of April 1, 2018, and at Century Regional Detention Facility ("CRDF") as of June 1, 2018, with Paragraph 18, which requires the training of Deputy Sheriffs and Custody Assistants on suicide prevention. The results are subject to verification by the Monitor's auditors.
The County has achieved Substantial Compliance at PDC East, PDC North, NCCF, and CRDF as of August 1, 2017 and at PDC South as of October 1, 2017, with Paragraph 20, which requires the training of Deputy Sheriffs on Crisis Intervention and Conflict Resolution and on working with mentally ill prisoners.
The County has maintained Substantial Compliance for twelve consecutive
2 Under Paragraph 111 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis. 3 The provisions that are no longer subject to monitoring at some are all of the facilities are highlighted in bold in Appendix A.
3

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 6 of 117 Page ID #:2961
months at PDC East, PDC South, PDC North, NCCF, IRC, and TTCF with Paragraph 21, which requires Custody personnel to maintain CPR certifications. The County also has maintained Substantial Compliance for six consecutive months at MCJ. The results for MCJ are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 22, which requires the County and the Sheriff to provide instructional material on the use of arresting and booking documents to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.
The County has maintained Substantial Compliance for twelve consecutive months as of January 1, 2018, with Paragraph 23, which requires that the Department conduct a systematic review of prisoner housing to reduce the risk of self-harm and to identify and address suicide hazards, and to develop plans to reasonably mitigate suicide hazards identified in the review.
The County has achieved Substantial Compliance as of October 1, 2017, with Paragraph 24, which requires the Department to conduct annual reviews and inspections of prisoner housing to identify suicide hazards.
The County has achieved Substantial Compliance as of October 1, 2017, through March 31, 2018 with Paragraph 27, which requires the Department ensure that all prisoners are screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. These results are subject to verification by the Monitor’s auditors.
The County has achieved Substantial Compliance at IRC as of April 1, 2017, through March 31, 2018 and at CRDF as of January 1, 2018, through March 31, 2018, with Paragraph 28, which requires the Department to expedite inmates having urgent or emergent mental health needs through the booking process.
The County has provided documentation reflecting that, as of April 1, 2017, through March 31, 2018, it achieved Substantial Compliance with Paragraph 29, which requires mental health assessments of prisoners with non-emergent mental health needs within 24 hours of the intake nursing assessment. The reported results are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 32, which requires that a serious suicide attempt be entered in the prisoner’s electronic medical record in a timely manner.
The County has provided documentation reflecting that, as of July 1, 2016, through June 30, 2017, it achieved Substantial Compliance with Paragraph 33, which requires mental health supervisors to review electronic medical records on a quarterly
4

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 7 of 117 Page ID #:2962
basis to assess their accuracy. These results are subject to verification by the Monitor's auditors and a qualitative assessment by the Subject Matter Expert.
The County has achieved Substantial Compliance as of November 1, 2017, through March 31, 2018 with Paragraph 35, which requires the Department ensure that custody staff refer prisoners who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules to identify prisoners with mental illnesses and grant prisoner's requests for out-of-cell interviews.
The County has provided documentation reflecting that it achieved Substantial Compliance at NCCF as of July 1, 2017 through March 31, 2018, and at CRDF as of October 1, 2017 through March 31, 2018, with Paragraph 39, which requires the County to use a confidential self-referral system for prisoners to request mental health care. The results are subject to verification by the Monitor's auditors and a qualitative assessment by the Subject Matter Expert.
The County has achieved Substantial Compliance at NCCF and PDC North as of October 1, 2017, through March 31, 2018, with Paragraph 43, which requires the Department to develop and implement policies for discipline of prisoners with serious mental illnesses.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 44, which requires the Department to install protective barriers in High Observation Housing and other mental health housing areas.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 45, which requires Suicide Prevention Kits and first-aid kits in control booths in all facilities.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 48, which requires the Department to have written housekeeping, sanitation, and inspection plans to ensure proper cleaning.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 49, which requires the Department to have maintenance plans to respond to routine and emergency maintenance needs.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 50, which requires pest control in the jails.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 51, which requires the Department to ensure that all prisoners
5

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 8 of 117 Page ID #:2963
have access to basic hygiene supplies in accordance with state regulations.
The County has maintained Substantial Compliance for twelve consecutive months at CRDF and PDC North with Paragraph 55, which requires custody, medical and mental health staff to meet daily in High Observation Housing and weekly in Moderate Observation Housing. The County also has provided documentation reflecting it achieved Substantial Compliance as of April 1, 2018, through June 30, 2018, at MCJ and TTCF. The results are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 56, which requires custody, medical, and mental health staff to communicate regarding any change in a housing assignment following a suicide attempt or serious change in mental health condition.
The County has maintained Substantial Compliance from April 1, 2017, through March 31, 2018, at MCJ with Paragraph 57, which requires safety checks in mental health housing.
The County has maintained Substantial Compliance for twelve consecutive months at PDC South, PDC North, and PDC East with Paragraph 58, which requires safety checks in non-mental health housing. The County also has maintained Substantial Compliance as of July 1, 2017, through March 31, 2018 at CRDF, and as of October 1, 2017, through March 31, 2018, at IRC.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, PDC East, and NCCF with Paragraph 59, which requires unannounced daily supervisory rounds to verify safety checks. The County also has maintained Substantial Compliance from January 1, 2018, through June 30, 2018, at PDC North and PDC South, from October 1, 2017, through June 30, 2018, at CRDF, and from April 1, 2018, through June 30, 2018, at TTCF.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC North, and PDC South with Paragraph 68, which requires staggered contraband searches in housing units. The County also has provided documentation reflecting that it has maintained Substantial Compliance for twelve consecutive months at TTCF. These results are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 71, which requires the County and the Sheriff to ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 72, which requires the Department and the County to report on meetings to review suicides and incidents of serious self-injurious behavior.
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The County has achieved Substantial Compliance as of October 1, 2017, through March 31, 2018 with Paragraph 73, which requires the Department prepare detailed reports of prisoners who threaten or exhibit self-injurious behavior.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 74, which requires the Department to have an objective law enforcement investigation of every suicide that occurs in the jails.
The County has achieved Substantial Compliance as of October 1, 2017, through March 31, 2018 with Paragraph 75, which requires the Department and the County to review every serious suicide attempt that occurs in the jails. The results are subject to verification by the Monitor's auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 76, which requires the Department to follow certain procedures whenever there is an apparent or suspected suicide.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 78, which requires the Suicide Prevention Advisory Committee to meet twice a year.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 82, which requires the Department to co-locate personnel responsible for collecting prisoners' grievances at CRDF.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ and IRC from July 1, 2015, through June 30, 2016; at TTCF from October 1, 2015, through September 30, 2016, at CRDF from April 1, 2016, through March 31, 2017, with Paragraph 83, which requires it to install closed circuit security cameras throughout all of the common areas in the jails The County has also achieved Substantial Compliance at NCCF and PDC North as of April 1, 2018, through June 30, 2018, and at PDC South as of July 1, 2018.
The County has provided documentation showing that it has maintained Substantial Compliance as of July 1, 2017, through March 31, 2018, with Paragraph 84, which requires investigations of force incidents and administrative actions to be completed timely.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, CRDF, PDC North, PDC South, PDC East, NCCF, and IRC with Paragraph 86, which requires inventory policies and control of weapons. It has also maintained Substantial Compliance as of April 1, 2018 through June 30, 2018 at TTCF.
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SIXTH REPORT 18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016. These trainings will include the following topics: (a) suicide prevention policies and procedures, including observation and
supervision of prisoners at risk for suicide or self-injurious behavior; (b) discussion of facility environments and staff interactions and why they
may contribute to suicidal behavior; (c) potential predisposing factors to suicide; (d) high-risk suicide periods and settings; (e) warning signs and symptoms of suicidal behavior; (f) case studies of recent suicides and serious suicide attempts; (g) emergency notification procedures; (h) mock demonstrations regarding the proper response to a suicide attempt,
including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance; (i) differentiating between suicidal and self-injurious behavior; and (j) the proper use of emergency equipment.
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STATUS (18):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (unverified) at MCJ and PDC South)

SUBSTANTIAL COMPLIANCE (as of September 1, 2017 (unverified) at NCCF)

SUBSTANTIAL COMPLIANCE (as of December 1, 2017 (unverified) at PDC East)

SUBSTANTIAL COMPLIANCE (as of April 1, 2018) (unverified) at TTCF, IRC, and PDC North)

SUBSTANTIAL COMPLIANCE (as of June 1, 2018 (unverified) at CRDF)

The Monitor, in consultation with the Mental Health Subject Matter Expert, concluded in the First Reporting Period that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training ("DeVRT"), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015. On May 30, 2017, the Monitor, in consultation with the Subject Matter Expert, approved a revision to the two-hour course on suicide prevention for existing Deputy Sheriffs and Custody Assistants.

The County's Initial Self-Assessment Status Report delivered on December 14, 2015, reported that the Department commenced its suicide prevention training for new Deputy Sheriffs and Custody Assistants on July 1, 2015, and for existing Deputy Sheriffs and Custody Assistants before the Effective Date of the Settlement Agreement.

Substantial Compliance is achieved when the Department reaches the 85% threshold for existing personnel at a facility, provided that it has achieved the 95% threshold for new personnel during the entire time from July 1, 2015 until it has reached the 85% threshold for existing personnel. The County's Sixth Self-Assessment reiterates that "the Department has continuously provided the required training for new Deputies in the Jail Operations Continuum and new Custody Assistants in the Custody Assistants Academy," but the Self-Assessment only reports results for new deputies from July 1, 2015, through June 30, 2016, which is before the Department achieved the Substantial Compliance threshold for existing personnel at any of the facilities. The Department needs to report the results for new deputies through March 31, 2018. The Substantial Compliance finding is subject to verification that existing deputies have continued to receive the required training through that date.

In the Fifth Reporting Period, the County reported that the Department achieved
Substantial Compliance at MCJ, and PDC South as of October 1, 2017, and at NCCF as of September 1, 2017.4 The County's augmented Fifth Self-Assessment reported

4 This is the first day of the month after the Department reached the required 85% threshold.

9

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Substantial Compliance at PDC East as of November 1, 2017.5 The County's Sixth SelfAssessment reports that the County achieved Substantial Compliance at TTCF (98% of existing personnel), IRC (97%), and PDC North (98%) as of April 1, 2018. The County's posted results report that it achieved Substantial Compliance at CRDF (85%) as of June 1, 2018. These results are subject to verification by the Monitor's auditors.6
5 All of the two-hour training of existing Deputy Sheriffs and Custody Assistants occurred after the revision of the suicide prevention course was approved by the Monitor on May 30, 2017. 6 The County's recently posted results, which reflect the Monitor’s approved definition of "unavailable," see p. 12, supra, have not been taken into consideration in this report. Those results will reflected in the Monitor's next report if verified by the Monitor's auditors.
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19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams ("JMET") at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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STATUS (19):

PARTIAL COMPLIANCE

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution training and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and paragraphs 4.6, 4.7 and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert and the Rosas Monitors approved the training materials developed by the Department for the DeVRT on March 4, 2016.

Substantial Compliance requires the County to show that 95% of the new deputies hired after July 1, 2015 and 85% of the existing deputies as of that date received the required DeVRT training. It also requires that 95% of the new Custody Assistants hired after that date and 85% of the existing Custody Assistants as of that date received the required training in working with mentally ill inmates.

The County's Sixth Self-Assessment reports that the Department achieved Substantial Compliance at all facilities for new Deputies and new Custody Assistants through the first quarter of 2018. The County's augmented Fifth Self-Assessment submitted in January 2018, reported that the Department maintained Substantial Compliance at all facilities for new Deputies and new Custody Assistants through September 30, 2017.

The County's Sixth Self-Assessment reports that the Department achieved Substantial Compliance with respect to the training of existing Deputies and Custody Assistants at IRC, MCJ, CRDF, TTCF, and NCCF(JMET) in the first quarter of 2018. The Department trained 95% of the existing Deputy Sheriffs and 89% of the existing Custody Assistants at TTCF by the end of the First Quarter of 2018; 100% of existing Deputies and 98% of existing Custody Assistants at IRC; 99% of existing Deputies and 92% of existing Custody Assistants at MCJ, and 100% of the existing Deputies in the JMET unit at NCCF.7

The Department's posted results exclude "unavailable" deputies who are not available "during the relevant month" due to, for example Injured On Duty. These deputies should not, however, be excluded unless they were "unavailable" to attend the DeVRT during a substantial period, since the training has been offered since March 4, 2016. Accordingly, deputies and Custody Assistants will not be deemed "unavailable" unless they have been on leave or otherwise unavailable for more than six months as of the date of the assessment.8

Although the Department reached the 85% threshold for the training of "existing" deputies at CRDF in the Third Quarter of 2017, the results for Custody Assistants at

7 There were no Custody Assistants assigned to the unit. 8 As noted, the County's recently posted results reflecting this approved definition of "unavailable" have
not been taken into consideration in this report.

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CRDF reported in the Fifth Self-Assessment were based upon a misinterpretation of Paragraph 19(b). The 85% threshold for existing deputies at CRDF is based upon the number of deputies assigned to the Mental Health Units at CRDF as of July 1, 2015, but the threshold for existing Custody Assistants is based upon the total number of Custody Assistants assigned to any unit at CRDF as of July 1, 2015. The Department's posted results for the First Quarter of 2018 indicate that, once again, it is not counting Custody Assistants "who were not assigned to Mental Health Housing Units" at CRDF.
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20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

SUBSTANTIAL COMPLIANCE (as of August 1, 2017 (verified) at CRDF, PDC East, PDC North, and NCCF)

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (verified) at PDC South)

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the curriculum for the Department’s Deescalation and Verbal Resolution Training ("DeVRT"), which provides for 32 hours of Crisis Intervention and Conflict Resolution training that meets the requirements of Paragraph 20 of the Settlement Agreement.

Substantial Compliance requires that 85% of deputies at the facilities designated in Paragraph 20(a) as of July 1, 2017, receive the required DeVRT training. The County reports that as of August 1, 2017, 85% of the deputies assigned to PDC East, 89% of the deputies assigned to PDC North, 85% of the deputies assigned to NCCF, and 91% of the deputies assigned to the non-mental housing units at CRDF, had received the required training, and as of October 1, 2017, 96% of the deputies assigned to PDC South had received the training. The results at CRDF, PDC East, PDC North, PDC South, and NCCF have been verified by the Monitor's auditors, and these facilities are no longer subject to monitoring.9

9 While the Department has achieved Substantial Compliance with the thresholds for the initial training of deputies at these facilities and Paragraph 20 is no longer subject to monitoring, the Monitor expects the Department to show that the deputies have attended the required refresher courses through the duration of the Settlement Agreement.
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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at PDC East and South)
SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at NCCF, PDC North and IRC)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at TTCF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018 (verified) at MCJ)
PARTIAL COMPLIANCE (at CRDF)
The Compliance Measures provide that the Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required CPR and first aid certifications for 12 consecutive months.
Pursuant to paragraph 111 of the Settlement Agreement, PDC South, PDC East, PDC North, NCCF, IRC, and TTCF were not subject to monitoring for Substantial Compliance with Paragraph 21 in the Sixth Reporting Period.
The County's Fifth Self-Assessment reported that the Department failed to achieve Substantial Compliance at MCJ in the Second Quarter of 2017 through August 2017, but achieved Substantial Compliance again in October 2017. These results have been verified by the Monitor's auditors.
The County's Sixth Self-Assessment reports that the Department continued to maintain Substantial Compliance at MCJ through the First Quarter of 2018. These results have been verified by the Monitor's auditors. The results for CRDF in the First Quarter of 2018 were in the range from 81% to 87%, which is sufficient for a finding of Partial Compliance.
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22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017)
The Justice Data Interface Controller ("JDIC") message the Department has been using since June 29, 2016, is sufficient to establish Substantial Compliance with Paragraph 22, and the County maintained Substantial Compliance for twelve consecutive through June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, the County was not subject to monitoring for Substantial Compliance with Paragraph 22 in the Sixth Reporting Period.
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23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: SUBSTANTIAL COMPLIANCE The Monitor has verified, with the advice of the Subject Matter Expert, that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department reports that it inspected all of the housing units by January 14, 2016, and it has provided the Monitor with completed checklists documenting the inspections. The County submitted an updated Suicide Hazard Mitigation plan to the Monitor on January 18, 2018. After consultation with the Mental Health Subject Matter Expert, the Monitor concluded that the updated Plan satisfies the requirements of Paragraph 23. The Department submitted another updated plan to the Monitor on July 12, 2018. After consultation with the Mental Health Subject Matter Expert, the Monitor concluded that the updated Plan satisfies the requirements of Paragraph 23. The County has now maintained Substantial Compliance with Paragraph 23 for twelve consecutive months and it is no longer subject to monitoring with this provision. Nevertheless, the Monitor and the Mental Health Subject Matter Expert encourage the County to submit in future reporting periods updated plans reflecting the Department's efforts to remediate additional suicide hazards it has identified in the jails.
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24. The County and the Sheriff will review and inspect housing areas on at least an annual basis to identify suicide hazards.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017) CDM 3-06/020.00 FACILITIES INSPECTIONS requires Custody Support Services (CSS) to "review and inspect housing areas on a least an annual basis to identify suicide hazards." The Monitor and Subject Matter reviewed a revised annual suicide hazard inspection tool that was submitted by the Department on December 13, 2016, and approved it with the caveat that, in order to achieve Substantial Compliance, the sample sizes of randomly selected cells must be large enough to ensure that the cells are representative of each housing type at a facility. Further, if a problem is found in the randomly selected cells, a complete inspection or remediation of the area or setting should then be conducted. An updated tool was submitted by the Department on February 9, 2017; it also was approved with the same caveats. The Department conducted an Annual Suicide Hazard Inspection at each of its jail facilities during the Fifth Reporting Period. The Monitor, after consultation with the Mental Health Subject Matter Expert, approved the sufficiency of Department's reports and concluded that the County had achieved Substantial Compliance as of October 1, 2017. The County will have maintained Substantial Compliance when it submits annual reports for each of its facilities for 2018 that are approved by the Monitor after consultation with the Mental Health Subject Matter Expert. The County's Sixth SelfAssessment reports that the "Department anticipates that the second annual inspection for each facility will be completed within the next few quarters."
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: PARTIAL COMPLIANCE
The Proposed Revision of the Station Jail Manual requires that any arrestee who "displays obvious suicidal ideation or exhibits unusual behavior that clearly manifest[s] self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, such inmates . . . shall be under unobstructed visual observation or in a suicidal restraint location with safety checks every 15 minutes."
The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent to determine compliance with Paragraph 25 of the Agreement. The County’s Sixth Self-Assessment reports that 60% of the records reviewed for the Fourth Quarter of 2017, and 62.9% of the records reviewed for the First Quarter of 2018 reflect the information required to establish Substantial Compliance with Paragraph 25. While short of the required 95%, this is an improvement over the Fifth Reporting Period and a significant improvement from the Fourth Reporting Period.
Both the County and DOJ expressed concerns about "documentation and record keeping" at the station jails. In addition, the Mental Health Subject Matter Expert has expressed some concern, however, about the number of safety checks that were at exactly 15 minutes, particularly since staggering is an important aspect of the checks.
On September 19, 2017, the Monitor visited five randomly selected station jails to observe where the inmates are housed pending transportation to IRC, CRDF, or a medical facility; to inspect for suicide hazards; and to interview Department personnel about the handling of suicidal inmates. Each of the facilities had closed circuit cameras in the booking cells, and each of the facilities that conducts 15-minute checks maintains a log of the checks. Custody personnel in each of the facilities were knowledgeable about the requirements of Paragraph 25. They all indicated that it is standard procedure to expedite the transfer of suicidal inmates to IRC, CRDF, or a medical facility.
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to "review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of 100 randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC." Substantial Compliance requires that (1) 95% of the forms "include the required mental health information" and (2) 90% of the prisoners having urgent or emergent needs were "seen by a QMHP within four hours."
The County’s posted results for the one randomly selected week in the Fourth Quarter of 2017 reflect that 90% of the screening forms reviewed had the required mental health information, and 64% of the prisoners were seen by a QMHP within four hours. The posted results for the First Quarter of 2018, reflect that 95% of the forms had the required information and 71% of the prisoners were seen within four hours. The timeliness of the responses by QMHP is significantly below the 90% threshold.
During the Sixth Reporting Period, the Mental Health Subject Matter Expert and the clinicians looked for "important inconsistences or obvious errors" in the intake records, and reviewed "subsequent records" to assess whether they were inconsistent with the screening or "cast doubt on the accuracy of the screening." They found that "36% of the cases [they] reviewed should have been detected at screening" and commented that "we continue to see instances where non-clinicians appear to be missing cases of serious mental illness at intake." In "spot check[ing]" data for Paragraph 29 for CRDF, the Mental Health Subject Matter Expert expressed concern that "some cases were categorized as routine that should have been expedites. Moving to nursing staff from Custody Assistants [to do the initial screening] may help,"10 but the Mental Health Subject Matter Expert and clinicians "continue to have concerns about the adequacy of the screening as conducted by nurses."
The County is still considering how to address the concerns expressed by the Mental Health Subject Matter Expert to ensure that all inmates with mental health needs are evaluated in private by the QMHP and all inmates are privately screened initially to determine if they have such needs as required by Paragraph 27.
10 As noted below, see p. 22, infra, "CHS has developed a new IRC screening form and changed the workflow from two to possibly three separate evaluations to one evaluation by a registered nurse to address" factors that impacted the timeliness of mental health evaluations of suicidal inmates in IRC.
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through December 31, 2017 (verified) and through March 31, 2018 (unverified))

The Compliance Measures require the Department to review the records of "randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC" to determine compliance with this provision. Substantial Compliance requires that 90% of the records reviewed reflected that the prisoners were screened for mental health needs within 12 hours and that the required documentation was available to the QMHP for 90% of the mental health assessments conducted by the QMHP.

The County’s Sixth Self-Assessment reports that in the Fourth Quarter of 2017, Qualified Medical Personnel or trained custody staff filled out a Medical/Mental Health Screening Questionnaire for all of the 100 randomly selected prisoners within 12 hours of their arrivals in the jails, and that the required documents were available to QMHPs who assessed all of the 35 inmates identified as having mental health needs. In the First Quarter of 2018, the required forms were filled out for all 100 of the prisoners within 12 hours and the required documentation was available to the QMHP's who assessed the 32 of the 33 (96%) of the inmates identified as having mental health needs.

The CHS Semi-Annual Report on Quality Improvement/Assurance submitted pursuant to Paragraph 62 notes that "CHS has developed a new IRC screening form and changed the workflow from two- to possibly three separate evaluations to one evaluation by a registered nurse, in an effort to address" factors that impacted the timeliness of mental health evaluations of suicidal inmates in the IRC. Based upon the pilot program that began on May 28, 2018, CHS noted "an unintended result of the change in workflow, which is that patients are waiting longer in the IRC for their initial screening by a nurse" from an average time of one hour from a "Random Sample of Suicidal Bookings" in the first quarter of 2018 to 7.47 hours and 8.58 hours for Suicidal Books in two separate weeks in June 2018. The Maximum Time to Initial Screening After Booking went from seven hours in the first quarter of 2018 to 51 and 65 hours in June. This raises serious concerns about whether the County is continuing to meet the 90% threshold for Substantial Compliance with Paragraph 27 in the Second Quarter of 2018 and is timely identifying inmates with urgent or emergent mental health needs.

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During the Sixth Reporting Period, the Mental Health Subject Matter Expert and the clinicians again looked for "important inconsistences or obvious errors" in the intake records, and reviewed "subsequent records" to assess whether they were inconsistent with the screening or "cast doubt on the accuracy of the screening." They found "that 100% of the intake documentation was complete and available,"[but that] 29% of routine cases that should have been detected were not," which is significantly higher than in a prior period.11 The Subject Matter Experts, notes that "[i]n general. . . the screening process itself seems to be detecting routine cases at a reasonable level; this is much lower risk than detecting those with emergent and urgent needs. Subsequent surveillance is detecting these cases fairly quickly as well. In our opinion, the process is adequate, and the periodic problems can be remedied by effective supervision staff."
Notwithstanding the percentage of routine cases not detected at intake, the County has achieved, and maintained for six months from October 1, 2017 through March 31, 2018, Substantial Compliance with Paragraph 27. In this case, the County met the quantitative requirements for Paragraph 27 during the six months from October 1, 2017, through March 31, 2018.12 The agreed upon Compliance Measures do not measure whether the routine cases are being detected, and the Mental Health Subject Matter opined that "the process is adequate." As noted in the Introduction to this Report, "the Monitor's determination of the County's compliance. . . is based upon the quantitative thresholds in the Compliance Measures" "unless the quality of the County's performance . . . is plainly inadequate or the results reported by Subject Matter Expert vary significantly from the results reported by the Department."
In order to satisfy the requirements of Paragraph 27, inmates must be privately screened. The windows in the intake-triage area where the Medical/Mental Health Screening Questionnaire is administered at CRDF are not sufficiently private to satisfy this requirement. As noted above, the County has begun a pilot program to restructure the booking at IRC and CRDF so that nurses conduct the assessments in the IRC clinic and in the nursing room at CRDF rather than having custody assistants conduct the initial assessments at the time of booking. To address a backlog that has been created in the IRC clinic from the pilot program, the Department is looking to move the nurses' assessments back to the booking area and is considering suggestions on how to make the process more private in that area. Assuming the Department is able to address the privacy concerns expressed by the Monitor and the Mental Health Subject Matter Expert, the County has now achieved Substantial Compliance with Paragraph 27, which it has maintained for six consecutive months through March 31, 2018. This finding is subject to an additional qualitative assessment by the Mental Health Subject Matter Expert finding "no deterioration in our qualitative assessment of false negatives" and verification of the results by the Monitor's auditors.
11 See Monitor's Fifth Report, p. 20, n. 12. 12 As noted above, the Monitor has serious concerns about whether the County has reached the quantitative thresholds required to maintained Substantial Compliance in the Second Quarter of 2018 and beyond.
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28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at IRC)
SUBSTANTIAL COMPLIANCE (as of January 1, 2018, through March 31, 2018 (verified) at CRDF)
The Compliance Measures require the Department to review the records of randomly selected prisoners at CRDF and IRC who have urgent or emergent mental health needs to determine whether they were expedited through the booking process.
The County’s Sixth Self-Assessment reports that the results for IRC for the Fourth Quarter of 2017 and First Quarter of 2018 (at 87% and 92%) are at or above the 85% threshold for expediting inmates through the booking process, and all inmates having urgent or emergent needs were under unobstructed visual observation and/or checked every 15 minutes during unannounced visits as required by Paragraph 28.
The CRDF results for these quarters reflect that the Department did not achieve Substantial Compliance in the Fourth Quarter of 2017, but achieved it in the First Quarter of 2018 when 87% of the inmates who had urgent or emergent mental health needs were expedited through the booking process, and all of the inmates identified as having urgent or emergent mental health needs were observed or checked as required by Paragraph 28.
The results at CRDF for the First Quarter of 2018 and at IRC for the Fourth Quarter of 2017 and the First Quarter of 2018 have been verified by the Monitor's auditors.13 The County has maintained Substantial Compliance with Paragraph 28 at IRC for twelve consecutive months, and IRC is no longer subject to monitoring for compliance with this provision.
The Mental Health Subject Matter Expert has expressed reservations about the County's Self-Assessment. He notes that "the county is only reviewing cases based on expression of current thoughts of suicide on the 15Q [initial intake form]; this is a much narrower universe than described in 26 (referred to in 28). Given our concerns about [the
13 DOJ expressed concerns about the IRC results because "[m]ovement histories. . .show that several inmates listed as expedited waited hours to be transported from booking to clinic." In response, the County indicated to the Monitor's auditors that delays may be "due to the inmate being uncooperative and hostile towards custody and nursing." DOJ also stated that "at least one inmate listed as expedited was moved from booking to classification before being sent to the clinic, which would suggest he was not properly expedited[.]" The auditors marked such records as "non-compliant," but noted that this "does not affect the overall compliance" rate.
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County] missing some cases [at intake] of those who are acutely psychotic. . . the county must expand the expedited case review." Further, the available video footage of inmates under unobstructed observation at CRDF was limited to two inmates. Going forward, the County should expand the universe of cases at CRDF to include "patients who are grossly psychotic and patients who are a danger to others due to mental illness" and provide a great number of videos confirming unobstructed observation.
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29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.

STATUS:

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through September 30, 2017 (verified) and through March 31, 2018 (unverified))

The Compliance Measures require the Department to review randomly selected records of the prisoners identified in the intake nursing assessment as having nonemergent mental health needs to determine if the Department completed mental health assessments for 85% of the prisoners within the required time periods.

The County’s Sixth Self-Assessment reports that in the Fourth Quarter of 2017 the County completed mental health assessments for 99% of the inmates at CRDF and IRC14 within the required time periods, and in the First Quarter of 2018, it completed 95% of the assessments within the required time periods.

Based on "spot check[ing]" the data for CRDF, the Mental Health Subject Matter Expert has expressed concerns that "some cases were categorized as routine that should have been expedites;" and "there were many instances where there was an unreasonable delay between custody assistants' [initial screenings at intake] and nurse assessments," which is what triggers the 24-hour requirement of Paragraph 29.15 These concerns are not, however, specifically applicable to the requirements of Paragraph 29 or the corresponding Compliance Measures, which measure the time between a nurse's assessment and the QMHP's mental health assessment of those inmates with nonemergent mental health needs.

These results are subject to verification by the Monitor's auditors. If the results are verified by the auditors, the Department will have maintained Substantial Compliance for twelve consecutive months and will no longer be subject to monitoring for compliance with Paragraph 29.

14 The County's Fifth Self-Assessment reported that mental health assessments were completed 93% of the time in the Fourth Quarter of 2017. A subsequently posted amended Self-Assessment reflects that 99% were completed timely. In either case, the results exceeded the 85% threshold. 15 This gap will disappear if the nurses do all screenings, but the County still needs to address the significant increases in time for the combined initial screening and nurses' assessment under the pilot program, which impacts when mental health assessments are required to be conducted pursuant to Paragraph 29. See p. 22, supra.
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30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected initial mental health assessments and report on (1) the percentage of assessments that have (i) included an initial treatment plan that addresses housing recommendations and preliminary discharge information and (ii) identified any immediate issues and whether a more comprehensive evaluation was indicated; and (2) whether the housing recommendations were followed.
The County's Sixth Self-Assessment reports that 100% of the housing assignments reviewed in the Fourth Quarter of 2017 followed the housing recommendations in the initial treatment plans, which exceeds the 95% threshold for Substantial Compliance, but only 80% of the initial mental health assessments had the information required by Paragraph 30, which is below the 85% threshold for the initial assessment component. The Self-Assessment reports that 100% of housing assignments and 62% of the initial assessments complied with the requirements of Paragraph 30 in the First Quarter of 2018.
The Mental Health Subject Matter Expert and the clinicians again evaluated "whether the determination of immediate issues [in random sample of mental health assessments] was reasonable in light of available information. . . [and] whether the initial treatment plan covered the elements required by existing County policy, which goes beyond the content of the formal compliance measure." They found that 85% of the cases "identified immediate issues," and that the determination of the immediate issues "was reasonable from a qualitative perspective" in 76% of the cases. The Subject Matter Expert concludes that the "County remains on the cusp of substantial compliance."
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31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk;
(b) hoarding medications; and
(c) prior suicide attempts.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected electronic medical records for prisoners in certain at-risk groups to determine if the required mental health alerts are in 85% of the records reviewed, which is the threshold for Substantial Compliance, for prisoners who report suicidal thoughts during the intake process; were removed from risk precautions in the prior quarter; or were identified as hoarding medicine.
The County’s Sixth Self-Assessment reports that for the Fourth Quarter of 2017, 88% of the records reviewed at TTCF, 94% of the records at CRDF, and 0% of the records at MCJ had the required mental health alerts. The County's augmented Sixth Self-Assessment reports that for the First Quarter of 2018, 91% of the records reviewed at TTCF, 94% of the records at CRDF, and 100% of the records at MCJ had the required mental health alerts.
The augmented Self-Assessment also reports that the County "continues to have difficulty with documenting and tracking inmates known to hoard medication." It reports, however, that it has achieved Substantial Compliance "at TTCF where nursing and mental health have demonstrated a record of coordinating with custody staff to accurately identify inmates who are hoarding medication." The posted Self-Assessment reported that the County reviewed 24 records of prisoners at TTCF who were identified as hoarding medicine, and found that 22 (or 91%) contained the required mental health alerts.16
In comments to the Monitor's draft report, DOJ noted that "source documents provided by the County show that required suicide alerts may have been missing in multiple cases that the County listed as compliant." In the course of reviewing the County's audit tool and source documents with the auditors in light of these comments,
16 The Monitor notes that the County reported an aggregate Compliance Percentage of 91% for the three required alerts, but that the Compliance Percentage of alerts for "prisoners who were removed from risk precautions in the prior quarter" was 84%, which is just below the required 85% for Substantial Compliance. The Monitor and Mental Health Subject Matter Expert believe that the County must satisfy the 85% threshold for Substantial Compliance for each of the required alert categories.
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the Monitor has a number of questions about the County's reported results regarding alerts for the group of prisoners removed from risk precautions at TTCF. The Monitor and auditors will meet with the parties during the next reporting period to discuss DOJ's concerns; the understandings of the parties with respect to the Paragraph 31 and Compliance Measure 31.1(b); and the Monitor's questions regarding the County's results.
The Mental Health Subject Matter Expert has expressed some concerns about the County's methodology in determining compliance with Paragraph 31. He notes that "[i]t is unclear how the county is finding cases of those placed on R[isk] P[recautions]. To be able to judge the accuracy of the findings, it is important to know the methodology." With respect to hoarding, "[t]he county is finding some cases by finding referrals that include hoarding. It is not clear how they are finding other cases; again, it is important to know the methodology." For example, if "[t]he county is not using custody cell search data to find cases of hoarding, that is likely part of the reason few cases are being detected for this measure. Only 5 hoarding cases were detected at CRDF for 2018Q1, which is much lower than would be expected."17
17 In contrast, for Paragraph 65, the County noted 53 medications found in 165 unannounced searches at CRDF during the First Quarter of 2018. Substantial amounts of medications were found during unannounced searches at the other facilities as well. See p. 76 infra.
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32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require that 95% of the electronic medical records of prisoners who had a serious suicide attempt reflect information regarding the attempt, and 85% of the records reflect that the information was entered into the record within one day of the attempt.
The County maintained Substantial Compliance with Paragraph 32 for twelve consecutive months as of December 31, 2016, and this provision was not subject to monitoring in the Sixth Reporting Period.
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33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:
(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;
(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;
(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and
(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (unverified))
The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected prisoners from each clinician’s caseload. The County has provided the required tool, and previously reported Substantial Compliance for the Third and Fourth Quarters of 2016, and the First Quarter of 2017.
All of the results previously reported by the County in its Self-Assessments are subject to verification by the Monitor's auditors, which will include verifying that the supervisors' reviews of the clinicians include the content required by Paragraph 33(b). The County's Augmented Sixth Self-Assessment reports "that 100% -- 15% more than the required 85% -- of the mental health supervisors complied with the requirements of this Provision for Fourth Quarter 2017." The County also reported the same results for the Third Quarter 2017. These results will be subject to verification by the Monitor's auditors if the results previously reported for the prior twelve months cannot be verified by the auditors and the Department is required to extend its Substantial Compliance into the Third Quarter of 2017.
The Mental Health Subject Matter Expert has concluded the County is doing an "adequate job meeting the requirements of [Paragraph] 33."
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34. The County and the Sheriff will conduct discharge planning and linkage to community mental health providers and aftercare services for all prisoners with serious mental illness as follows:
(a) For prisoners who are in Jail seven days or less, a preliminary treatment plan, including discharge information, will be developed.
(b) For prisoners who are in Jail more than seven days, a QMHP will also make available:
(i) for prisoners who are receiving psychotropic medications, a 30-day prescription for those medications will be offered either through the release planning process, through referral to a re-entry resource center, or through referral to an appropriate community provider, unless clinically contraindicated;
(ii) in-person consultation to address housing, mental health/medical/substance abuse treatment, income/benefits establishment, and family/community/social supports. This consultation will also identify specific actions to be taken and identify individuals responsible for each action;
(iii) if the prisoner has an intense need for assistance, as described in DMH policies, the prisoner will further be provided direct linkage to an Institution for Mental Disease ("IMD"), IMD-Step-down facility, or appropriately licensed hospital;
(iv) if the prisoner has a moderate need for assistance, as described in DMH policies, and as clinically appropriate to the needs of the prisoner, the prisoner will be offered enrollment in Full Service Partnership or similar program, placement in an Adult Residential Facility ("Board and Care") or other residential treatment facility, and direct assistance accessing community resources; and
(v) if the prisoner has minimal needs for assistance, as described in DMH policies, the prisoner will be offered referrals to routine services as appropriate, such as General Relief, Social Security, community mental health clinics, substance abuse programs, and/or outpatient care/support groups.
(c) The County will provide a re-entry resource center with QMHPs available to all prisoners where they may obtain information about available mental health services and other community resources.
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STATUS (34):

STAYED PENDING LITIGATION

Paragraph 34 is the subject of on-going litigation as a result of a First Amended Complaint in Intervention challenging the provisions relating to discharge planning. The County’s Sixth Self-Assessment reports that the litigation "is on-going" and, "[a]ccordingly, the Department has stayed its collection of compliance data with respect to this [p]rovision."

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35. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team ("JMET") member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: SUBSTANTIAL COMPLIANCE (as of November 1, 2017,18 through March 31, 2018 (verified))
The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral ("BOMHR") records for prisoners referred by custody staff to a QMHP or JMET member for "routine" mental health care to determine the timeliness of the referrals. Substantial Compliance requires that "85% of the BOHMR forms reflect that the referral occurred before the end of the shift in which the potential need for mental health care is identified."
The County's Sixth Self- Assessment reports that the Department "has developed an electronic version of the BOHMR" and it has "concluded that 100% -- 15% more than the required 85% -- of BOHMR forms reflected that referrals occurred prior to the end of the shift in which the potential need for mental health care is identified" in both the Fourth Quarter of 2017 and the First Quarter of 2018. The Mental Health Subject Matter Expert reviewed the majority of the posted BOHMRs, which included "the time of the incident and the time the BOHMR was submitted," and he commented that Custody staff "are to be commended" for "including good comments and important information on the BOHMRs[.]" The results have been verified by the Monitor's auditors.
18 The County implemented the electronic version of the BOHMR as of November 6, 2017 and reported results for the Fourth Quarter of 2017 for the month of November.
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36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected records of prisoners newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; and provide a staffing schedule for on-call services. The County's Sixth Self-Assessment reports that 78% of the prisoners identified in the two randomly selected weeks in the Fourth Quarter of 2017 and 72% of the identified prisoners in the First Quarter of 2018 received an assessment by a QMHP within four hours.19
DOJ and the County have agreed that, instead of unannounced quarterly visits, "the Department will randomly select five BOMHRS" from a randomly selected date, to "review videos to determine how the inmate was being observed while waiting for the QMHP," and "produce screen shots and movement records as part of their selfassessment."
The County reports that in the Fourth Quarter of 2017 all five selected prisoners at CRDF, and four of the five at TTCF were on the videos "under unobstructed visual observation pending assessment." In the First Quarter of 2018, only one of the five prisoners at CRDF and all the five inmates at TTCF were under the required observation.
The Sixth Self-Assessment reports that the County achieved 100% compliance with a staffing schedule that provides on-call services 24 hours a day, 7 days a week in both the Fourth Quarter of 2017 and the First Quarter of 2018 pursuant to Compliance Measure 36.2. This Compliance Measure does not, however, simply require 24/7 coverage. It requires the Monitor, in consultation with the Subject Matter Experts, to "review" the staffing schedule "to verify the adequacy of the on-call system." The
19 The Mental Health Subject Matter Expert previously noted that many cases may not be true emergencies because the inmates are using the threat of suicide "to secure exit from NCCF." He indicated that it "might be reasonable to exclude" from the four-hour assessment requirement those inmates in general population at NCCF who are transferred to IRC as a result of threatening to commit suicide rather than engaging in self-injurious behavior. The parties have agreed to exclude these NCCF inmates from the four-hour assessment requirement.
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Mental Health Subject Matter Expert commented that "unless the county has another explanation for its inability to respond to adverse triggering events within 4 hours, it is likely that inadequate staffing is the problem."20
He also noted that "the county is generally doing a good job of detecting adverse triggering events; using the methodology of our qualitative assessments to detect false negatives, the county was performing well. . . .The problem is that the clinical response is generally marginal or poor and there is almost no meaningful attempt to address recurrent self-harm"
20 As noted above, the County reported that only 78% and 72% of the inmates received an assessment by a QMHP within four hours during the Fourth Quarter of 2017 and the First Quarter of 2018. In reporting results for Paragraph 43, the County's Sixth Self-Assessment notes that staffing shortages impacted "the County's ability to achieve Substantial Compliance" with the requirement that QMHP's be consulted prior to transferring inmates from mental health housing locations to discipline.
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37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral ("BOMHR") Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter, review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner and incident reports for self-injurious behavior by prisoners appearing in the selected courts, and determine if these incidents are reflected in BOMHR forms completed by the Court Services Division staff in the selected courts.
The County’s Sixth Self-Assessment reports that 68% of the incidents covered by Paragraph 37 in six randomly selected courts were reflected on BOMHRs in the Fourth Quarter of 2017 and 52% of the incidents in six other courts were reflected on BOMHRs in the First Quarter of 2018. These results are well below the 93% and 87% results in the prior two quarters.21
During the Sixth Reporting Period, the Monitor conducted random checks of courthouse lock-ups to determine where these prisoners are housed and if they are "under unobstructed visual observation or subject to 15-minute checks." There no issues with respect to housing of prisoners who display "obvious suicidal ideation" or "unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis." The Court Services Division personnel explained that these prisoners were kept under direct observation or subjected to 15-minute checks; they completed the new electronic BOMHR forms to notify Custody personnel of observed mental health issues; and they undertook, with the cooperation of the courts, to expedite court appearances of inmates with mental health issues so that they could be transported to back to the Downtown Jail Complex or CRDF as soon as possible. Most of the cells in the randomly selected Courts had cameras in the cells and the Court Services Division personnel indicated that inmates with mental health issues were housed in those cells. With the exception a few cells in the Central Arraignment Court at Bauchert Street, there were no concerns about visibility into the cells, and the Department has now addressed the problem at the Central Arraignment Court. Although the reported results are lower than in the last reporting period, based upon the Monitors' observations and the results, the Monitor has concluded that the Department achieved Partial Compliance with Paragraph 37 during the Sixth Reporting Period.
21 Although Compliance Measure 37-2 requires the Department to "select different courts so that all 35 courts are selected at least once per year," only twenty-five of the Courts have lock-ups and handle defendants in custody.
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38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision.
The County's reported results, which were verified by the Monitor's auditors, showed that it had maintained Substantial Compliance with Paragraph 38 for twelve consecutive months as of December 31, 2016. Accordingly, pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 38 was not subject to monitoring in the Sixth Reporting Period.
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39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their requests to custody staff or other prisoners.

STATUS

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018, (unverified) at CRDF)

SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through March 31, 2018 (unverified) at NCCF)

PARTIAL COMPLIANCE (at TTCF and MCJ)

NOT RATED (PDC North, PDC East and PDC South)

Substantial Compliance requires the Department to (a) verify that housing areas have the required forms and (b) review randomly selected self-referrals for mental health care from prisoners to confirm that (i) the referrals "were forwarded to DMH" by the Department, and (ii) that "DMH documented the timeliness and nature of DMH's response to the self-referrals[.]" The thresholds for Substantial Compliance are that 90% of the self-referrals must be forwarded by the Department to the Department of Health Services – Custody Health Services (DHS-CHS) and 90% must contain the required documentation of DHS-CHS's response.

During tours of the jail facilities in the Sixth Reporting Period, the Monitor observed that healthcare referral forms for prisoners requesting medical or mental health care and envelopes were available either in the modules or at the Deputies' stations adjacent to these housing areas, and prisoners are able to ask staff for the forms and envelopes if they do not have access to the box or it is empty. In some areas in Men's Central Jail where the inmates are in single cells in rows (e.g., for K-10 inmates), the forms are in boxes outside of the rows and must be obtained from the Deputies and Custody Assistants assigned to the areas.

Based upon a review of the County’s policies and procedures, multiple tours of the facilities, interviews, and the County’s Sixth Self-Assessment, the Monitor is satisfied that the Department has adequate processes and procedures for inmates to make confidential self-referrals for mental health care.

The County's Sixth Self-Assessment reports that it achieved Substantial Compliance with Compliance Measure 39.4(a) in the Fourth Quarter of 2017 and the First Quarter of 2018 in that more than 85% of the housing areas in all of the facilities had the self-referral forms.

The County's Sixth Self-Assessment also reports that in the Fourth Quarter of 2017, 100% of the self-referrals from CRDF, TTCF, MCJ, and NCCF were forwarded by the Department to DHS-CHS as required by Compliance Measure 39.4(b), and DHSCHS documented the timeliness and nature of its response in 90% of the CRDF referrals

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and 100% of the NCCF referrals, but that only 66% of the TTCF referrals and 68% of the MCJ referrals had the documentation as required by Compliance Measure 39.4(c). The Self-Assessment also reports that "the County was unable to assess PDC South, PDC East, and PDC North during this quarter" due to their delay in adopting referral guidelines implemented in July 2017.
The County's Augmented Sixth Self-Assessment reports that for the First Quarter of 2018, 100% of the self-referrals reviewed by the Department at CRDF were forwarded to CHS and that 91% of the time "CHS documented the timeliness and nature of CHS' response to the self-referrals received from the Department."22 The results for the other facilities were as follows: 100% and 77% for self-referrals at MCJ; 100% and 60% for TTCF;23 and 100% and 100% for NCCF. The "County determined that it had not reached substantial compliance at PDC North (Buildings 1, 3 and 4); PDC South and PDC East during this quarter as it was unable to assess those facilities" for the same reasons stated above.
As noted in prior reports, absent extenuating circumstances, Mental Health Services clinicians must respond to self-referrals within seven days. In prior periods, the County counted from when Mental Health Services received the self-referral from Medical Services rather than from when the inmate made the self-referral that was collected by the Sheriff's Department. The County's approach would be reasonable if Medical Services promptly forwarded the self-referral to Mental Health Services, but this was not always the case. As a result of a County reorganization, both Mental Health and Medical Services are now under "Correctional Health Services" (CHS), which is part of the Department of Health Services (DHS). Since there is no distinction between Mental Health and medical care in Correctional Health Services, it is reasonable to count the seven day-response time from CHS' receipt of the self-referral from the Sheriff's Department. This is based upon the assumption that the Department is promptly forwarding the referral to the CHS within 24 hours of collecting the self-referral.24
The Mental Health Subject Matter Expert has expressed a concern that the County is "counting as compliant cases where MH does not ever see the patient but has placed the patient on a list to be seen. What typically happens is that the patient is placed on a list to see JMET or a psychiatrist but is released before being seen. . . .While technically there is a MH response, it is not a clinical response – it is a plan to respond. . . [I]t is
22 The Monitor’s auditors have been unable to verify these results because in some cases the inmate was seen by a clinician before he or she submitted a self-referral for mental health services and the documentation is insufficient to determine if the mental health services addressed the inmates’ requests. 23 The County noted "that staffing difficulties impacted compliance at TTCF in implementing this provision." 24 If this assumption is not correct, it may be necessary to revisit the start date once again to ensure that the self-referrals are being addressed within a reasonable amount of time. Per DOJ's request, the Monitor and the auditors will review the referrals to verify that the Department is promptly forwarding the referrals to CHS.
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highly questionable to say that there has been a timely response to a request when a patient is never actually seen or waits over a month to be seen."25
When compliance is measured from the date the self-referral form is received by Correctional Health Services, the Monitor's auditors determined that the County was not in Substantial Compliance at CRDF for the Third Quarter of 2017.
The reported results for CRDF for the Fourth Quarter of 2017 and First Quarter of 2018, and for NCCF for the Third and Fourth Quarters of 2017 and the First Quarter of 2018, are subject to verification by the Monitor’s auditors, based upon an assessment of the timeliness of Mental Health Services' responses from the date the inmate's selfreferral was received by Correctional Health Services and a qualitative assessment by Mental Health Subject Matter Expert and the clinicians.
25 He notes that not every request requires a patient contact (e.g., a medication refill), "but if the determination is made that a patient needs to been seen, the timeliness of the response should be based on when the patient was seen."
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40. The County and the Sheriff will ensure a QMHP will be available on-site, by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County (1) to provide the Monitor with oncall schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week, and (2) randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify that a QMHP responded to all referrals, and 90% of the referrals within four hours.
The County’s Sixth Self-Assessment reports that for the Fourth Quarter of 2017 and the First Quarter of 2018, a QMHP responded 100% of the time and 94% of the responses were within four hours.
During a March 2018 site visit, the Mental Health Subject Matter Expert and the clinicians found that the response by a QMHP was within four hours in 18 out of 23 cases (78%). The Mental Health Expert noted the County's "sample was larger [and] more representative. So it is likely that they are meeting time lines." He stated, however, that "the real issue for us is that the quality of the response is very often not 'clinically appropriate;'" in this quarter the services were clinically appropriate in only 54% of the cases. He views this as "a substantial problem;" QMHP's often order housing changes or precautions, but "[t]here is rarely a clinical response that addresses the crisis itself." Based upon this finding, and notwithstanding the quantitative results, the County has achieved Partial Compliance with Paragraph 40 rather than Substantial Compliance.
The County voiced concerns about what it considers to be an expansion of paragraph 40 and an undefined and subjective standard. The County also asserts that this relates to crisis intervention services provided quickly to identify safety concerns and mental health care is covered by other provisions. The Mental Health Subject Matter Expert observes, however, that "a crisis response would, at a minimum, characterize the cause of the crisis, conduct a relevant risk assessment, and create a plan of action based on that assessment."
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41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: NOT RATED
Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. In the Fourth Reporting Period, the Monitor did not rate the County's compliance with Paragraph 41 because all of the FIP patients on suicide watch during the period either remained on suicide watch at the end of the period or they "did not remain in the system (they were transferred to prison), and therefore did not go through the protocols."
During the Fifth Reporting Period, the parties agreed to revisions to the Compliance Measures that will increase the number of inmates subject to the step-down protocols of Paragraph 41 and ensure that the County's implementation of step-down protocols for FIP patients on suicide watch "ameliorate the impact of the restrictions" and have the necessary "level of precautions based upon individual assessment[s]" of the patients. The revised Compliance Measures were reviewed by the Mental Health Subject Matter Expert.
The County's Sixth Self-Assessment reports that the "County is in the process of finalizing an EMR template to meaningfully, and sufficiently, assess the County's compliance with the application of this Compliance Measure to the relevant universe of patients and affiliated step-down protocols," which are expected to be in place during the next reporting period.
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42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement "step-down" procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: PARTIAL COMPLIANCE
The County’s Sixth Self-Assessment reports that for the Fourth Quarter of 2017 at CRDF, 100% of the medical records reviewed reflected that "inmates in HOH and placed on risk precautions were assessed by a QMHP"; "47% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and "100% -- 15% more than the required 85% -- of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 100%, 38%, and 100%.
For the First Quarter of 2018 at CRDF, 100% of the records "reflected that inmates in HOH and placed on risk precautions were assessed by a QMHP"; 60% "of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and 70% "of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 100%, 68% and 33%.
The most recent results reported by the County show an improvement from prior reporting period, particularly at TTCF. The Mental Health Subject Matter Expert notes, however, that the QMHPs decisions regarding step-down "are not always individualized" and the reasons for not placing an inmate on step-down procedures are not stated.
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43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018 at NCCF and PDC North (verified))
PARTIAL COMPLIANCE (at CRDF, MCJ, and TTCF)
In response to comments by the Monitor and DOJ, the Department submitted proposed revisions to its discipline policies on May 30, 2017. After consulting with the Subject Matter Experts, the Monitor provided his written comments to the Department on June 29, 2017. The DOJ provided its comments to the Department the same day. The County's Sixth Self-Assessment reports that the Department is "currently in the process of reviewing and approving the revised policies," which were shared with the Monitor and DOJ in May of last year.
The Sixth Self-Assessment reports the County "made changes in housing arrangements to develop mental health discipline pods, and implemented new guidelines and policy which reduce the number of patients eligible for discipline at TTCF and CRDF."
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The County's Sixth Self-Assessment reports on the current practices regarding the discipline for inmates with P2, P3, and P4 designations in mental health housing locations. The Self-Assessment again reports that "the County continues to experience staffing shortages which impact the County's ability to achieve Substantial Compliance with this Provision and is taking steps to address this issue."
The County's Sixth Self-Assessment also reports that it achieved Substantial Compliance at NCCF and PDC North in the Fourth Quarter of 2017 where "100% -equal to the required 100% of the required weekly row walks through disciplinary units occurred pursuant to Compliance Measure 43.9(d)." Although not stated in the SelfAssessment, it appears that the other Compliance Measures are not applicable because NCCF and PDC North did not have any prisoners transferred to disciplinary housing from mental health housing. For example, the results for CRDF and TTCF also showed that 100% of the weekly row walks occurred, but these facilities did not achieve Substantial Compliance because the consultations with QMHPs required pursuant to Compliance Measure 43-9(b) did not occur "prior to transfers from mental health housing to discipline housing." As acknowledged in the Self-Assessment, "the County continues to experience systematic problems with QMHP discipline clearance for inmates in mental health housing."
The County's Augmented Sixth Self-Assessments again reports that it achieved Substantial Compliance at NCCF and PDC North in the First Quarter of 2018. It did not, however, achieve Substantial Compliance at the remaining facilities with mentally ill inmates, although it did report improvements in compliance with consultations with QMHPs prior to transfers from mental health housing to discipline housing. These results have been verified by the Monitor's auditors.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 49 of 117 Page ID #:3004
44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County has maintained Substantial Compliance with Paragraph 44 of the Agreement since January 1, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 44 was not subject to monitoring during the Sixth Reporting Period.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 50 of 117 Page ID #:3005

45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at CRDF, NCCF, PDC EAST, PDC SOUTH, and TTCF)

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ and PDC North)

The County has maintained Substantial Compliance with Paragraph 45 for twelve consecutive months at all facilities as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 45 was not subject to monitoring during the Sixth Reporting Period.

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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 51 of 117 Page ID #:3006
46. The County and the Sheriff will immediately interrupt, and if necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to review the documentation from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment.
Prior to this Sixth Reporting period, the Department had been unable to collect the universe of incidents when an inmate threatened self-injurious behavior as opposed to when an inmate exhibited such behavior. The County's Sixth Self-Assessment reports that, with the implementation of the electronic BOMHRs at all facilities,"[b]eginning with the First Quarter of 2018, the Department is able to provide data as to inmates who threaten self-injurious behavior."
The County's Sixth Self-Assessment reports that for the Fourth Quarter of 2017, "94% -- rather than the required 95% -- of the records reviewed . . . reflected that appropriate aid and (when necessary) immediate interruption of self-injurious behavior was provided by the Department." In the First Quarter of 2018, 97% of the records reflected that the appropriate aid and necessary interruption was provided by the Department.
The County is relying almost entirely on the BOHMRs to determine if there was "immediate interruption" of the self-injurious behavior and if "appropriate aid" was provided in compliance with this Paragraph. Although the BOHMRs show when the inmate engaged in the self-injurious behavior, when the inmate was seen by a medical provider, and when a mental health clinician made an assessment, the BOHMRs do not always show what the County did to "interrupt" the behavior or what aid the County provided to the inmate.
The County notes that "[t]he purpose of this provision is to ensure that custody staff and QMHP's are immediately and properly responding to an inmate who threatens or exhibits behavior to prevent self-harm or further self-harm. In this regard, the BOHMRs have been effectively used to ensure the prevention of suicides and suicide attempts." While this may be true, Paragraph 46 requires the Department to "immediately interrupt" self-injurious behavior and provide "appropriate aid." Without more information, the BOHMRs do not always document what the Department did to address these requirements in specific cases.
To establish Substantial Compliance, the County must either provide more detail in the BOHMRs (e.g., what the deputy did to interrupt on-going self-injurious behavior) or rely on additional documentation reflecting the information required by this provision.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 52 of 117 Page ID #:3007
47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: NON-COMPLIANCE The County’s posted Self-Assessment sets forth the number of Critical Incidents in each category during the Third and Fourth Quarters of 2017 using the definition of Critical Incidents in the revised Compliance Measures. There were a total of 81 Critical Incidents in those two quarters. The County's Self-Assessment does not assess whether staffing was a factor in these incidents because the County is still "working to develop the methodology to determine and assess whether staffing was a factor in any noncompliance with the Agreement, any critical incident, or the Department's handling of the incident."
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 53 of 117 Page ID #:3008
48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations ("CCR") Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County maintained Substantial Compliance with Paragraph 48 of the Agreement at all facilities for twelve consecutive months as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 48 was not subject to monitoring in the Sixth Reporting Period. Nevertheless, during inspections in the Sixth Reporting Period, the Monitor and Subject Matters Experts observed "an acceptable level of cleanliness, sanitation, repair and safety" in each facility.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 54 of 117 Page ID #:3009
49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016, through February 28, 2017)
The County maintained Substantial Compliance with Paragraph 49 of the Agreement at all facilities for twelve consecutive months as of February 28, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 49 was not subject to monitoring during the Sixth Reporting Period. Nevertheless, during inspections in the Sixth Reporting Period, the Monitor noted that the lighting systems, heating, ventilation and cooling systems in each facility were "adequately maintained and installed."
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 55 of 117 Page ID #:3010

50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at all facilities other than PDC South and PDC East)

SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at PDC South and PDC East)

The County maintained Substantial Compliance with Paragraph 50 of the Agreement at all facilities for twelve consecutive months as of March 31, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 50 was not subject to monitoring during the Sixth Reporting Period.

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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 56 of 117 Page ID #:3011

51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) for all facilities other than CRDF)

SUBSTANTIAL COMPLIANCE (as of July 1, 2016 through June 30, 2017 (verified) at CRDF)

The County maintained Substantial Compliance with Paragraph 51 of the Agreement at all facilities for twelve consecutive months as of June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 51 was not subject to monitoring during the Sixth Reporting Period.

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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 57 of 117 Page ID #:3012
52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52. All of the Compliance Measures have a 95% threshold for Substantial Compliance.
The County’s Sixth Self-Assessment reports that in the Fourth Quarter of 2017 at CRDF, 69% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 6% "of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP regarding allowable property;" 66% "of electronic medical records for inmates assigned to HOH reflect that property restrictions were based upon the clinical judgment of a QMHP;" and 85% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
In the First Quarter of 2018 at CRDF 50% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 8% of the electronic medical records "reflected a recommendation by a QMHP regarding allowable property;" 91.6% of electronic medical records "reflect that property restrictions were based upon the clinical judgment of a QMHP;" and 94% of the inmates in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 58 of 117 Page ID #:3013
For the Fourth Quarter of 2017 at TTCF, the County reports that 73% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 52% of the electronic medical records "reflected a recommendation by a QMHP regarding allowable property;" 95% of the electronic medical records "reflect that property restrictions were based upon the clinical judgment of a QMHP"; and 93% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
For the First Quarter of 2017 at TTCF, the results were 87% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 44% of the electronic medical records "reflected a recommendation by a QMHP regarding allowable property," 100% of the electronic medical records "reflect that property restrictions were based upon the clinical judgment of a QMHP;" and 97% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
During an April 2018 qualitative assessment, the Mental Health Subject Matter Expert and the clinicians found that
in 20/25 cases (80%) [at CRDF and TTCF], a QMHP provided an initial assessment (identical to last year). A QMHP saw the patient within 24 hours 18/25 times (72%), a modest improvement from 64%. There was a significant improvement in subsequent assessment of property restrictions with 16/25 (64%) current. The recommendations were followed 20/25 (80%) that we could determine the property in the cell, an improvement of over 20%. Determining whether other allowable property was in the cell was difficult, but we found it present in 16/19 (84%) of cases. The qualitative evaluation of whether the allowable property was based on relevant risks remained poor with only 5/25 (20%) of initial assessments and 8/25 (32%) of current assessment demonstrating a link between identified risks and property restrictions.
The Mental Health Subject Matter Expert commented that
[t]here was often no discussion of why certain items were restricted or even why restrictions were needed at all, most notable in cases where there was no identified risk on the formal risk assessment tool.
These results demonstrate a slight improvement in this measure from previous assessments, but the lack of improvement in the quality of the assessments is concerning. In many instances, it appears that prisoners are transferred to HOH after expressing suicidal ideation and have property substantially limited with little consideration of the nature and degree of risk. While some degree of conservatism is understandable, the best risk reduction strategy is to conduct adequate assessments and then act on the basis of the findings.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 59 of 117 Page ID #:3014
53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to audit the records of prisoners who were eligible, but rejected or disqualified, for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone. The County reports that in the Fourth Quarter of 2017 and the First Quarter of 2018, 74% and 80% respectively of the mentally ill prisoners who were eligible for and denied work were not denied the work due to a mental health diagnosis or prescription for psychotropic medication alone. The results for the Fourth Quarter of 2017 do not seem to capture the number of prisoners at CRDF who asked for, but were denied, programing in the quarter. The CRDF data was, however, captured in the First Quarter of 2018. The Mental Health Subject Matter Expert and clinicians reviewed the documents posted by the County and noted that "[i]t is difficult to determine if . . . denials reflect lack of eligibility due to mental health diagnosis alone, or issues relating to housing placement of patients as a class, rather than individual determinations of eligibility."
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 60 of 117 Page ID #:3015
54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to audit the records of a maximum of 100 randomly selected prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. In the Fifth Reporting Period, the County reported that it achieved and maintained Substantial Compliance for the period from March 1, 2016 through December 31, 2016. The results were verified by the Monitor’s auditors.
The Mental Health Subject Matter Expert then expressed a concern that the randomly selected population "does not pre-select for patients on [mental health] rolls or on medication, so it is possible that all cases reviewed had no mental health problem that might have resulted in a denial." To address this concern, with the approval of the parties, the Monitor revised the Compliance Measures for Paragraph 54, effective January 1, 2018, to reflect an alternative pool of inmates proposed by the County. Because Monitor's auditors had verified that the County has maintained Substantial Compliance under the existing Compliance Measures, the parties agreed that the County will only be required to maintain Substantial Compliance under the revised Compliance Measures for two additional quarters.
The County's Sixth Self-Assessment reports Substantial Compliance as of the First Quarter of 2018. This is based upon posted results showing that during two random weeks in the quarter, only two out of 43 inmates who requested programing were denied their requests solely due to their prescriptions for psychotropic medication or mental health status. This report of 96% compliance does not, however, indicate whether any inmates were denied "privileges." 26 Accordingly, the County has achieved Partial Compliance rather than Substantial Compliance.
26 The County's posted results show the "[n]umber of incidents of inmates solely denied [their request for programing] due to their prescription for psychotropic medication or mental health status," but Paragraph 54 and the revised Compliance Measures provide that a prisoners cannot be denied "privileges or programing" solely because of either their "mental health status" or a "prescription for psychotropic medication." See Revised Compliance Measure 54.5(b). As noted by the Mental Health Subject Matter Expert, "the essential privileges that should be considered are access to the dayroom, recreation, and visitation."
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 61 of 117 Page ID #:3016
55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through September 30, 2017 (verified) at CRDF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through March 31, 2018 (verified) at PDC North)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through June 30, 2018 (unverified) at MCJ and TTCF)
During the Sixth Reporting Period, the Monitor and a DOJ representative attended a daily HOH meeting at CRDF, which included custody, medical, and mental health personnel who appeared to be very knowledgeable about the condition and issues of individual HOH inmates. The Mental Health Subject Matter Expert also attended a number of meetings for HOH and MOH units at both CRDF and TTCF, which were well attended, and the staff actively participated and addressed salient issues.
The County's Sixth Self-Assessment reports that the Department has maintained Substantial Compliance for twelve consecutive months through the Third Quarter of 2017 at CRDF. These results have been verified by the Monitor's auditors and CRDF is no longer subject to monitoring for compliance with Paragraph 55.
The County's Sixth Self-Assessment also reports that the Department has maintained Substantial Compliance for twelve consecutive months through the First Quarter of 2018 at PDC North. These results have been verified by the Monitor's auditors and PDC North will no longer be subject to monitoring for compliance with Paragraph 55.
The results for the First Quarter of 2018 at MCJ and TTCF show only Partial Compliance because one of the five weekly MOH meetings did not have representatives from each of the units (i.e., custody, medical and mental health). The results for the Second Quarter of 2018 at MCJ and TTCF show Substantial Compliance. These results have not been verified by the Monitor’s auditors.
On July 12, 2018, the Department provided a semi-annual report "verifying the coordination and communication at the staff meetings" in HOH and/or MOH units during the first six months of 2018 as required by Compliance Measures 55.2, 55.4 and 55.6(c).
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56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH; and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing.
The County’s Sixth Self-Assessment reports that it has achieved Substantial Compliance for the First and Second quarters of 2017, which means that it has maintained Substantial Compliance for 18 consecutive months. The results for the twelve months from January 1, 2016 through December 31, 2016 have been verified by the Monitor's auditors, and the County is no longer subject to monitoring for compliance with Paragraph 56.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 63 of 117 Page ID #:3018
57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57):

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at MCJ)

PARTIAL COMPLIANCE (at TTCF, CRDF, and PDC North)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit in two randomly selected weeks to determine if the safety checks were staggered and conducted as required by Paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit for one randomly selected week to determine if a QMHP approved the new mental health housing assignments as required by Paragraph 57(e). The thresholds for achieving Substantial Compliance with these two Compliance Measures is 95%.

The County’s Sixth Self-Assessment reports that it has maintained Substantial Compliance with Compliance Measure 57.5(b) in the Fourth Quarter of 2017 and the First Quarter of 2018 in the MOH unit at MCJ (the "Hope Dorm") where 98% and 97% of the safety checks were in compliance. It also reports that "100% -- 5% more than the required 95% -- of inmates [at MCJ] analyzed pursuant to Compliance Measure 57-5(c) had received QMHP approval for their housing assignments" in both quarters. The results have been verified by the Monitor's auditors and MCJ is no longer be subject to monitoring for compliance with Paragraph 57.27

The Sixth Self-Assessment reports that the County achieved Partial Compliance in the HOH and MOH units at TTCF (92% and 92%) and CRDF (89% and 92%), and in the MOH units at PDC North (82% and 84%).

The Self-Assessment also reports that in the Fourth Quarter of 2017 83% of the new mental health housing assignments in CRDF and 98% of the assignments in TTCF were approved by a QMHP. In the First Quarter of 2018, 100% of the new mental housing assignments at both TTCF and CRDF were approved by a QMHP.28

27 Although the cell checks in the Hope Dorm are not well-staggered, as previously noted, "significant variations are less important in the Hope Dorm because it is a direct observation dorm with Department personnel stationed inside the dorm 24 hours per day." See Monitor's Fifth Report, 57 at n. 27. 28 In order to satisfy Compliance Measure 57.5(c), inmates must be moved expeditiously after a QMHP approves a new housing assignment within 48 hours of the QMHPs' approvals of new housing assignments. Placements in FIP should be as soon as possible.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 65 of 117 Page ID #:3020
58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells; (b) At least every 30 minutes in dormitory-style housing units where the unit
does not provide for unobstructed direct supervision of prisoners from a security control room; (c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes; (d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing; (e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner; (f) Custody staff will document their checks in a format that does not have pre-printed times; (g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and (h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
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Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 66 of 117 Page ID #:3021

STATUS (58):

SUBSTANTIAL COMPLIANCE (as of January 1, 2016 through December 31, 2016 (verified) at PDC South, PDC North, and PDC East)

SUBSTANTIAL COMPLIANCE ( as of July 1, 2017, through March 31, 2018 (verified) at CRDF)

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018 (verified) at IRC)

PARTIAL COMPLIANCE (at NCCF, TTCF, and MCJ)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by Paragraph 58. The thresholds for achieving Substantial Compliance is 90%.

The County maintained Substantial Compliance with Paragraph 58 for twelve consecutive months at PDC South, PDC North, and PDC East as of December 31, 2016. Pursuant to Paragraph 111, those facilities were not subject to monitoring in the Sixth Reporting Period.

The County's Sixth Self-Assessment also reports that for the Fourth Quarter of 2017 and the First Quarter of 2018, the following percentages of safety checks were in compliance with Paragraph 58: CRDF (93% and 90%);29 TTCF (95% and 97%); MCJ (94% and 92%); NCCF (82% and 58.5% ) and IRC (95% and 92%). Based upon the audit by the Monitor's auditors, it does not appear that the cell checks at MCJ and TTCF were staggered as required by Paragraph 58.

In order to stagger the safety checks at NCCF, the Department has installed door tags in centralized locations that deputies use to start their safety check rounds. By starting at the same location, they are then able to stagger the order in which they check the dorms in each unit.

In the Fifth Report, the Monitor expressed concerns that deputies are more concerned about the timeliness, as opposed to the quality, of the cell checks in mental health housing, which have tighter 15- and 30-minute requirements. This remains a concern. The videos reviewed during the death review of a death in MCJ showed a Custody Assistant conducting cell checks in a row of cells without ever looking in any of the cells. The Department personnel at the death review acknowledged that these safety checks were wholly inadequate.

29 Substantial Compliance requires achieving the 90% threshold based upon the aggregate data for the two randomly selected weeks.
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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31, 2017 (verified) at PDC East and MCJ)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at NCCF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through June 30, 2018 (verified) at CRDF)
SUBSTANTIAL COMPLIANCE (as of January 1, 2018, through June 30, 2018 (verified) at PDC North and PDC South)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through June 30, 2018 (verified) at TTCF)
Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if the supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. In response to the Monitor's comments, the Department's e-UDAL forms were modified to include a specific notation that the Supervisor verified that the safety checks were conducted.
The County's Sixth Self-Assessment reports that the Department has maintained Substantial Compliance at PDC East and MCJ for twelve consecutive months from January 1, 2017 through December 31, 2017 (and continuing to March 31, 2018). It also reports that the Department has maintained Substantial Compliance at NCCF for twelve consecutive months from April 1, 2017 through March 31, 2018. The results have been verified by the Monitor's auditors and these facilities are no longer subject to monitoring for compliance with Paragraph 59.
The County's posted results show that it has maintained Substantial Compliance for the period from October 1, 2017 through June 30, 2018 at CRDF; for the period from January 1, 2018 through June 30, 2018 at PDC North and PDC South; and for the period from April 1, 2018 through June 30, 2018, at TTCF . These results have also been verified by the Monitor's auditors.
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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
Compliance Measures 60.2 and 60.3(b) require the County to prepare semi-annual reports setting forth (a) any identified clinical issues in the areas identified in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the previous six months; and (c) an assessment of the effectiveness of steps taken by the Department to address issues identified during earlier reporting periods.
The Mental Health Subject Matter Expert has stated that "CHS is clearly developing a sound QM system. It is based on well-established principles and methods of QM. They are taking appropriate and measured steps to implement their plan." The Monitor and Mental Health Subject Matter Expert note the Department has continued to enhance its participation in the quality management process as required by Paragraphs 60 and 77.
On July 12, 2018, the County submitted a CHS Semi-Annual Report on Quality Improvement/Assurance. It reports that the "QI redesign team continues to meet on a weekly basis [to] cover topical QI issues, granular patient cases, as well as serve a planning platform for ongoing redesign work" and on the "shift" in CIRC and Joint Quality Improvement Committee ("JQIC") meetings to "discussion of system root causes. . .rather than simply cataloging issues for future workgroups." The Mental Health Subject Matter Expert notes that this is "an important advance."
As in the past, the report includes aggregate data on incidents of Self-Directed Violence ("SDV") broken down on a monthly basis by age, race/ethnicity, gender, facility, days in custody, method of attempt, and risk rating. It also includes aggregate data on CIRC meetings in the Sixth Reporting Period. It also includes "a summary table of 16 individual case presentations" at CIRC meetings that breaks down each incident by the categories set forth in Paragraph 61(a)(i) through (vi) and then assesses issues identified per Paragraph 61(b) through (e).
The Semi-Annual Report also includes sections that "review, collect, and aggregate data" and, to an extent, recommend improvements in the areas required by Paragraph 61(b) through (e).30 It also includes a summary of "Quality Improvement Processes/Projects," including the efforts of the compliance team "to meet with individual program managers and supervisors in an effort to provide better understanding of the progress toward meeting compliance expectation for the provision under their area of responsibility" and to "problem solve barriers related to provision non-compliance" in
30 See p. 68, infra.
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lieu of relying on Quality Management and Program Staff Meetings to achieve compliance with the provisions of the Settlement Agreement.
The Mental Health Subject Matter Expert notes that "[c]onjoint QM [with custody] and analysis (rather than the mere presentation) of aggregate data are the primary developments that remain." The County is "providing some reasonable. . .data and analysis on suicide and self-harming," but it has not provided sufficient detail on the elements detailed in Paragraph 61(a) through (e):
"While some of the [County's] studies. . .are very good targeted [quality improvement] projects, there is as yet no systematic approach or overarching analysis of aggregate data regarding these required elements. It is especially important for the county to develop and maintain on-going tracking (typically using a dashboard format) of aggregate data measuring critical aspects of these measures. . . .In each area, there needs to be an on-going analysis of key measures[.]" The County reports that it "is committed to improving and sustaining its sound QI Program and expects to develop more detailed metrics, benchmarks, and patterns in future reports."
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts:
(i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints;
(c) Psychotropic medications;
(d) Access to care, timeliness of service, and utilization of the Forensic Inpatient Unit; and
(e) Elements of documentation and use of medical records.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County’s semi-annual reports to (a) review, collect, and aggregate data in the areas set forth in paragraph 61; (b) recommend corrective actions and systemic improvements in those areas; and (c) assess the effectiveness of actions and improvements in prior reporting periods.
The CHS Semi-Annual Report includes aggregate data on incidents of SelfDirected Violence ("SDV") broken down on a monthly basis by age, race/ethnicity, gender, facility, days in custody, method of attempt, and CIRC risk rating score. It also includes aggregate data on CIRC meetings in the Sixth Reporting Period, broken down by these categories and also by prior suicide attempts and proximity to court dates. Although this satisfies the requirement to review, collect, and aggregate data as required by Paragraph 61(a)(i) through (vi), there is no discussion about possible corrective actions or systemic improvements based upon this information.
The Semi-Annual Report also includes sections that "review, collect, and aggregate data" and, to an extent, recommend improvements in the areas required by Paragraph 61(b) through (e):
 aggregate data on the use of clinical restraints in the Mental Health Unit of the CTC reflecting a high level of compliance with Paragraph 69 of the Settlement Agreement;
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 "a summary of a quality improvement study" relating to the "Renewal of Psychotropic Medication by the Mental Health Nursing Staff" that was instituted to address the shortage of available psychiatrists and recommendations of "possible actions."31
 the work of a multidisciplinary workgroup that "has been systematically working to align our pill call procedure with best practices" to address the requirements of Paragraph 65.
 a summary of "interventions" to address root causes for problems with the "timely evaluation of suicidal patients" during the intake process; an analysis of the factors that "Negatively Impacted the Timeliness of MH Evaluations of Suicidal Inmates in the IRC;" and aggregate data on IRC evaluations completed within four hours to meet the requirements of Paragraph 26.
 a study "to better understand the primary drug use of the population served and to prioritize the implementation of additional services/protocols needed to improve patient care" and a summary of current and future "efforts to treat addiction within the Los Angeles County Jail system[.]"
 "admission and discharge data" for the Mental Health Unit of the Correctional Treatment Center.
 the work of a Hoarding Workgroup that is "trying to formulate a clear and more consistent definition of hoarding and examine issues related to identifying hoarding behavior within the jail system" to address the requirements of Paragraph 31, and that identified a potential problem with the removal of the Suicide Risk/Hoarding Medication Alert in patients' medical records.
 the development of a new form that "clearly defines the step-down protocols" required by Paragraph 41 and "helps to inform patient care through improved documentation of patient status."
 a summary of the work to develop "risk precaution training" for the clinical staff that is "focused on risk assessment, risk precaution criteria, step-down protocols, . . .mental health alerts, [and] the [Suicide Risk Precaution Checklist] SRAC" to address the requirements of Paragraph 42 and to revise the SRAC.
31 The study concluded that while the "project has assisted in ensuring continuity of medication administration for the majority of patients," there "is room for improvement in that a minority of patients had their medications renewed numerous consecutive times by nursing without a face-to-face evaluation, and a small minority had their medications expire without further renewal." It recommended possible actions to "[i]nstruct nursing staff to directly request high-priority assignment of a psychiatry appointment" in certain circumstances and "[i]mprove the system to identify all medications about to expire[.]"
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The Mental Health Subject Matter describes these activities as "[a]ll good targeted QI projects," but they do not "represent an on-going collection and analysis" of aggregate data, "which would set benchmarks and look at trends and patterns of usage."
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the County's semi-annual Self-Assessments to set forth (a) the "development of corrective action plans to address the most recent recommendations of the quality improvement program;" and (b) the "implementation and tracking of corrective action plans to address recommendations of the program in prior quarters." The CHS Semi-Annual Report on Quality Improvement/Assurance was submitted to the Monitor on July 12, 2018. The most recent CHS Semi-Annual Report on Quality Improvement/Assurance again sets forth "responses" to issues identified in CIRC meetings about specific Self-Directed Violence incidents, but it does not separately set forth "recommendations of the quality improvement program" or describe or track corrective action plans to address such recommendations and there "are no CAPs based upon other QM findings such as an analysis of aggregate data." The Semi-Annual Report on the activities of the Custody Compliance and Sustainability Bureau ("CCSB") describes the corrective action plans identified during the Executive Inmate Death Reviews of suicides that occurred in May and July of last year and the status of those CAPs as of January 2018, and also describes other corrective actions the Department has taken.
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63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.

STATUS: NON-COMPLIANCE

The Compliance Measures require that the County's Self-Assessment set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period; (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. In addition, for two random weeks, the Department is required to review the count sheets documenting the number of occupied and available beds in the MOH and HOH units at TTCF and CRDF. Substantial Compliance requires "the immediate availability of HOH and MOH beds at TTCF and CRDF 95% of the time."

The County reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the Fourth Quarter of 2017 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 100% 50%

The County also reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the First Quarter of 2018 are as follows:

TTCF CRDF

MOH 100%
0%

HOH
0% 100%32

The average Daily Population in HOH33 at TTCF increased from 836 in the two randomly selected weeks in the Fourth Quarter of 2017 to 918 in the two randomly selected weeks in the First Quarter of 2018. Yet, the average number of HOH Beds decreased from 883 in the Fourth Quarter of 2017 to 763.5 in the First Quarter of 2018. Despite an almost 9.8% increase in number of HOH inmates at TTCF, there was a 9%

32 The Department reports that the "[a]vailability of beds in HOH was 13 of 14 days = 92%," but the daily posted figures for the two random weeks show that HOH beds were available on all 14 days. 33 This includes inmates in HOH and "the number of inmates awaiting evaluation in the intake module." It is not clear if this includes all of the inmates "awaiting evaluation;" presumably some of the inmates awaiting evaluations will not be designated for HOH following their evaluations.

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decrease in the number of HOH beds.34 The County's Augmented Sixth Self-Assessment reports that the Department is
unable to assess electronically information about the availability of HOH and MOH beds. Accordingly, the County was unable to report on the immediate availability of beds (that is, more beds than prisoners) during the reporting period as required by the Compliance Measure 63.3
34Some of the HOH beds may have become MOH beds to address a significant increase in the number of MOH patients at TTCF.
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64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in an initial 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed.
On July 14, 2017, the County submitted to the Monitor a Plan Regarding Availability of Licensed Inpatient Mental Health Care (Long Term and Short Term Plans) to provide "an update regarding the County's current efforts to meet the needs of the acutely mentally ill." The County reiterates in its Sixth Self-Assessment, "the County is pursuing a dual strategy to increase inpatient beds and the resources necessary to obviate the need for these beds. With increased services to address the underlying mental health needs (both through appropriate medication and clinical treatment), and the County's strong effort to divert people from the jails the need for inpatient services should decline."
The County's Sixth Self-Assessment reports that "the County has opened 18 inpatient beds at Olive View-UCLA Medical Center. These beds will house individuals who are diverted from the County Jail, either pre-trial or once they have been brought into the jail and are awaiting trial. The County's Office of Diversion will manages these beds beginning in early July 2018, and will be responsible for identifying appropriate individuals for these beds." As previously noted, the County needs to "report on the effectiveness of the measures in the updated [plans], including any reductions in the number of patients on the FIP waiting list and who are incompetent to stand trial," and also "the effectiveness of initiatives to divert MIST patients and involuntary medicate incompetent patients in the jail."
The County's Sixth Self-Assessment reports that "[c]urrently, the FIP waitlist consists of 64 patients.35 Eleven of these individuals are taking medications on a
35 This is an increase from 36 inmates on the FIP waitlist in the prior reporting period.
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voluntary basis and are, therefore, not prioritized for admission to the FIP."36 Further, "the current average time from referral to admission for the most acute is approximately two days, and can be more than 20 days for those on the FIP waitlist that are less acute."37 It appears that the County's plans are not sufficient to "reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails."
The Monitor's Fourth Report stated that the County's long-term "plans must have a reasonable basis for projecting need in order to establish Substantial Compliance with Paragraph 64." In response, the County's Fifth Self-Assessment described the County's "new level of care system that designates patients into categories based on acuity and treatment needs" and "tracking system to monitor the number of patients who meet this criteria on any given day." As noted in the Monitor's Fifth Report, this "may provide a reasonable basis for projecting 'the number of licensed inpatient mental health beds necessary to serve the inmate population,'" but the County needs to use this "methodology" to determine "the projected capacity required" in the long term and project how many beds will be required over several years. Without using this (or some other) methodology to project the number of FIP patients in the future, it is not possible to assess whether the County's plans for adding FIP beds are reasonable and sufficient.
36 The Mental Health Subject Matter Expert notes that "[w]hether [the patient is] taking medication or not is not the issue. The issue is whether the patient is a danger to self or others or gravely disabled, whether or not they are taking medications." 37 As noted by the Mental Health Subject Matter Expert, the reasons for the wide range are "not clear since all of the patients are at the same acuity level" (i.e., P4). He reports that he is unable to ascertain the methodology for these figures.
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires that (1) the County's Self-Assessments set forth the (a) the results of weekly medication audits documenting the visual observation of the administration of medication during the quarter; (b) unauthorized medications found as a result of cell searches during the reporting period; and (c) incidents involving confirmed prescription drug overdoses; and that (2) "the Monitor concludes, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner 85% of the time."
During the Sixth Reporting Period, the Monitor and DOJ representatives again observed pill calls at CRDF and TTCF. Although improved from prior reporting periods, the pill calls were still not sufficiently rigorous to ensure that inmates take the medication provided by the nurses. Once again, there were occasions when inmates turned away before swallowing the medication and neither the nurse nor the deputy verified that that the inmates had swallowed the medication before returning to their cells or bunks.
On April 6, the County provided a flow chart entitled "Provision 65 Pill Call – Ideal State Pod-Front Pill Call Procedures” (excluded HOH cell-to-cell procedure) that is the product of a work group convened to develop a "new method and practice of administering medications." The Monitor and Mental Health Subject Matter Expert concluded that the flow chart is a "reasonable approach," but that the "primary issue will be the nature of the interventions adopted by custody and healthcare staff in response to lack of cooperation" and "what happens if they are not able to verify that the inmate ingested the pills," which the flow chart partially addresses.
In the County's posted Self-Assessment, the "County acknowledges ongoing issues regarding the reporting and compliance with [Compliance Measure 65-1(a)]" and it has found "inconsistencies. . .with the current auditing practice" for this measure. Accordingly, "the County and Department have temporarily paused reporting for 651(a)." Once again, medication was found during a significant number of cell or module searches during the First and Second Quarters of 2018.38 There were also nine confirmed drug overdoses during the First Quarter of 2018.
38 During the First Quarter of 2018, 53 medications "not appropriately possessed by inmates" were found during 165 unannounced searches at CRDF, 390 medications were found during 118 searches at TTCF, 1580 medications during 400 searches at MCJ, and 42 medications during 670 searches at NCCF and 30 medications during 154 searches at PDC North. There were no medications found during searches at PDC South and PDC East. There was a significant reduction in the number of medications found at MCJ and PDC North in the Second Quarter of 2018, but similar results were reported for the other facilities.
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66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with a Serious Mental Illness ("SMI") to assess whether they have remained on an active mental health caseload and that 95% of HOH prisoners, 90% of MOH prisoners, and 85% of other prisoners with a serious mental illness been offered "clinically appropriate structured mental health treatment" and been seen by a QMHP at least monthly, regardless of whether they refuse medications. For the Fourth Quarter of 2017, the County posted results show that 14% of prisoners in HOH, 12% in MOH, and 41% with serious mental illness who reside in other housing areas were "offered clinically appropriate structured mental health treatment and were seen by a QMHP at least once a month." The Sixth Self-Assessment reports, in part, that: The County continues to work towards improved uniformity and standardization of the intake assessment process performed in the reception centers. The County has continued to hire staff to replace those departing service in the jails, along with creation of fourteen new clinical social worker positions. . . . CHS' training department is also in the process of gaining authorization to provide continuing education credits to social workers and psychologists. The County believes that doing so will help ensure that strengthened training programs are provided to staff on topics relevant to working with the jail population and to ensure patients receive clinically appropriate mental health treatments.
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings; (c) the use of clinically appropriate interventions with such prisoners to
encourage medication compliance; (d) consideration of the need to transfer non-compliant prisoners to higher
levels of mental health housing; and (e) individualized consideration of the appropriateness of seeking court orders
for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a). STATUS: NON-COMPLIANCE Substantial Compliance requires the County to "review the electronic medical records of 25% of the prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records [of 85% of the prisoners] reflect the documentation and consideration of the matters required by the terms of Paragraph 67." The Sixth Self-Assessment reports acknowledges that the County "has historically experienced challenges implementing and assessing compliance with this Provision." It also reports that "[a]t this time it is not possible to extract this information from the Powerchart system. We continue to work with Cerner to obtain a report of those individuals who refuse 50% of any psychotropic medication within a seven day period. Until this occurs, support staff are able to generate lists of patients who refuse three doses of a medication in one week. These lists are being forwarded to clinicians for follow-up attention."
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ, NCCF, PDC East, PDC South, and PDC North)

SUBSTANTIAL COMPLIANCE (as of January 1, 2017 through December 31, 2017 (unverified) at TTCF)

PARTIAL COMPLIANCE (at CRDF)

Substantial Compliance requires that "85% of the housing units are searched for contraband at least once in the previous quarter; and 95% of the HOH units visually inspected prior to housing prisoners in these units." Self-Assessments to include a summary of searches conducted in the second Quarter of the last reporting period and the first quarter of the current reporting period and to randomly select and review 25 Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units.

The County’s posted Self-Assessments report that in the Fourth Quarter of 2017, 88% of the housing units at CRDF were searched at least once in the quarter, and 80% of the randomly selected HOH cells at CRDF were visually inspected before housing prisoners in these units. During the First Quarter of 2018, 93% of the housing units at CRDF were searched at least once in the quarter, and 92% of the randomly selected HOH cells at CRDF were visually inspected before housing prisoners in these units.

During the Sixth Reporting Period, the County provided additional records and screen shots of CCTV footage to show that the HOH cells at TTCF were visually inspected more than 95% of the time in the Third Quarter of 2017.39 In cases where there was a date discrepancy in the source documents, CCTV footage showed that the HOH cells were visually inspected before the prisoners were housed in these units. In the Fourth Quarter of 2017, 96% of the housing units at TTCF were searched at least once in the quarter, and 96% of the randomly selected HOH cells at TTCF were visually inspected before housing prisoners in these units. These results are subject to verification by the Monitor's auditors. If verified, TTCF will have maintained Substantial Compliance with Paragraph 68 for more than 12 consecutive months.
The County previously maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC South, and PDC North, which do not have HOH cells, and these facilities were not subject to monitoring for compliance with Paragraph 68 during the Sixth Reporting Period.

39 In its comments to the Monitor's Draft Report, DOJ indicated that it "believes that CCTV footage is a valuable tool for confirming whether cell inspections occur as documented[.]"

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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved,40 and documented, and that the results of medical welfare checks on restrained prisoners were also documented.
The County’s Sixth Self-Assessment reports that for the Fourth Quarter of 2017, 100% "of electronic medical records reviewed. . .reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required by this Provision." The County’s Sixth Self-Assessment also reports that, for the First Quarter of 2018, 86% of the medical records reviewed "reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required by this Provision." This is below the 95% threshold for Substantial Compliance.
The Mental Health Subject Matter Expert and the clinicians "assessed the formal elements of the measure, including whether a psychiatrist timely approved the restraints and performed an assessment, whether a QMHP was present at the time of restraint, and whether the myriad monitoring requirements were met. [They] continued to have difficulty finding all the information on restraint[s], though it was more available than previously. The logs do not address all the monitoring requirements and associated notes may or may not address them, so it was not possible to find documentation of all the requirements."
The Mental Health Subject Matter Expert believes that "the requirements of [this Compliance Measure] are excessive and do not match standards published by organizations such as the Centers for Medicare and Medicaid Services (CMS)[.]" He would allow for "telephonic orders for restraint by psychiatrists" and assessments within 24 hours. Based upon these standards, the Subject Matter Expert believes that "restraints are being managed well, but proof of practice is challenging."
40 Per agreement of the parties, with the concurrence of the Monitor and Subject Matter Expert, "a nonpsychiatrist physician can order medical/clinical restraints as long as it is for medical reasons."
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: PARTIAL COMPLIANCE
The Mental Health Subject Matter Expert and DOJ have expressed concern about the Department's Substantial Compliance with paragraph 70(c) if all inmates in HOH are routinely handcuffed when they are out of their cells "in a housing pod at the same time." One of the clinicians observed that "[o]ur recent onsite observations suggested that not all patients required such restraints all the time."41 The Mental Health Subject Matter Expert is of the view that the Department's own "policies impose other requirements for review of restraints that the Department is not following for this population."
As the County "previously reported[,] the Department routinely handcuffs inmates in HOH and HOH_MIST housing when more than one HOH inmates is out of the cell in a housing pod at the same time. This category of inmates, as a whole, is a safety concern as they are deemed unpredictable and potentially dangers." Nevertheless, in response to the concerns expressed by the Mental Health Subject Matter Expert and DOJ, the Department has developed a pilot program "whereby each patient begins and ends their mental health treatment in the same module. . .[T]he HOH inmates enter in one pod and gradually step-down to the next pod, which allows more and more privileges as their behavior improves."42 The program started in one module in January 2018 and is planned "to expand to a second module in July 2018." Based upon a recent site visit to
41 The Mental Health Subject Matter Expert notes that paragraph 70(b) is also implicated because it required that restraint's "will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape." 42 Although the County does not agree that paragraph 70(c) requires individualized assessments of HOH inmates, who are often unpredictable and dangerous, the County agreed to establish a progressive stepdown program to address the concerns expressed by the Mental Health Subject Matter Expert and DOJ.
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TTCF by the Monitor, it appears that the program is more fluid than a formal step-down from pod to pod in a module. The Monitor and Mental Health Subject Matter Expert will observe the pilot program during the next Reporting Period to assess whether it satisfies the requirements of Paragraph 70(c).43 To achieve Substantial Compliance with Paragraph 70(c), the County needs to adopt some means of conducting individual assessments to determine which inmates need to be restrained, throughout HOH.
43 The County also reports that it "conducts daily huddle meeting to assess whether HOH inmates are suitable for a double man cell, or transfers to Enhanced Mental Health Housing or MOH. Notably, most inmates are moved to [a] lower level."
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71. The County and the Sheriff will ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (verified))
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71.
The County maintained Substantial Compliance with Paragraph 71 for twelve consecutive months during a prior reporting period and Paragraph 71 was not subject to monitoring in the Sixth Reporting Period.
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72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31, 2017)
Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings that review incidents of serious self-injurious behavior in the reporting period.
The Monitor's Fifth Report noted that "[n]either the posted audit source document nor the synopsis of each review in CHS' semi-annual report are. . . , sufficient for the Monitor to assess, as requested by DOJ, 'whether the County is adequately reviewing potential non-custody staff misconduct.'" In response, the County explained that "in light of confidentiality issues," review of non-custody staff misconduct would not be "part of the public discussion or documentation that takes place in the Critical Incident Review Committee (CIRC)/Death Review meetings. The review process itself would occur as an administrative or human resources process."
The County reports that "DHS-CHS tracks on an ongoing basis the number of CHS staff whose conduct is under review for possible misconduct. . . .As of May 10, 2018, 42 staff were "under review/investigation, with anticipated interventions ranging from additional training to removal from regular duties. . . . .The investigations involve a variety of conduct, not all of which is related to the performance of their clinical/patient care duties. . . .[and] include, but are not limited to, reviews of conduct related to critical incidents (CIRCs) or suicides."44
The Mental Health Subject Matter Expert and the clinicians conducted a qualitative assessment of eight CIRC reviews in February to April 2018. They concluded that all "clearly addressed whether staff engaged in any violations;"45 7 of the 8 "addressed whether any improvements to policy, training, operations, treatment programs, or facilities are warranted;" and determinations "to seek improvements" were reasonable in every case. The Subject Matter Expert notes that the "county is diligently conducting these reviews and in almost all cases doing a thorough job."
44 While this report gives the Monitor some confidence that the County is investigating and addressing noncustody staff misconduct, it does not indicate the results of any disciplinary hearings (without disclosing the names of the personnel under investigation) or the discipline imposed, or otherwise provide sufficient information for the Monitor "to assess" "whether the County is adequately reviewing potential non-custody staff misconduct." The Monitor agrees with DOJ that "more information about the disposition of individual investigations involving non-custody staff" is needed, without disclosing the names of the non-custody staff. 45 In the reviews conducted by one of the clinicians, this included "both custody and non-custody staff."
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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018 (verified))
Substantial Compliance requires the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicide during the reporting period.
The County’s Sixth Self-Assessment reports that for the Fourth Quarter of 2017, "98% -- 8% more than the required 90% -- of reports reviewed have all of the information required by paragraph 73 of the Settlement Agreement." It also reports "no incidents involving an apparent or suspected suicide occurred," and thus no notifications to the Office of Inspector General was required during this quarter.
The County’s Sixth Self-Assessment also reports that for the First Quarter of 2018, "94% -- 4% more the required 90% -- of reports reviewed have all of the information required by paragraph 73 of the Settlement Agreement" and that "100% -equal to the required standard of 100% -- of incidents involving an apparent or suspected suicide were reported to the Inspector General[.]" The Mental Health Subject Matter Expert reports that the "electronic BOHMRs are being filled out well with a good deal of quality observations.”46 The County's reported results during the First Quarter of 2018 have been verified by the Monitor's auditors.
46 The County may be underreporting its compliance rate with Paragraph 73 since it found six of the reports it reviewed to be non-compliant because it was unable to locate the injury report that had been prepared even though posted results indicate that the BOHMR had all of the required information. Paragraph 73 provides, however, that the required "detailed report" may be a BOHMR, Inmate Injury Report and/or an Incident Report.
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74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)
Substantial Compliance requires the Department to provide the Monitor with an Executive Suicide Death Review reflecting the results of the Department’s investigation of any suicide in the Jails within six months of the suicide. The review must reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded.
Although this provision was not subject to monitoring during the Sixth Reporting Period, the County provided the Monitor with the Executive Inmate Death Review for the suicide that occurred during the Fifth Reporting Period. The Homicide Report that was submitted for the suicide satisfied the requirements of Paragraph 74. In addition, the County continued to notify the Monitor of all inmate deaths, including suicides, and the subsequent death reviews. The Monitor attended the suicide death reviews for the suicides that occurred on January 26, 2018, March 26, 2018, and April 1, 2018.
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75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017 through March 31, 2018) (unverified)
Substantial Compliance requires (a) DMH to review documentation of randomly selected suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (b) that the Department and DMH reviewed the relevant information known at that time and the status of any corrective actions taken, and they considered the need for additional corrective action if necessary; and (c) that the information is reflected in the Department's database for tracking and statistical analysis.
The County's Fifth Self-Assessment reported that for the Third Quarter of 2017, "93% -- 8% more than the required 85% -- of documents reviewed showed DMH staff considered the inmate's mental health status and need for immediate corrective action;" "100% -- 5% more than the required 95% -- of suicide attempts are reflected in the Department's database;" and "100% -- more than the required 95% of the suicide attempts" were reviewed by "management and command-level personnel" from Custody, mental health, and medical as required by Compliance Measure 75-5(b).
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Although the results reported by the County met the quantitative thresholds for Substantial Compliance, the County's Fifth Self-Assessment noted that the "County is aware of concerns with the reporting system, which is why [its] self-assessment reflects only Partial Compliance." As explained in the Sixth Self-Assessment, "the County determined that in certain patient charts there were instances were an [Self-Directed Violence] SDV notification was not received via email as it should have been."
The County's Sixth Self-Assessment reports that the "County has now conducted a two part review and analysis of the data collected and determined that in addition to the email alerts, there are multiple checks and balances within the system that serve as additional alerts for SDV incidents including incident reports, a Chief's Memo regarding significant incidents, and BOMHRs. . . .As part of its review, the County conducted an audit of Third and Fourth Quarters, 2017 data and has confirmed that it met the thresholds for [the previously reported] Substantial Compliance for Third Quarter, 2017."47
The County's Sixth Self-Assessment reported that for the Fourth Quarter of 2017, "94% -- 9% more than the required 85% -- of documents reviewed showed DMH staff considered the inmate's mental health status and need for immediate corrective action;" "100% -- 5% more than the required 95% -- of suicide attempts are reflected in the Department's database;" and "100% -- more than the required 95% of the suicide attempts" were reviewed by "management and command-level personnel" from Custody, mental health, and medical as required by Compliance Measures 75-5(b) and (c). The County's augmented Sixth Self-Assessment reports for the First Quarter of 2018 "that 95%—10% more than the required 85%—of documents reviewed showed CHS staff considered the inmate's mental health status and need for immediate corrective action. . .pursuant to Compliance Measure 75-5(a). The County also concluded that 100% - 5% more than the required 95% - of the suicide attempts reviewed were compliant with Compliance Measure 75-5(b) [and] that 100% -- 5% more than the required 95%— of suicide attempts are reflected in the Department's database for tracking and statistical analysis pursuant to Compliance Measure 75-5(c)." The results are subject to verification by the Monitor's auditors.
The Mental Health Subject Matter Expert and the clinicians reviewed seven cases that were the subject of CIRC reviews during the First Quarter of 2018 and one case in the Second Quarters of 2018, and concluded as follows: In 88% of the cases,48 "the DMH 2-day review demonstrated that the mental health status of the patient at the time of the incident was reviewed" and "that the need for corrective action plans was considered." In 88% of the cases, the 30-day review demonstrated that "the events preceding and following the incident, the prisoner’s incarceration history, the prisoner’s
47 The County also submitted a separate "Note to Monitor re Provision 75" that described the County's twopart review and analysis collected for Third and Fourth Quarters 2017[.]" 48 The one case that was out of compliance was in the First Quarter of 2018, which reduces the compliance percentage for the First Quarter to 85.7%. Nevertheless, given the small size of the sample of the qualitative review, the Monitor is of the view that the County is in Substantial Compliance "based upon the quantitative thresholds in the Compliance Measures." See p. 1, supra.
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mental health history, and the prisoner’s health status history" were reviewed and the required content was addressed.49
The Mental Health Subject Matter Expert concludes that; In general, the county is doing a good job of these reviews. They continue to streamline and organize the process and are developing better mechanisms for focusing reviews and tracking CAPs. In our view, the 2day reviews (chart reviews) are more extensive than needed and should focus on identifying critical clinical problems, urgent need for corrective action, and determination of the severity of the event. The continued work on CQIP in general is bringing better organization to the whole process. In short, we see solid progress here.
49 The Mental Health Subject Matter Expert and clinicians also found that in only 62% of cases, the "30day review clearly demonstrated consideration of the need for additional corrective action." The County notes, however, that "[p]articipants at every CIRC are asked whether there are additional corrective actions or other items to be considered."
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76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)

The County previously maintained Substantial Compliance with Paragraph 76 for twelve consecutive months and this provision was no longer subject to monitoring during the Sixth Reporting Period. Nonetheless, the County continued to conduct the reviews required by Paragraph 76 for the suicides that occurred during this period and invited the Monitor to attend these meetings.

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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
The Semi-Annual Report of CCSB Activities reports that during the Sixth Reporting Period, "there were three (3) suicides, twelve (12) suicide attempts, and [306] self-injurious behavior incidents identified in the jails." 16 of the 306 incidents were discussed during six CIRC meetings. The Semi-Annual Report indicates that "[o]f the potential issues discussed, a total of fifty (50) Correction Action Plan/Issues (CAP) items were created. . . Some of the issues identified in the CIRCs have been sufficiently addressed by the CAPs implemented and are unlikely to occur again. However, other issues remain that involve factors such as mental health, systemic issues and facility layout/construction projects, and will likely require longer-term solutions. Custody Compliance and Sustainability Bureau (CCSB) is responsible for monitoring the implementation and tracking of CAPs to address the issues identified."
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The Semi-Annual Report includes the following sections:
(a) "Administrative Review of Suicides." This summarizes the 24-hour, 7day, and 30-day reviews of the three suicides that occurred during the Sixth Reporting Period. It also cross-references CHS' semi-annual report, which summarizes the reviews of serious suicide attempts by the CIRC. The Monitor remains satisfied that CCSB is ensuring that CHS and the Department are timely and thoroughly conducting administrative review of suicides and serious suicide attempts in the jails as required by Compliance Measure 77-2(a).
(b) "Patterns and trends and statistical analysis of suicides and serious suicide attempts in jails." This section breaks down the 16 incidents self-injurious behavior incidents reviewed at CIRC meetings50 by age, race, day of the week, method, mental health housing, and relationship to time of arrest and appearance in court. There is, however, no statistical analysis of this data.
(c) "Corrective actions taken by the department to mitigate suicide risks" section. This section describes the corrective actions taken by the Department to mitigate suicide risks at the jails, in addition to the cross-referenced CAPs discussed at the Executive Inmate Review Committee meetings under the "Administrative Review of Suicides" section and the responses to issues discussed by CIRC in its reviews of serious suicide attempts and other incidents involving self-directed violence. Taken together, the report on CCSB's activities and CHS's Semi-Annual Report satisfy the requirements of Compliance Measures 77-2(c).
(d) "Technical issues provided to, or obtained for other administrative units within the Custody Division to address suicide-risk issues." This section describes the roll-out and training of the use of the electronic form by the Court Services Division and the "improvements in communications." This was largely done in the prior reporting period and "[f]uture plans are to include [station jails] and outside agencies." It does not appear, however, that CCSB provided any technical assistance to other administrative units within the Custody Division in this reporting period.
(e) "Analysis of staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts." This section reports that the Executive Inmate Death Review Committee meetings reviewed each of the three suicides during the Sixth Reporting Period and "determined that staffing levels had no bearing on the ability to discover the inmate in distress, or on the subsequent life saving measures." It does not analyze whether staffing levels had any bearing on the 16 incidents of serious suicide attempts/self-directed violence that were analyzed by the CIRC. A sub-section reports that "it was determined each of the three inmates who committed suicide during the period were correctly classified and housed, based upon criteria known at the time." Another sub-section on Employee Performance reports that "[d]uring each Executive Death Review and CIRC
50 The report does not include the three suicides reviewed during Executive Inmate Death Review meetings in the breakdown.
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meeting, employee performance is discussed," and "no employee's action resulted in disciplinary action during the reviews," although "there were noted shortcomings in documentation or process that resulted in additional CAPs, counseling, or training."
(f) "Remedial measures, including policy revisions, re-training, or staff discipline, to address issues related to suicide and serious suicide attempts." This describes a series of the remedial measures taken to address process and procedure issues such as protocol for completing a SRC, "the use of the 'Red Book' . . .to assist nursing in prioritizing referrals, and changes in P- levels." None of the issues addressed appeared to be significant.
(g) "Summaries of meeting with DMH to develop, implement, and track corrective action plans." This section reports that "Corrective Action Plans are primarily identified and discussed at CIRC meetings. At the JQIC meetings there is follow up to verify that the CAPs have been addressed and verify their effectiveness. CCSB tracks all suicide-related CAPs, whether they are CHS or LASD CAPs, and does so continuously outside the CIRC and JQIC context." The CIRC meetings are summarized in the CHS semi-annual report, see pp. 66-8, supra, and this section of the CCSB report summarizes JQIC meetings during the Sixth Reporting Period the status of the corrective actions plans that were discussed by staff members from CHS, CCSB, and the involved jail facilities at the JQIC meetings.
CCSB is to be commended for the work it has done to facilitate the implementation of various provisions of the Settlement Agreement. Paragraph 77 also requires the unit "to oversee the County's jail suicide prevention program in coordination with [CHS]" and Paragraphs 60 and 62 impose obligations on CCSB to work with CHS to "implement a quality improvement plan to identify and address clinical issues that place prisoners at significant risk of suicide and self-injurious behavior" and "develop, implement and track corrective action plans addressing recommendations of the quality improvement program." As noted by the Mental Health Subject Matter Expert, it is not clear that there is an "overarching Q[uality] M[anagement] approach at the Department" that is fully integrated with CHS's program.
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of May 11, 2016, through May 18, 2017)
Substantial Compliance requires (1) the Committee to meet twice per year and (2) "recommend coordinated approaches to suicide prevention in the Jails."
The County maintained Substantial Compliance with paragraph 78 for twelve consecutive months as of May 18, 2017, and this provision was not subject to monitoring in the Sixth Reporting Period.
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; describe the medication support services available for prisoners not in mental health housing who are receiving psychotropic medications; and review electronic medical records of such to confirm that medication support services were provided to these prisoners.
The County’s posted results show that in the Fourth Quarter of 2017, 54% of the prisoners who resided outside of mental health housing and were receiving psychotropic medications were "provided with medication support services," which is below the 85% threshold required by Compliance Measure 79.5(d) for Substantial Compliance.51 The Sixth Self-Assessment reports that the County has "determined that a shortage of medical doctors treating patients in the general population has hindered its ability to comply with this provision."
The qualitative assessments by the Mental Health Subject Matter Expert and the clinicians "have continued to reveal little substantial progress in the provision of therapeutically appropriate treatment. . . . Group activities are generic and seldom appear based on individual patient need." As acknowledged in the County's Self-Assessment, "the County is not yet able to render structured treatment according to sound treatment methods reflect in treatment plans."
51 As in the past, the Sixth Self-Assessment does not address Compliance Measures 79.1(a)-(c) and 79.5(b), which require the County to maintain records of "therapeutically appropriate individual visits and group programming, and the names of supervisors who reviewed the documentation of group sessions"
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business workday. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

NON-COMPLIANCE

Paragraph 80 requires that, "no later than 18 months after the Effective Date [July 1, 2015]," 100% of the prisoners in HOH receive "ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week." The parties have agreed that up to five hours of the structured time can consist of education or work programs, but at least five hours of the time must be therapeutic.

The County's posted results for the First Quarter of 2018 shows that 50% of the prisoners at CRDF and 71% of the prisoners at TTCF were offered 10 or more hours of unstructured, out-of-cell recreational time. The County's Sixth Self-Assessment reports that "[w]ith respect to the structured out-of-cell time, [County Health Services] is in the process of developing an electronic system so that clinicians, and not custody staff, will be able to track the structured out-of-cell time offered." It did not, however, report on the percentage of prisoners who were offered 10 or more hours of structured therapeutic or programmatic time per week.52

The Mental Health Subject Matter Expert and the two clinicians "observed and coded the out-of-cell time for each inmate" in two HOH pods at CRDF and TTCF during the period from December 17, 2017, through January 18, 2018. They were "on the units for 8-10 hours each day" and they coded various activities (e.g., yard, mental health groups). They report that "[s]everal important observations stood out to us:" "almost half of the inmates did not come our during the day shift;" CRDF had "much less out of cell time than at TTCF;" and "the progressive [Living Module] unit at TTCF (161) is doing a good job of getting inmates out of their cells[.]" Overall, "the county is far short of getting even an hour of structured out of cell time daily (there is little to no structured out of cell time in the evenings). Unstructured time is highly variable but averages only an hour and a half daily(excluding evening hours which are likely to be substantial."

52 The Mental Health Subject Matter Expert notes that the County's "data is difficult to interpret." The outof-cell hours on the sheets do not add up in many instances and numbers are reported that are clearly erroneous. The County appears to have collapsed refusals and those deemed ineligible into a single category but are using notes to distinguish them. This is at least a beginning. However, the County is still counting both as out of cell time."
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81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
Policies approved by the Rosas Monitors and adopted by the Department in the First Reporting Period implemented the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
In the Second Reporting Period, the Rosas Monitors approved policies to implement the following provisions of the Rosas Implementation Plan: Paragraphs 6.16.20 (grievance system); Paragraph 8.2 (combining "Complaints of Retaliation"). They also approved revised policies to implement Paragraphs 13.1-13.2 (discipline for PREA violations, dishonesty, and failure to report force incidents).
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 of the Rosas Implementation Plan reflect training requirements that were supposed to be, but were not, completed by December 31, 2016. This is due in part to the delays that have occurred in the review and approval of the Department's use of force and investigations training program. The Monitor has retained auditors to review the Department's training records and verify the Department's compliance with the training requirement of the Rosas plan at CRDF, NCCF, PDC North, PDC South, and PDC East.
On July 10, 2018, the Department presented to the Rosas Monitors its Custody
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Operations Employee Review System it has implemented "to facilitate the identification, tracking, analysis, and review of specific employee-related incidents and issues." The system generates monthly reports reflecting use of force, grievances against staff, and Watch Commander Service Comment Reports for individual employees over a three month period to identify potentially problematic employees. The Rosas Monitors concluded that this system addresses the requirements of Paragraphs 19.1, 19.2, and 19.3 of the Rosas plan for an Early Warning System.
Paragraphs 4.10 and 9.1 of the Rosas Implementation are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Accordingly, the Department has implemented all of the provisions of the Rosas Implementation Plan.
In the Sixth Reporting Period, the Monitor reviewed 24 randomly selected completed force packages for CRDF, NCCF, and PDC North. These packages were not reviewed by a Use of Force Subject Matter Expert because the parties did not agree on a replacement for the Use of Force Subject Matter Expert who tragically passed away in Los Angeles on November 3, 2017, after touring CRDF with the Monitor. Overall, the Monitor concluded that the Department is complying with its policies regarding the use of force and documentation of force incidents at CRDF and PDC North jail facilities, and that the force investigations are thorough and complete. There were no cases in which the Monitor concluded that the force was not in compliance with the applicable provisions of the Rosas Plan, and only one case in which reporting and investigation of force was not in compliance with the other applicable provisions of the plan. Once again, however, the Monitor was unable to determine whether the Department was in compliance with policies pertaining to the timeliness of reports and the interviews of inmate witness.
All of the force incidents at CRDF and PDC North reviewed by the Monitor and Subject Matter Expert were captured on fixed closed circuit television cameras at CRDF and PDC North. Although the closed circuit camera televisions is not required to be fully operational at NCCF until July 1, 2018, all of the force incidents at NCCF reviewed by the Monitor during the Sixth Reporting Period were captured on the CCTV's that have been installed at NCCF.
During the Sixth Reporting Period, the Monitor met with the Inmate Grievance Teams at CRDF and NCCF on March 27 and April 4, 2018, respectively. The Monitor also met again with the Division Inmate Grievance Coordinator who has oversight responsibility for the implementation of the new grievance system to discuss improvements to the tracking system that are being implemented throughout the Custody Division. The grievance teams at both CRDF and NCCF have made significant improvements in the tracking of inmate grievances, reducing the back-log of overdue grievance investigations and closing out investigations that had been opened for more than 30 days at their institutions.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 15, 2016, through December 31, 2017)
The Rosas Monitors have approved a de-centralized inmate grievance system, which includes an Inmate Grievance Team co-located at Century Regional Detention Facility. The Department published its new grievance policies on July 15, 2016.
CRDF has its own Inmate Grievance Team with the staffing required by CDM 801.020.00. The Monitor met with CRDF's Inmate Grievance Team during the Sixth Reporting Period and reviewed the operation of the grievance system at CRDF.
Pursuant to Paragraph 111 of the Settlement Agreement, the County was not subject to monitoring for Substantial Compliance with Paragraph 82 in the Sixth Reporting Period.
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83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement ("Common Areas"), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2015, through June 30, 2016 at MCJ and IRC)
SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at TTCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31 2017 at CRDF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, though June 30, 2018, at NCCF and PDC North)
SUBSTANTIAL COMPLIANCE (as of July 1, 2018 at PDC South)
The Monitor visited NCCF and PDC North on April 4, 2018, and confirmed that the closed circuit security cameras were operational in Common Areas at those facilities, although the Department has ordered an additional eight cameras to cover blind spots at PDC North and is waiting for new computers that will allow supervisors to view all of the cameras at NCCF on large monitors in sergeants offices.53 As of April 4, the Department was in the process of finishing the installation of cameras at PDC South. On July 12, 2018, the Department submitted a report showing all of the cameras requested and operational at each of these facilities.
Paragraph 83 also requires the Department to provide evidence that all video recordings of force incidents were adequately stored and retained for a period of at least one year after the force incident occurs. The County's Sixth Self-Assessment reports that it has achieved Substantial Compliance for this measure at CRDF in the Fourth Quarter of 2017. NCCF and PDC North are still subject to this requirement of Paragraph 83 until March 31, 2020, and PDC South is subject to it until June 30, 2020.
53 The cameras can, however, be viewed on desktops in the sergeants offices.
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The County previously maintained Substantial Compliance with Paragraph 83 at IRC, MCJ, and TTCF for twelve consecutive months and were not subject to monitoring during the Sixth Reporting Period. Further, CRDF is no longer subject to monitoring with Paragraph 83.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:
(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and
(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through March 31, 2018 (verified))
Substantial Compliance under the Compliance Measures requires the Department to demonstrate that 95% of the investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies. Although Paragraph 84 requires the Department to implement policies for the "timely and thorough" investigation of force incidents, the subparagraphs and the Compliance Measures are focused on the timeliness of the completion of the investigations resulting in the imposition of discipline. The Monitor's determination of the Department's compliance with Paragraph 84 will be largely based upon the timeliness of the completion of the investigations, but the Monitor also has randomly selected and reviewed several internal investigations, which appeared to be thorough and unbiased.
The County’s Sixth Self-Assessment reports that the Department achieved Substantial Compliance in the Fourth Quarter of 2017 and the First Quarter of 2018. The Department concluded that all of the randomly selected "investigations of force incidents which involved a violation of policy or misconduct [in the Fourth Quarter of 2017 and the First Quarter of 2018] were completed and administrative action was timely taken pursuant to 84-2." The reported results have been verified by the Monitor's auditors.
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85. The County and the Sheriff will ensure that Internal Affairs Bureau management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training. The County's posted results show that only 57.5% of the IAB investigators completed all three of the required courses as of the end of the Second Quarter of 2018.
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86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 at MCJ and CRDF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2017 at PDC North)
SUBSTANTIAL COMPLIANCE (as of February 1, 2017, through March 31, 2018 at PDC South and PDC East)
SUBSTANTIAL COMPLIANCE (as of March 1, 2017 through March 31, 2018 at NCCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through March 31, 2018 at IRC)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through June 30, 2018, at TTCF)
CDM 7-08/080 ACCOUNTABILITY OF SPECIALWEAPONS, effective October 14, 2016, requires each facility to have unit orders that "establish procedures for the storage, issuance, reissuance, accountability, maintenance, and periodic inventory of all weapons. . . stored at, or issued from, the facility," which includes detailed requirements for the "Inventory, Control, and Accountability of Aerosol Chemical Agents."
In addition to providing written policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment, Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with up-to-date Unit Orders for each jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons.
The Monitor and Use of Force Subject Matter Expert inspected the armories at TTCF on March 28, 2018. The Monitor inspected the armories and sub-armories at NCCF and PDC South on April 4, 2018, and checked the available inventory logs. The Monitor inspected the armories at IRC on April 10, 2018.
The inventory logs were checked daily in the IRC, PDC North, and TTCF armories, and weekly in the PDC South armory. 54 The main armory and the sub-
54 Because PDC East is a fire camp with very few inmates, weapons in the armory are almost never used.
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armories at NCCF are checked daily and the inventories matched the weapons in the subarmories. Each of these facilities has reasonably up-to-date unit orders and all weapons were accounted for during recent inspections. The Department submitted the required armory audit logs for all of the facilities that were subject to monitoring for Fourth Quarter of 2017 and the First Quarter of 2018.
The Department previously maintained Substantial Compliance with Paragraph 86 for twelve consecutive months at MCJ, CRDF, and PDC North. Pursuant to Paragraph 111, the armories at MCJ, CRDF, and PDC North were not subject to monitoring in the Sixth Reporting Period. The Department has maintained Substantial Compliance with Paragraph 86 for twelve consecutive months at NCCF, PDC South, PDC East, and IRC and will no longer be subject to monitoring in future periods.
The Monitor noted significant improvement in the armories at TTCF. Although there were a few days when the inventory logs were only checked in two of the three shifts, the inventory lists checked by the deputies accurately reflected what was in the armory and sub-armories, the facilities were well-organized, and it was easy to locate the weapons and rounds of ammunition. The Monitor is of the view that the Department has achieved Substantial Compliance with Paragraph 86 at TTCF as of April 1, 2018.
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APPENDIX A

NO. PROVISION

STATUS

SUBSTANTIAL COMPLIANCE DATES

18 Suicide Prevention Training Substantial Compliance (MCJ, NCCF, PDC South, PDC East, TTCF, IRC, PDC North, & CRDF)

(10/1/17 at MCJ & PDC South) (9/1/17 at NCCF) (12/1/17 at PDC East) (4/1/18 at TTCF, IRC, & PDC North) (6/1/18 at CRDF)

19 Crisis Intervention &

Partial Compliance

Conflict Resolution Training

20 Training at NCCF, PDC and Substantial Compliance (PDC

CRDF

East, PDC North, PDC South,

NCCF, & CRDF)

(8/1/17 at PDC East, PDC North, NCCF, & CRDF)1 (10/1/17 at PDC South)

21 CPR Certification

Substantial Compliance (NCCF, PDC East, PDC North, PDC South, TTCF, IRC, & MCJ) Partial Compliance (CRDF)

(10/1/15 – 9/30/16 at PDC East, & PDC South) (1/1/16 – 12/31/16 at NCCF, PDC North, & IRC) (4/1/16 – 3/31/17 at TTCF) (10/1/17 – 3/31/18 at MCJ)

22 Use of Arresting and Booking Documents

Substantial Compliance

(7/1/16 – 6/30/17)

23 Suicide Hazard Mitigation Plans

Substantial Compliance

(1/1/18 & 7/1/18)

1 Substantial Compliance Dates in bold reflect that the Department has achieved Substantial Compliance with the training requirements or maintained Substantial Compliance for twelve consecutive months with the other requirements; the results were verified by the Monitor's auditors when required; and the County or designated facilities are no longer subject to monitoring of this provision pursuant to paragraph 111 of the Settlement agreement.

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 111 of 117 Page ID #:3066
APPENDIX A

24 Suicide Hazard Inspection Substantial Compliance

(10/1/17)

25 Transportation of Suicidal Inmates (station jails)

Partial Compliance

26 Identification and Evaluation Partial Compliance of Suicidal Inmates

27 Screening for Mental Health Substantial Compliance Care and Suicide Risk

(10/1/17 – 3/31/18)

28 Expedited Booking of Suicidal Inmates

Substantial Compliance (IRC & CRDF)

(4/1/17 – 3/31/18 at IRC) (1/1/18 – 3/31/18 at CRDF)

29 Mental Health Assessments Substantial Compliance (of non-emergent mental health needs)

(4/1/17 – 3/31/18)

30 Initial Mental Health Assessments & Treatment Plans

Partial Compliance

31 Electronic Medical Records Partial Compliance Alerts

32 Electronic Medical Records Substantial Compliance – Suicide Attempts

(1/1/16 – 12/31/16)

33 Supervisor Reviews of

Substantial Compliance

Electronic Medical Records

(7/1/16 – 6/30/17)

34 Discharge Planning

Stayed Pending Litigation

35 Referral for Mental Health Care

Substantial Compliance

(11/1/17 – 3/31/18)

36 Assessments After Triggering Events

Partial Compliance

37 Court Services Division Referrals

Partial Compliance

38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

(1/1/16 – 12/31/16)

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 112 of 117 Page ID #:3067
APPENDIX A

39 Confidential Self-Referral

Substantial Compliance (NCCF & CRDF) Partial Compliance (MCJ & TTCF) Not Rated (PDC South, PDC East, & PDC North)

(10/1/17 – 3/31/18 at CRDF) (7/1/17 – 3/31/18 at NCCF)

40 Availability of QMHPs

Partial Compliance

41 FIP Step-Down Protocols Not Rated

42 HOH Step-Down Protocols Partial Compliance

43 Disciplinary Policies

Substantial Compliance (NCCF & PDC North) Partial Compliance (CRDF, MCJ, & TTCF)

(10/1/17 – 3/31/18 at NCCF & PDC North)

44 Protective Barriers

Substantial Compliance

(1/1/16 – 12/31/16)

45 Suicide Intervention and First Aid Kits

Substantial Compliance

(10/1/15 – 9/30/16 at CRDF, NCCF, TTCF, PDC East, & PDC South) (1/1/16 – 12/31/16 at MCJ & PDC North)

46 Interruption of Self-Injurious Partial Compliance Behavior

47 Staffing Requirements

Non-Compliance

48 Housekeeping and Sanitation Substantial Compliance

(1/1/16 – 12/31/16)

49 Maintenance Plans

Substantial Compliance

(3/1/16 – 2/28/17)

50 Pest Control

Substantial Compliance

(1/1/16 – 12/31//16 at MCJ, NCCF, PDC North, TTCF, & CRDF) (4/1/16 – 3/31/17 at PDC South & PDC East)

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 113 of 117 Page ID #:3068
APPENDIX A

51 Personal Care & Supplies
52 HOH Property Restrictions 53 Eligibility for Education,
Work and Programs 54 Privileges and Programs2 55 Staff Meetings
56 Changes in Housing Assignments
57 Inmate Safety Checks in Mental Housing
58 Inmate Safety Checks in Non-Mental Housing

Substantial Compliance
Partial Compliance Partial Compliance

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC East, PDC North, PDC South, & TTCF) (7/1/16 – 6/30/17 at CRDF)

Partial Compliance

Substantial Compliance (CRDF, PDC North, MCJ, & TTCF)

(10/1/16 – 9/30/17 at CRDF) (4/1/17 – 3/31/18 at PDC North) (4/1/18 – 6/30/18 at MCJ & TTCF)

Substantial Compliance

(1/1/16 – 12/31/16)

Substantial Compliance (MCJ) Partial Compliance (TTCF, CRDF, & PDC North)

(4/1/17 – 3/31/18 at MCJ)

Substantial Compliance (PDC South, PDC North, PDC East, CRDF, & IRC ) Partial Compliance (NCCF, MCJ, & TTCF)

(1/1/16 – 12/31/16 at PDC South, PDC North, & PDC East) (7/1/17 – 3/31/18 at CRDF) 10/1/17 – 3/31/18 at IRC)

2 Per agreement of the parties, the County must maintain Substantial Compliance for two additional quarters under the revised Compliance Measures.

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 114 of 117 Page ID #:3069
APPENDIX A

59 Supervisor Rounds
60 Implementation of Quality Improvement Program
61 Requirements of Quality Improvement Program
62 Tracking of Corrective Action Plans

Substantial Compliance (at PDC North, PDC East, MCJ, CRDF, PDC South, NCCF, & TTCF)
Partial Compliance

(1/1/17 – 12/31/17 at PDC East & MCJ) (4/1/17 – 3/31/18 at NCCF) (10/1/17 – 6/30/18 at CRDF) (1/1/18 – 6/30/18 at PDC North & PDC South) (4/1/18 – 6/30/18 at TTCF)

Partial Compliance

Partial Compliance

63 Sufficient HOH and MOH Housing
64 Plans for Availability of Inpatient Health Care

Non-Compliance Partial Compliance

65 Administration of Psychotropic Medication
66 Active Mental Health Caseloads
67 Prisoner Refusals of Medication
68 Contraband Searches
69 Clinical Restraints in CTC

Partial Compliance
Non-Compliance
Non-Compliance
Substantial Compliance (MCJ, NCCF, PDC East, PDC South PDC North, & TTCF) Partial Compliance (CRDF)
Partial Compliance

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC East, PDC South, & PDC North) (1/1/17 – 12/31/17 at TTCF)

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 115 of 117 Page ID #:3070
APPENDIX A

70 Security Restraints in HOH Partial Compliance and MOH

71 Therapeutic Services for

Substantial Compliance

Inmates in Clinical Restraints

72 Administrative Reviews

Substantial Compliance

73 Reporting of Self-Injurious Substantial Compliance Behavior and Threats

74 Law Enforcement Investigations of Suicides

Substantial Compliance

75 Management Reviews of Suicide Attempts

Substantial Compliance

76 Management Reviews of Suicides

Substantial Compliance

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Substantial Compliance Committee

79 Therapeutic Services in Mental Health Housing

Non-Compliance

80 Out-of-Cell Time in HOH Non-Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

82 Collection of Grievances at Substantial Compliance CRDF

83 Closed Circuit Cameras

Substantial Compliance (MCJ, TTCF, IRC, CRDF, NCCF, PDC North, & PDC South)

(7/1/16 – 6/30/17) (1/1/17 – 12/31/17) (10/1/17 – 3/31/18) (9/1/16 – 12/31/17) (10/1/17 – 3/31/18) (9/1/16 – 12/31/17)
(5/11/16 – 5/18/17)
(7/15/16 – 12/31/17) (7/1/15 – 6/30/16 at MCJ & IRC) (10/1/15 – 9/30/16 at TTCF) (4/1/16 – 3/31/17 at CRDF) (4/1/18 – 6/30/18 at NCCF & PDC North) (7/1/18 at PDC South)

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 116 of 117 Page ID #:3071
APPENDIX A

84 Investigation of Staff Misconduct
85 Internal Affairs Bureau Training
86 Maintenance and Inventory of Security Equipment

Substantial Compliance

(7/1/17 – 3/31/18)

Non-Compliance

Substantial Compliance (MCJ, CRDF, PDC North, PDC South, PDC East, NCCF, IRC, & TTCF)

(4/1/16 – 3/31/17 at MCJ & CRDF) (10/1/16 – 12/31/17 at PDC North) (2/1/17 – 3/31/18 at PDC South & PDC East) (3/1/17 – 3/31/18 at NCCF) (4/1/17 – 3/31/18 at IRC) (4/1/18 – 6/30/18 at TTCF)

Case 2:15-cv-05903-DDP-JEM Document 141 Filed 08/31/18 Page 117 of 117 Page ID #:3072
APPENDIX B

First4 Second Third Fourth Fifth Sixth

Substantial Partial

Non-

Substantial

Compliance Compliance1 Compliance Compliance

(Provisions)

(Facilities)2

No Longer
Subject To Monitoring3

5

16

10

14

30

13

24

22

27(1)

10

29

4(2)

24

26(1)

10

29

10(2)

23

24(2)

7

34

15(5)

32

22

7

38

18(9)

1 The figure in parenthesis under Partial Compliance is the number of additional
provisions where some facilities were in Partial Compliance and other facilities were in Non-
Compliance. 2 This represents the number of provisions where the Department is in Substantial
Compliance at all or some of the facilities. 3 The figure in parenthesis under No Longer Subject to Monitoring is the number of
additional provisions where some facilities are no longer subject to monitoring. 4 During the First Reporting Period, 43 provisions were not subject to monitoring.

 
 Case 2:15-cv-05903-DDP-JEM Document 148 Filed 02/28/19 Page 1 of 124 Page ID #:3169

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) 601 West Fifth Street, 12th Floor

3 Los Angeles, CA 90071-2025

4

Telephone: (213) 613-4655 Facsimile: (213) 613-4656

5 Monitor
6

7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

WESTERN DIVISION

11

12 UNITED STATES OF AMERICA,

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Plaintiff,

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v.

CV No. 15-05903 DDP (JEMX) MONITOR’S SEVENTH REPORT

16 COUNTY OF LOS ANGELES AND

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LOS ANGELES COUNTY SHERIFF JIM MCDONNELL, in his Official

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Defendants.

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MONITOR’S SEVENTH REPORT

Case No. 2:14cr00282-R

Case 2:15-cv-05903-DDP-JEM Document 148 Filed 02/28/19 Page 2 of 124 Page ID #:3170

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Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and the

4 Los Angeles County Sheriff during the six-month period from July 1, 2018, to

5 December 31, 2018, “to implement the Agreement and evaluating the extent to

6 which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

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13 DATED: February 28, 2019

Respectfully submitted,

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SCHEPER KIM & HARRIS LLP

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RICHARD E. DROOYAN

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By: /s/ Richard E. Drooyan Richard E. Drooyan

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Monitor

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MONITOR’S SEVENTH REPORT

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MONITOR’S SEVENTH REPORT
This Seventh Report sets forth the Monitor’s assessments of the implementation of the Settlement Agreement (the "Agreement") between the County of Los Angeles (the "County") and the United States Department of Justice ("DOJ") for the treatment of mentally ill inmates in the County’s jail facilities by the Los Angeles Sheriff’s Department (the "Department") and the County's Department of Health Services ("DHS").1 It covers the County's reported results for the period from July 1, 2018, through December 31, 2018 (the "Seventh Reporting Period").
As used herein, "Substantial Compliance" means that the County has "achieved compliance with the material components of the relevant provisions of this Agreement in accordance with the [agreed-upon Compliance Measures for assessing Substantial Compliance]," which it must maintain for twelve-consecutive months; "Partial Compliance" means that the County has achieved "compliance on some, but not all, of the material components of the relevant provision of this Agreement;" and "NonCompliance" means that the County has not met "most or all of the material components of the relevant provisions of this Agreement."
This Seventh Report is based upon the Monitor's review of the policies, procedures, and directives proposed and/or implemented by the Department and Correctional Health Services ("CHS") in the Seventh Reporting Period; assessments and observations of the Subject Matter Expert; and multiple tours of the jails by the Monitor, the Subject Matter Experts, and the two clinicians retained by the Monitor to assist the Mental Health Subject Matter Expert. It is also takes into consideration the County’s Self-Assessment Status Report (the "Seventh Self-Assessment"), which was received on December16, 2018; the Semi-Annual Report of the Department's Custody Compliance and Sustainability Bureau ("CCSB"), which was received on January 3, 2019; the County's Augmented Self-Assessment Status Report (the "Augmented Seventh SelfAssessment") and the CHS's Semi-Annual Report on Quality Improvement/Assurance, which were received on January 14, 2019 and results reported by the County through that date. Finally, it takes into consideration the comments the Monitor received from the County and DOJ on the draft of this Report that was submitted to the parties on February 1, 2019.
During the Seventh Reporting Period, the Mental Health Subject Matter Expert, with the assistance of the clinicians, conducted additional qualitative assessments of the County's compliance with certain Substantive Provisions in the Settlement Agreement, and they again used different methodologies to test some of the County's reported results. The Monitor's determination of the County's compliance, with the advice of the Subject Matter Expert, is based upon the quantitative thresholds in the Compliance Measures (and any other applicable requirements in the Compliance Measures), unless the quality of the County's performance as determined by the qualitative assessment is plainly inadequate or the results reported by Subject Matter Expert vary significantly from the
1 The Department of Health Services includes Correctional Health Services, which is responsible for Medical and Mental Health Services in the Los Angeles County jails.
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results reported by the Department.
During the Seventh Reporting period, the County established compliance with additional provisions of the Settlement Agreement, and made progress in addressing the significant challenges to achieving and maintaining Substantial Compliance with respect to its quality improvement plans and the private screening of inmates at IRC and CRDF. It still faces significant challenges with respect to therapeutic services and out-of-cell time.
As in prior reports, this Seventh Report reflects the results of audits by the Monitor's auditors to verify results reported by the County. The Monitor has deemed the County to be in Substantial Compliance "as of" the beginning of the quarter reported by the County if the auditors have verified that the County has met the thresholds in the Compliance Measures. If the auditors were not able to verify the results reported by the County, the twelve-month period for maintaining Substantial Compliance will commence in a future period when the County's reported results are verified by the auditors. If the County maintains Substantial Compliance with a provision for twelve consecutive months, pursuant to Paragraph 111 of the Agreement, the Monitor and Subject Matter Experts will "no longer. . .assess or report on that provision" in future reporting periods.
Some of the Substantial Compliance results reported by the County in the Seventh Reporting Period have not been audited by the Monitor’s auditors and cannot be considered final until verified by the auditors. The County will not be deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the twelve-month compliance period if the results are not verified by the auditors.
Appendix A to this Seventh Report shows the status of each of the 69 provisions of the Agreement that are subject to monitoring and the twelve-month triggering dates where the County is deemed to be in Substantial Compliance. Appendix B shows the County's progress from the Initial Reporting Period through the Seventh Reporting Period in achieving Substantial Compliance and in maintaining Substantial Compliance for twelve consecutive months on provisions that are no longer subject to monitoring.
As has been the case since the beginning of the Initial Reporting Period, the County cooperated completely with the Monitor and the Subject Matter Experts during the Seventh Reporting Period. The Department, CHS, and County Counsel facilitated our visits and inmate interviews, answered our questions, and responded to our requests for documents and information. We appreciate their responsiveness, transparency, professionalism, and courtesy in handling our monitoring requests.
Richard Drooyan, Monitor February 28, 2019
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EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the County and the Department are in Substantial Compliance with 31 provisions, in Partial Compliance with 22 provisions, and in Non-Compliance with 7 provisions. In addition, there are 7 provisions in which the Department is in Substantial Compliance at some facilities and in Partial Compliance or Non-Compliance at other facilities. There is also one provision (Paragraph 34), that remained stayed pending litigation initiated by third party intervenors, and one provision (Paragraph 39) for which the Department is in Substantial Compliance at certain facilities, Partial Compliance at other facilities, and Not Rated at other facilities. There are 39 provisions for which the County and the Department are in Substantial Compliance at some or all of the facilities.2
There are 23 provisions that are no longer subject to monitoring because the County and Department maintained Substantial Compliance for twelve consecutive months as required by Paragraph 111 of the Settlement Agreement as verified by the Monitor's auditors as required. There are another 11 provisions for which some facilities are no longer subject to monitoring because those facilities maintained Substantial Compliance for the required twelve consecutive months.3
As of the date of this Report, and subject to verification by the Monitor's auditors and qualitative assessments in some cases, the County and the Department are in Substantial Compliance at some or all of the facilities with the following provisions of the Settlement Agreement:
The County has achieved Substantial Compliance with Paragraph 18, which requires the training of Deputy Sheriffs and Custody Assistants on suicide prevention as follows: at Men's Central Jail ("MCJ") and Pitchess Detention Center ("PDC") South as of October 1, 2017, at North County Correctional Facility ("NCCF") as of September 1, 2017, at PDC East as of December 1, 2017, at Twin Towers Correctional Facility ("TTCF"), the Inmate Reception Center ("IRC") and PDC North as of April 1, 2018. The County has provided documentation reflecting that the County has achieved Substantial Compliance with Paragraph 18 at Century Regional Detention Facility ("CRDF") as of June 1, 2018. The results at CRDF are subject to verification by the Monitor's auditors.
The County has provided documentation reflecting that the County has achieved Substantial Compliance at MCJ, NCCF, and IRC as of April 1, 2018, and at TTCF as of July 1, 2018, with Paragraph 19, which requires the training of Deputy Sheriffs on Crisis Intervention and Conflict Resolution and the training of Deputy Sheriffs and Custody Assistants in working with mentally ill prisoners. The results are subject to verification by the Monitor's auditors.
2 Under Paragraph 111 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis. 3 The provisions that are no longer subject to monitoring at some or all of the facilities are highlighted in bold in Appendix A.
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The County has achieved Substantial Compliance at PDC East, PDC North, NCCF, and CRDF as of August 1, 2017 and at PDC South as of October 1, 2017, with Paragraph 20, which requires the training of additional Deputy Sheriffs on Crisis Intervention and Conflict Resolution and on working with mentally ill prisoners.
The County has maintained Substantial Compliance for twelve consecutive months at PDC East, PDC South, PDC North, NCCF, IRC, and TTCF with Paragraph 21, which requires Custody personnel to maintain CPR certifications. The County also has provided documentation that it has maintained Substantial Compliance for twelve consecutive months at MCJ and for three consecutive months at CRDF. The results for MCJ and CRDF are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 22, which requires the County and the Sheriff to provide instructional material on the use of arresting and booking documents to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.
The County has maintained Substantial Compliance for twelve consecutive months as of July 12, 2018, with Paragraph 23, which requires that the Department conduct a systematic review of prisoner housing to reduce the risk of self-harm and to identify and address suicide hazards, and to develop plans to reasonably mitigate suicide hazards identified in the review.
The County has maintained Substantial Compliance for twelve consecutive months as of September 30, 2018, with Paragraph 24, which requires the Department to conduct annual reviews and inspections of prisoner housing to identify suicide hazards.
The County has maintained Substantial Compliance for twelve consecutive months at IRC as of March 31, 2018, with Paragraph 28, which requires the Department to expedite inmates having urgent or emergent mental health needs through the booking process.
The County has maintained Substantial Compliance for twelve consecutive months as of March 31, 2018, with Paragraph 29, which requires mental health assessments of prisoners with non-emergent mental health needs within 24 hours of the intake nursing assessment.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 32, which requires that a serious suicide attempt be entered in the prisoner’s electronic medical record in a timely manner.
The County has maintained Substantial Compliance for twelve consecutive months as of June 30, 2017, with Paragraph 33, which requires mental health supervisors to review electronic medical records on a quarterly basis to assess their accuracy.
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The County has maintained Substantial Compliance as of November 1, 2017, through September 30, 2018, with Paragraph 35, which requires the Department to ensure that custody staff refer prisoners who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules to identify prisoners with mental illnesses and grant prisoner's requests for out-of-cell interviews.
The County has provided documentation reflecting that it achieved Substantial Compliance at NCCF as of July 1, 2017, through June 30, 2018, and at PDC North as of July 1, 2018, through September 30, 2018, with Paragraph 39, which requires the County to use a confidential self-referral system for prisoners to request mental health care. The results are subject to verification by the Monitor's auditors and a qualitative assessment by the Subject Matter Expert.
The County has maintained Substantial Compliance at NCCF and PDC North for twelve consecutive months, as of September 30, 2018, with Paragraph 43, which requires the Department to develop and implement policies for discipline of prisoners with serious mental illnesses.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 44, which requires the Department to install protective barriers in High Observation Housing and other mental health housing areas.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 45, which requires Suicide Prevention Kits and first-aid kits in control booths in all facilities.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 48, which requires the Department to have written housekeeping, sanitation, and inspection plans to ensure proper cleaning.
The County has maintained Substantial Compliance for twelve consecutive months as of February 28, 2017, with Paragraph 49, which requires the Department to have maintenance plans to respond to routine and emergency maintenance needs.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 50, which requires pest control in the jails.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 51, which requires the Department to ensure that all prisoners have access to basic hygiene supplies in accordance with state regulations.
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The County has maintained Substantial Compliance for twelve consecutive months at CRDF and PDC North with Paragraph 55, which requires custody, medical and mental health staff to meet daily in High Observation Housing and weekly in Moderate Observation Housing. The County also has provided documentation reflecting that it achieved Substantial Compliance as of April 1, 2018, through September 30, 2018, at MCJ. The results at MCJ are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 56, which requires custody, medical, and mental health staff to communicate regarding any change in a housing assignment following a suicide attempt or serious change in mental health condition.
The County has maintained Substantial Compliance for twelve consecutive months as of March 31, 2018, at MCJ with Paragraph 57, which requires safety checks in mental health housing.
The County has maintained Substantial Compliance for twelve consecutive months at PDC South, PDC North, and PDC East as of December 31, 2016, with Paragraph 58, which requires safety checks in non-mental health housing. The County also has maintained Substantial Compliance as of July 1, 2017, through March 31, 2018 at CRDF; and as of October 1, 2017, through March 31, 2018, at IRC. The County has provided documentation that it has maintained Substantial Compliance as of April 1, 2018, through June 30, 2018 at CRDF; and April 1, 2018, through September 30, 2018 at IRC. The results at CRDF and IRC are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, PDC East, NCCF, and CRDF with Paragraph 59, which requires unannounced daily supervisory rounds to verify safety checks. The County also has achieved and maintained Substantial Compliance from January 1, 2018, through September 30, 2018, at PDC North and PDC South, and from April 1, 2018, through September 30, 2018, at TTCF.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC North, PDC South, and TTCF with Paragraph 68, which requires staggered contraband searches in housing units.
The County has achieved Substantial Compliance as of July 1, 2018, through September 30, 2018, with Paragraph 69, which requires the County and the Sheriff to use clinical restraints only in the Correctional Treatment Center with the approval of a licensed psychiatrist who performed an individualized assessment. The results are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months as of June 30, 2017, with Paragraph 71, which requires the County and the Sheriff to ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of
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restraint.
Subject to further verification, the County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 72, which requires the Department and the County to report on meetings to review suicides and incidents of serious self-injurious behavior.
The County has maintained Substantial Compliance for twelve consecutive months as of September 30, 2018, with Paragraph 73, which requires the Department to prepare detailed reports of prisoners who threaten or exhibit self-injurious behavior.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 74, which requires the Department to have an objective law enforcement investigation of every suicide that occurs in the jails.
The County has maintained Substantial Compliance for twelve consecutive months as of September 30, 2018, with Paragraph 75, which requires the Department and the County to review every serious suicide attempt that occurs in the jails.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 76, which requires the Department to follow certain procedures whenever there is an apparent or suspected suicide.
The County has maintained Substantial Compliance for twelve consecutive months as of May 18, 2017, with Paragraph 78, which requires the Suicide Prevention Advisory Committee to meet twice a year.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 82, which requires the Department to co-locate personnel responsible for collecting prisoners' grievances at CRDF.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, IRC, TTCF, and CRDF, with Paragraph 83, which requires it to install closed circuit security cameras throughout all of the common areas in the jails. The County has also achieved Substantial Compliance at NCCF and PDC North as of April 1, 2018, through September 30, 2018, and at PDC South as of July 1, 2018, through September 30, 2018.
The County has maintained Substantial Compliance for twelve consecutive months as of June 30, 2018, with Paragraph 84, which requires investigations of force incidents and administrative actions to be completed timely.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, CRDF, PDC North, PDC South, PDC East, NCCF, and IRC with Paragraph 86, which requires inventory and control of weapons. It has also maintained Substantial Compliance as of April 1, 2018, through December 31, 2018, at TTCF.
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SEVENTH REPORT
18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016.
These trainings will include the following topics:
(a) suicide prevention policies and procedures, including observation and supervision of prisoners at risk for suicide or self-injurious behavior;
(b) discussion of facility environments and staff interactions and why they may contribute to suicidal behavior;
(c) potential predisposing factors to suicide;
(d) high-risk suicide periods and settings;
(e) warning signs and symptoms of suicidal behavior;
(f) case studies of recent suicides and serious suicide attempts;
(g) emergency notification procedures;
(h) mock demonstrations regarding the proper response to a suicide attempt, including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance;
(i) differentiating between suicidal and self-injurious behavior; and
(j) the proper use of emergency equipment.
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STATUS (18):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (verified) at MCJ and PDC South)

SUBSTANTIAL COMPLIANCE (as of September 1, 2017 (verified) at NCCF)

SUBSTANTIAL COMPLIANCE (as of December 1, 2017 (verified) at PDC East)

SUBSTANTIAL COMPLIANCE (as of April 1, 2018 (verified) at TTCF, IRC, and PDC North)

SUBSTANTIAL COMPLIANCE (as of June 1, 2018 (unverified) at CRDF)

The Monitor, in consultation with the Mental Health Subject Matter Expert, concluded in the First Reporting Period that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training ("DeVRT"), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015. On May 30, 2017, the Monitor, in consultation with the Subject Matter Expert, approved a revision to the two-hour course on suicide prevention for existing Deputy Sheriffs and Custody Assistants.

The County's Initial Self-Assessment Status Report delivered on December 14, 2015, reported that the Department commenced its suicide prevention training for new Deputy Sheriffs and Custody Assistants on July 1, 2015, and for existing Deputy Sheriffs and Custody Assistants before the Effective Date of the Settlement Agreement.

Substantial Compliance is achieved when the Department reaches the 85% threshold for existing personnel at a facility, provided that it has achieved the 95% threshold for new personnel during the entire time from July 1, 2015 until it has reached the 85% threshold for existing personnel.

In the Fifth Reporting Period, the County reported that the Department achieved Substantial Compliance at MCJ and PDC South as of October 1, 2017, and at NCCF as of September 1, 2017.4 The County's Augmented Fifth Self-Assessment reported Substantial Compliance at PDC East as of November 1, 2017.5 The results at MCJ, PDC South, and NCCF have been verified by the Monitor’s auditors.

The County's Sixth Self-Assessment reported that the County had achieved Substantial Compliance at TTCF (91% of existing personnel), IRC (93%), and PDC North (97%) as of April 1, 2018. The results at TTCF, IRC, and PDC North have been

4 This is the first day of the month after the Department reached the required 85% threshold. 5 All two-hour training of existing Deputy Sheriffs and Custody Assistants occurred after the revision of the
suicide prevention course was approved by the Monitor on May 30, 2017.

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verified by the Monitor’s auditors. The County's posted results report for the Seventh Reporting Period reflect that it
achieved Substantial Compliance at CRDF (85%) as of June 1, 2018. The results at CRDF are subject to verification by the Monitor's auditors.
The County's Seventh Self-Assessment reiterates that "the Department continuously provides the required training for new Deputies in the Jail Operations Continuum and new Custody Assistants in the Custody Assistants Academy" and that the Department has now reported the results for new Deputies and new Custody Assistants through March 31, 2018. These results have been verified by the Monitor's auditors. Accordingly, the Department will no longer be subject to monitoring for the training of new Deputies in the Jail Operations Continuum and new Custody Assistants in the Custody Assistant Academy as required by Paragraph 18, although the Monitor expects that the Department will continue to provide this training to new Deputies and Custody Assistants hired in the future.
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19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams ("JMET") at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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STATUS (19):

SUBSTANTIAL COMPLIANCE (as of April 1, 2018, (unverified) at NCCF, MCJ, and IRC)

SUBSTANTIAL COMPLIANCE (as of July 1, 2018, (unverified) at TTCF)

PARTIAL COMPLIANCE (at CRDF)

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution training and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and Paragraphs 4.6, 4.7 and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert and the Rosas Monitors approved the training materials developed by the Department for the DeVRT on March 4, 2016.

Substantial Compliance requires the County to show that 95% of the new Deputies hired after July 1, 2015 and 85% of the existing Deputies as of that date received the required DeVRT training. It also requires that 95% of the new Custody Assistants hired after that date and 85% of the existing Custody Assistants as of that date received the required training in working with mentally ill inmates.

The County's Seventh Self-Assessment reported that the Department achieved Substantial Compliance at all facilities for new Deputies and new Custody Assistants through the Third Quarter of 2018. These reported results are subject to verification by the Monitor's auditors.

The County's Sixth Self-Assessment also reported that the Department achieved Substantial Compliance with respect to the training of existing Deputies and Custody Assistants at IRC, MCJ, CRDF, TTCF, and NCCF (JMET) in the First Quarter of 2018. The Department trained 95% of the existing Deputy Sheriffs and 89% of the existing Custody Assistants at TTCF by the end of the First Quarter of 2018; 100% of existing Deputies and 98% of existing Custody Assistants at IRC; 99% of existing Deputies and 92% of existing Custody Assistants at MCJ; and 100% of the existing Deputies in the JMET unit at NCCF.6

The Department initially posted results for the First Quarter of 2018 that excluded "unavailable" Deputies who were not available "during the relevant month" due to, for example, Injured On Duty. These deputies should not, however, be excluded unless they were "unavailable" to attend the DeVRT during a substantial period, since the training has been offered since March 4, 2016. Accordingly, Deputies and Custody Assistants are not deemed "unavailable" unless they have been on leave or otherwise unavailable for more than six months as of the date of the assessment.7

6 There were no Custody Assistants assigned to the unit. 7 There were no "unavailable" existing deputies in the JMET unit at NCCF.

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Using the Monitor's approved definition of "unavailable" personnel, the Department's revised results show that it trained 98% of the existing Deputies and 88% of the existing Custody Assistants at IRC through March 2018; 99% of the existing Deputies and 85% of the existing Custody Assistants at MCJ through March 2018; and 95% of existing Deputies and 89% of existing Custody Assistants at TTCF through June 2018. These results are subject to verification by the Monitor's auditors. If verified by the Monitors, the Department will no longer be subject to monitoring at these facilities for the initial training required by Paragraph 19. It will, however, be subject to monitoring in future periods for Substantial Compliance with the refresher course requirements.
The Department reports that it trained 96% of the "existing" Deputies at CRDF through the Second Quarter of 2018, using the approved definition of "unavailable personnel," but only 21% of the existing Custody Assistants. This is because the Department previously interpreted Paragraph 19(b) to apply only to Custody Assistants assigned to the Mental Health Unit at CRDF rather than all Custody Assistants at CRDF. These results are sufficient, however, to establish Partial Compliance at CRDF.
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20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

SUBSTANTIAL COMPLIANCE (as of August 1, 2017 (verified) at CRDF, PDC East, PDC North, and NCCF)

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (verified) at PDC South)

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the curriculum for the Department’s Deescalation and Verbal Resolution Training ("DeVRT"), which provides for 32 hours of Crisis Intervention and Conflict Resolution training that meets the requirements of Paragraph 20 of the Settlement Agreement.

Substantial Compliance requires that 85% of Deputies at the facilities designated in Paragraph 20(a) as of July 1, 2017, receive the required DeVRT training. The County reports that as of August 1, 2017, 85% of the Deputies assigned to PDC East, 89% of the Deputies assigned to PDC North, 85% of the Deputies assigned to NCCF, and 91% of the Deputies assigned to the non-mental housing units at CRDF, had received the required training, and as of October 1, 2017, 96% of the Deputies assigned to PDC South had received the training. The results at CRDF, PDC East, PDC North, PDC South, and NCCF have been verified by the Monitor's auditors, and these facilities were not subject to monitoring for the initial training courses during the Seventh Reporting Period.

While the Paragraph 20 is no longer subject to monitoring for the initial training courses, the Monitor expects the Department to show that the Deputies and Custody Assistants have attended the refresher courses required by this provision through the duration of the Settlement Agreement.

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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at PDC East and South)
SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at NCCF, PDC North, and IRC)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at TTCF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018 (verified) and through September 30, 2018 (unverified) at MCJ)
SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through September 30, 2018 (unverified) at CRDF)
The Compliance Measures provide that the Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required CPR and first aid certifications for twelve consecutive months.
Pursuant to Paragraph 111 of the Settlement Agreement, PDC South, PDC East, PDC North, NCCF, IRC, and TTCF were not subject to monitoring for Substantial Compliance with Paragraph 21 in the Seventh Reporting Period.
The County's Fifth Self-Assessment reported that it achieved Substantial Compliance at MCJ in October 2017, which it maintained through the remainder of 2017. These results have been verified by the Monitor's auditors.
The County's Sixth Self-Assessment reported that the Department continued to maintain Substantial Compliance at MCJ through the First Quarter of 2018. These results have been verified by the Monitor's auditors. The County's Seventh Self-Assessment reports that it continued to maintain Substantial Compliance at MCJ through the Third Quarter of 2018. These results are subject to verification by the Monitor's auditors. If verified, Paragraph 21 is no longer subject to monitoring at MCJ.
The County's Seventh Self-Assessment reflects that it achieved Substantial Compliance with Paragraph 21 at CRDF in June 2018. These results are subject to verification by the Monitor's auditors.
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22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017)
The Justice Data Interface Controller ("JDIC") message the Department has been using since June 29, 2016, is sufficient to establish Substantial Compliance with Paragraph 22, and the County maintained Substantial Compliance for twelve consecutive through June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, the County was not subject to monitoring for Substantial Compliance with Paragraph 22 in the Seventh Reporting Period.
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23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: SUBSTANTIAL COMPLIANCE The Monitor has verified, with the advice of the Subject Matter Expert, that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department reports that it inspected all of the housing units by January 14, 2016, and it has provided the Monitor with completed checklists documenting the inspections. The County submitted an updated Suicide Hazard Mitigation plan to the Monitor on January 18, 2018. After consultation with the Mental Health Subject Matter Expert, the Monitor concluded that the updated Plan satisfies the requirements of Paragraph 23. The Department submitted another updated plan to the Monitor on July 12, 2018. After consultation with the Mental Health Subject Matter Expert, the Monitor concluded that the updated Plan satisfies the requirements of Paragraph 23. The County has maintained Substantial Compliance with Paragraph 23 for twelve consecutive months and this provision is no longer subject to monitoring.
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24. The County and the Sheriff will review and inspect housing areas on at least an annual basis to identify suicide hazards.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018)
CDM 3-06/020.00 FACILITIES INSPECTIONS requires Custody Support Services (CSS) to "review and inspect housing areas on a least an annual basis to identify suicide hazards."
The Monitor and Subject Matter reviewed a revised annual suicide hazard inspection tool that was submitted by the Department on December 13, 2016, and approved it with the caveat that, in order to achieve Substantial Compliance, the sample sizes of randomly selected cells must be large enough to ensure that the cells are representative of each housing type at a facility. Further, if a problem is found in the randomly selected cells, a complete inspection or remediation of the area or setting should then be conducted. An updated tool was submitted by the Department on February 9, 2017; it also was approved with the same caveats.
The Department conducted an Annual Suicide Hazard Inspection at each of its jail facilities during the Sixth and Seventh Reporting Periods. As noted by the Mental Health Subject Matter Expert, "the County is doing a good job of inspections, but remediation and follow-through are not clearly demonstrated and tracked." The second Annual Suicide Hazard Inspection reports are sufficient "to identify suicide hazards" for purposes of Paragraph 24, and the Department has maintained Substantial Compliance with this provision for twelve consecutive months. Accordingly, Paragraph 24 is no longer subject to monitoring. Corrective action implementation and tracking must, however, be addressed by the Custody Compliance and Sustainability Bureau ("CCSB") under Paragraph 77(c), which requires CCSB to "ensure that corrective actions are taken to mitigate suicide risk. . . obtaining where appropriate, technical assistance. . .when such assistance is needed to address suicide-risk issues."
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: PARTIAL COMPLIANCE A provision of the Station Jail Manual adopted in March 2018 requires that any arrestee who "displays obvious suicidal ideation or exhibits unusual behavior that clearly manifest[s] self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, such inmates . . . shall be under unobstructed visual observation or in a suicidal restraint location with safety checks every 15 minutes." The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent to determine compliance with Paragraph 25 of the Agreement. The County’s Seventh SelfAssessment reported that 71% of the records reviewed for the Second Quarter of 2018 and 75% of the records reviewed for the Third Quarter of 2018 reflect the information required to establish Substantial Compliance with Paragraph 25. While once again short of the 95% threshold for Substantial Compliance, the Department continued to show improvement in the Seventh Reporting Period. The Mental Health Subject Matter Expert reviewed "a number of the source documents from 2018Q3" and is of the opinion that the "County is making progress on this provision and is nearing substantial compliance."
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to "review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of 100 randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC." Substantial Compliance requires that (1) 95% of the forms "include the required mental health information" and (2) 90% of the prisoners having urgent or emergent needs were "seen by a QMHP within four hours."
The County’s Seventh Self-Assessment reports that for the one randomly selected week in the Second Quarter of 2018, 93% of the screening forms reviewed had the required mental health information, and 55% of the prisoners were seen by a QMHP within four hours. For the Third Quarter of 2018, 88% of the forms had the required information and 45% of the prisoners were seen within four hours. The timeliness of the responses by QMHPs remains significantly below the 90% threshold. The County has adopted a pilot program that requires it to "conduct the [initial and nursing] assessments at the windows in the IRC clinic, and in the nursing room at CRDF," which the County believes "will improve compliance."
The Mental Health Subject Matter Expert and the clinicians did a qualitative assessment of the "completeness of intake documentation" and "whether patients with emergent or urgent needs were missed at intake[.]" They "found that 96% of the intake documentation was complete and available," only 9% "of urgent/emergent cases that should have been detected at admission were not," and there was "much less inconsistency and errors in the records." They "continue[d] to see very clear improvement in the screening and detection processes. Assuming some of the logistical challenges of having nurses do all intake screenings are solved, [they] are confident that the intake process is working well for detecting urgent and emergent cases." As is evident from the Department's reported results, the "primary problem is the timeliness of the QMHP assessments."
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review the records of "randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC" to determine compliance with this provision. Substantial Compliance requires that 90% of the records reviewed reflected that the prisoners were screened for mental health needs within 12 hours and that the required documentation was available to the QMHP for 90% of the mental health assessments conducted by the QMHP.
As noted in the Monitor's Sixth Report, the County achieved, and maintained Substantial Compliance with Paragraph 27 for six months from October 1, 2017, through March 31, 2018. The County's Seventh Self-Assessment reflects that the County maintained Substantial Compliance with Paragraph 27 in the Second Quarter of 2018, but only achieved Partial Compliance in the Third Quarter of 2018, when the required forms were filled out for only 67 of the 100 of the randomly selected prisoners within 12 hours. The County attributes this to "an unintended consequence of the restructuring" of the "IRC booking front to provide privacy during the screening process[.]"8
The Mental Health Subject Matter Expert and the clinicians did a qualitative assessment of the "completeness of intake documentation" and "whether patients with routine needs were missed at intake[.]" They found "that 100% of the intake documentation was completed and available," and 25% "of routine cases that should have been detected were not." The Subject Matter Expert notes that, "[i]n general. . .the screening process itself seems to be detecting routine cases at a reasonable level, especially in light of the improvements in detecting urgent and emergent cases."
In order to satisfy the requirements of Paragraph 27, inmates must be privately screened. Nurses at CRDF now conduct the assessments in a room off a hallway near the booking front and nurses at IRC now conduct the assessments at windows behind the inmate seating areas in the IRC clinic. The room at CRDF is completely private and satisfies the requirements of Paragraph 27. Although the windows in the IRC clinic are
8 This unintended consequence was first noticed by CHS in the pilot program that began on May 28, 2018. As noted in the Monitor's Sixth Report, this "raises serious concerns about whether the County is continuing to meet the 90% threshold for Substantial Compliance with Paragraph 27 in the Second Quarter of 2018[.]" See Monitor's Sixth Report, pp. 22 and 23, note 12.
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not as private as the room at CRDF, the Monitor stood in the inmate seating area while inmates were interviewed by the nurses in IRC and could not hear the conversations between the nurses and the inmates. The Monitor is of the view that these windows are sufficiently private to satisfy the requirements of Paragraph 27. If the County decides to add windows to expedite the assessments, it must ensure that those windows are also far enough away from the inmate seating area to ensure inmate privacy.
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28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at IRC) PARTIAL COMPLIANCE (at CRDF)
The Compliance Measures require the Department to review the records of randomly selected prisoners at CRDF and IRC who have urgent or emergent mental health needs to determine whether they were expedited through the booking process.
The County's Seventh Self-Assessment reflects that 100% of the inmates with urgent or emergent mental health needs were expedited through the booking process at CRDF in the Second Quarter of 2018 and 85% were expedited in the Third Quarter of 2018. These results were at or above the threshold for Substantial Compliance. All of the inmates identified as having urgent or emergent mental health needs were observed or checked as required by Paragraph 28 in the Second Quarter of 2018, but only 60% were observed or checked in the Third Quarter of 2018, which was below the 95% threshold for Substantial Compliance.
The County previously had maintained Substantial Compliance with Paragraph 28 at IRC for twelve consecutive months, and IRC was not subject to monitoring for compliance with Paragraph 28 in the Seventh Reporting Period.
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29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified))
The Compliance Measures require the Department to review randomly selected records of the prisoners identified in the intake nursing assessment as having nonemergent mental health needs to determine if the Department completed mental health assessments for 85% of the prisoners within the required time periods.
The County’s Sixth Self-Assessment reports that in the Fourth Quarter of 2017 the County completed mental health assessments for 99% of the inmates at CRDF and IRC within the required time periods, and in the First Quarter of 2018, it completed 95% of the assessments within the required time periods.
The Monitor and Mental Health Subject Matter Expert have concerns about how the County defines "weekends." It was using the 72-hour time frames for the QMHP mental health assessment if the nursing assessment occurred less than 24 hours before the start of the weekend, which is reasonable because the 24-hour time frame expires on the weekend, but it was also using the 72-hour time frame if the nursing assessment occurred less than 24 hours before the end of the weekend so that the 24-hour time frame expires during the regular work week.9 Accordingly, the County has maintained Substantial Compliance for twelve consecutive months and will no longer be subject to monitoring for compliance with Paragraph 29.10
9 The Monitor’s auditors verified the County's results using the extended 72-hour time frame for conducting the QMHP mental health assessments of the prisoners only if the nursing assessment is less than 24 hours before the weekend starts and then only if it is less than 24 hours before the weekend ends. 10 DOJ has expressed concern that "the substantial and unexplained drop" in the compliance rating posted by the County for CRDF in "the very next quarter" after CRDF had maintained Substantial Compliance for twelve consecutive months "suggests that the timeliness of QMHP assessments may be an ongoing issue." The Monitor and Mental Health Subject Matter Expert share this concern. The County should continue to review the timeliness of the assessments and post the results of its reviews.
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30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected initial mental health assessments and report on (1) the percentage of assessments that have (i) included an initial treatment plan that addresses housing recommendations and preliminary discharge information and (ii) identified any immediate issues and whether a more comprehensive evaluation was indicated; and (2) whether the housing recommendations were followed.
The County's Seventh Self-Assessment reports that 100% of the housing assignments reviewed in the Second Quarter of 2018 followed the housing recommendations in the initial treatment plans, which exceeds the 95% threshold for Substantial Compliance, but only 69% of the initial mental health assessments included an initial treatment plan that had the information required by Paragraph 30, which is below the 85% threshold for Substantial Compliance. The results for the Third Quarter of 2018 were that 98% of the housing assignments followed the housing recommendations and 63% of the initial mental health assessments had the required information.11
The Mental Health Subject Matter Expert and the clinicians again evaluated "whether the determination of immediate issues [in random sample of mental health assessments] was reasonable in light of available information. . . [and] whether the initial treatment plan covered the elements required by existing County policy, which goes beyond the content of the formal compliance measure." They found that 100% of the cases "identified immediate issues," and that the determination of the immediate issues "was reasonable from a qualitative perspective" in 95% of the cases. The Subject Matter Expert concludes that "[t]his is a notable improvement."12
11 One of the clinicians notes that the "County's reporting methodology does not identify what elements of the required information are missing in those instances determined to be non-compliant. . . .For performance improvement purposes, this level of information will be important." 12 The Subject Matter Expert and clinicians also found that 65% of the cases at CRDF and 90% of the cases at TTCF had preliminary discharge information and that 74% of the cases at CRDF and 85% of the cases at TTCF met the County's "policy requirements regarding discharge planning[.]" Although the Revised Paragraph 34 will govern the requirements for discharge planning going forward, the Subject Matter Expert notes that "it is clear that there has been greater attention to these issues at intake."
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31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk;
(b) hoarding medications; and
(c) prior suicide attempts.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected electronic medical records for prisoners in certain at-risk groups to determine if the required mental health alerts are in 85% of the records reviewed, which is the threshold for Substantial Compliance, for prisoners who report suicidal thoughts during the intake process; were removed from risk precautions in the prior quarter; or were identified as hoarding medicine.
The County’s Seventh Self-Assessment reports that for the Second Quarter of 2018, 86% of the records at CRDF had the required mental health alerts, 78% of the records at TTCF had the alerts, and 100% of the records at MCJ had the alerts. As previously noted, the County must satisfy the 85% threshold for Substantial Compliance for each of the required alert categories.
The County's Augmented Seventh Self-Assessment reports the following results for the Third Quarter of 2018: at CRDF, 80% (current suicide risk), 96% (removed from risk precautions),13 and 40% (hoarding) of the records had the required mental health alerts; at TTCF, 79% (current suicide risk), 92% (removal from risk precautions), and 76% (hoarding) of the records had the alerts; at MCJ, 77% of the records had the alerts for hoarding; and at NCCF, 100% of the records had the alerts for hoarding.14
The County's Seventh Self-Assessment reports that the "County continues to work on ways to improve its documentation and tracking of inmates known to hoard
13 DOJ has expressed concerns about how the County is making determinations that no alerts are necessary for some inmates, noting that "several inmates [at TTCF] on risk precautions for suicidal ideation [in 3Q18] have no corresponding suicide risk alerts," and the County's internal audit states "None required." While the County's response explains when inmates are placed on risk precautions and reviews each case referenced by DOJ, it does not address DOJ's concern about how the determinations are made. In order to achieve Substantial Compliance, the County will need to provide some explanation for the clinical judgment that no alert is required for an inmate who has been removed from risk precautions. 14 The County did not report any results for mental health alerts for prisoners at MCJ or NCCF because "Compliance Measures 31-1(a) and 31-1(b) refer to the intake and HOH populations respectively." As noted by the Mental Health Subject Matter Expert, however, "[w]hile the events qualifying an inmate for [each] measure may occur in those settings, the measure still applies upon transfer to another setting, including MCJ and NCCF."
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medications" and has "expanded the categories of information included in its audit universe for inmates potentially hoarding medications" to include "referrals from nursing to mental health related to hoarding, the list of suspected or confirmed overdoses from medication, and inmate segregation reports that refer to inmates disciplined for having contraband pills." The Mental Health Subject Matter Expert concurs that "[e]xpanding the universe is needed," but questions "[w]hether limiting custody identification of hoarding to those instances when a [disciplinary] segregation report is done will capture a significant number of hoarding cases[.]" Anytime Custody finds contraband pills (i.e., pills in excess of what is ordered or that are not ordered for an inmate), "there should be a determination of hoarding and medication non-adherence by qualified clinical staff." DOJ concurs and adds that "[h]oarding alerts should also be entered for inmates any time that an inmate has been found to have overdosed." The County agrees that hoarding alerts should be entered under these circumstances.
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32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require that 95% of the electronic medical records of prisoners who had a serious suicide attempt reflect information regarding the attempt, and 85% of the records reflect that the information was entered into the record within one day of the attempt.
The County maintained Substantial Compliance with Paragraph 32 for twelve consecutive months as of December 31, 2016, and this provision was not subject to monitoring in the Seventh Reporting Period.
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33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:
(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;
(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;
(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and
(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (verified))
The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected prisoners from each clinician’s caseload. The County has provided the required tool, and previously reported Substantial Compliance for the Third and Fourth Quarters of 2016, and the First and Second Quarters of 2017.
The Monitor’s auditors have verified the County’s results previously reported in its Self-Assessment. Accordingly, the County has maintained Substantial Compliance for twelve consecutive months and will no longer be subject to monitoring for compliance with Paragraph 33.
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34 (Revised). Consistent with existing Correctional Health Services policy, the County and the Sheriff will conduct clinically appropriate release planning for all prisoners who are being released to the community and who have been identified by a QMHP as having a mental illness and needing mental health treatment, or as having a DSM-5 major neuro-cognitive disorder that caused them to be housed in the Correctional Treatment Center at any time during their current incarceration. For prisoners with mental illness and needing mental health treatment, the release planning services will be guided by the prisoner’s level of care. Specifically, prisoners who any time during their incarceration meet mental health level of P3, or P4 will be presumptively referred for release planning services, and prisoners who meet mental health level of care P2 will receive release planning services upon referral by a clinician or upon their request. Prisoners who have a DSM-5 major neuro-cognitive disorder that caused them to be housed in the Correctional Treatment Center will also be referred for release planning services consistent with the Correctional Health Services policy applying to prisoners with mental illness.
(a) Release planning will consider the need of the prisoner for housing; transportation to the prisoner's community-based provider, residence, or shelter within the County; bridge psychotropic medications; medical/mental health/substance abuse services; income/benefits establishment; and family/community/social supports (“Release Planning Areas”).
(b) Release planning will be based on an individualized assessment of the prisoner's needs and, unless the prisoner is unable or unwilling to participate, will be undertaken in collaboration with the prisoner. For prisoners referred for release planning services, those services will include:
(i) An Initial Release Plan that will be created at intake or no later than ten days after the referral for release planning, which referral shall normally occur at the time of intake. The Initial Release Plan will include preliminary identification of needs in each of the Release Planning Areas and preliminary recommendations for services to address those needs, and a referral for assistance in obtaining California identification when needed and when the prisoner is eligible; and/or
(ii) A Comprehensive Release Plan that will be initiated no later than thirty days after the referral for release planning. The Comprehensive Release Plan will include (A) collecting information regarding the prisoner’s needs; (B) coordinating with community-based providers to identify available services that meet the prisoner's needs; (C) facilitating the transition of care to community-based providers, and (D) assisting in obtaining identification and/or benefits when needed, when the prisoner is eligible, and as offered by the Sheriff’s Community Transition Unit.
(c) The County will maintain a re-entry resource center with staff supervised by a QMHP. The re-entry resource center will:
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(i) Provide information appropriate to the released prisoner about available housing, transportation, medical/mental health/substance abuse services, income/benefits establishment, community/social supports, and other community resources; and (ii) Provide released prisoners with copies of their release plans, as available. (d) All prisoners who are receiving and continue to require psychotropic medications will be offered a clinically appropriate supply of those medications upon their release from incarceration. Unless contraindicated, this will be presumed to be a 14-day supply or a supply with a prescription sufficient so that the prisoner has the psychotropic medication available during the period of time reasonably necessary to permit the prisoner to consult with a doctor and obtain a new supply. (e) Nothing in Paragraph 34 will require prisoners to accept or participate in any of the services provided under this Paragraph. (f) Neither the County nor the Sheriff shall be in violation of this paragraph if after reasonable efforts as set forth in Correctional Health Services Policy M380.01, Release Planners are unable to identify available post-release services.
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STATUS (34):

STAYED PENDING LITIGATION

During the Seventh Reporting Period, the parties and the Intervenors reached an agreement on the revised Paragraph 34 ("Revised Paragraph 34") set forth above. They also agreed on revised Compliance Measures and a revised policy to implement Revised Paragraph 34.

On December 10, 2018, the Court issued an order pursuant to the parties' joint stipulation revising Paragraph 34. The County is expected to report the status of its compliance with Revised Paragraph 34 beginning in January 2020.

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35. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team ("JMET") member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: SUBSTANTIAL COMPLIANCE (as of November 1, 2017, through September 30, 2018 (verified))
The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral ("BOMHR") records for prisoners referred by custody staff to a QMHP or JMET member for "routine" mental health care to determine the timeliness of the referrals. Substantial Compliance requires that "85% of the BOHMR forms reflect that the referral occurred before the end of the shift in which the potential need for mental health care is identified."
The County's Sixth Self-Assessment reported that the Department "has developed an electronic version of the BOHMR" and it "concluded that 100% -- 15% more than the required 85% -- of BOHMR forms reflected that referrals occurred prior to the end of the shift in which the potential need for mental health care is identified" in both the Fourth Quarter of 2017 and the First Quarter of 2018. These results were verified by the Monitor's auditors.
The County's Seventh Self-Assessment reports that the 100% of BOHMR forms reviewed in both the Second and Third Quarters of 2018 "reflected that referrals occurred prior to the end of the shift in which the potential need for mental health care is identified." The Mental Health Subject Matter Expert reviewed a number of the BOHMR forms and found that those that reflect mental health events "are being completed promptly." These results have been verified by the Monitor's auditors.
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36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected records of prisoners newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; and provide a staffing schedule for on-call services. The County's Seventh Self-Assessment reports that 82% of the prisoners identified in the two randomly selected weeks in the Second Quarter of 2018 received an assessment by a QMHP within four hours as required by Compliance Measure 36-4(a).15 The County's Augmented Seventh SelfAssessment reports that 84% of the prisoners identified in the two weeks in the Third Quarter of 2018 received the assessment within four hours.
DOJ and the County have agreed that "the Department will randomly select five BOMHRS" from a randomly selected date, to "review videos to determine how the inmate was being observed while waiting for the QMHP," and "produce screen shots and movement records as part of their self-assessment."
The County's Seventh Self-Assessment reports that in both the Second and Third Quarters of 2018, 80% of the selected prisoners at CRDF, and 100% at TTCF were on the videos "under unobstructed visual observation pending assessment."
The Seventh Self-Assessment also reports that the County achieved 100% compliance with a staffing schedule that provides on-call services 24 hours a day, 7 days a week in the Second Quarter of 2018. The County's posted results show the same results for the Third Quarter of 2018. Compliance Measure 36.2 does not, however, simply require 24/7 coverage. It requires the Monitor, in consultation with the Subject Matter Experts, to "review" the staffing schedule "to verify the adequacy of the on-call system." The Mental Health Subject Matter Expert previously commented that "unless the county has another explanation for its inability to respond to adverse triggering events within 4 hours, it is likely that inadequate staffing is the problem."
15 The Mental Health Subject Matter Expert and clinicians found that 79% of the identified prisoners received an assessment by a QMHP within four hours, "64% had an adequate assessment of the event and 36% had an adequate plan."
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37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral ("BOMHR") Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: PARTIAL COMPLIANCE The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter, review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner and incident reports for self-injurious behavior by prisoners appearing in the selected courts, and determine if these incidents are reflected in BOMHR forms completed by the Court Services Division staff in the selected courts. The County’s Seventh Self-Assessment reports that 100% of the incidents covered by Paragraph 37 in six randomly selected courts were reflected on BOMHRs in the Second Quarter of 2018 and 88% of the incidents in six other courts were reflected on BOMHRs in the Third Quarter of 2018. These results are well above the 68% and 52% results in the prior two quarters. The Mental Health Subject Matter Expert notes that "most locations are doing much better with notifications and monitoring."
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38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET Deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision.
The County's reported results, which were verified by the Monitor's auditors, showed that it had maintained Substantial Compliance with Paragraph 38 for twelve consecutive months as of December 31, 2016. Accordingly, pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 38 was not subject to monitoring in the Seventh Reporting Period.
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39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their requests to custody staff or other prisoners.

STATUS

SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through September 30, 2018 (unverified) at PDC North)

SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through June 30, 2018 (unverified) at NCCF)

PARTIAL COMPLIANCE (at TTCF, CRDF and MCJ)

NOT RATED (PDC East and PDC South)

Substantial Compliance requires the Department to (a) verify that housing areas have the required forms and (b) review randomly selected self-referrals for mental health care from prisoners to confirm that (i) the referrals "were forwarded to DMH" by the Department, and (ii) that "DMH documented the timeliness and nature of DMH's response to the self-referrals[.]" The thresholds for Substantial Compliance are that 90% of the self-referrals must be forwarded by the Department to the Department of Health Services – Custody Health Services (DHS-CHS) and 90% must contain the required documentation of DHS-CHS's response.

Based upon a review of the County’s policies and procedures, multiple tours of the facilities, interviews, and the County’s Seventh Self-Assessment, the Monitor is satisfied that the Department has adequate processes and procedures for inmates to make confidential self-referrals for mental health care.

The County's Seventh Self-Assessment reports that it achieved Substantial Compliance with Compliance Measure 39.4(a) in the Second and Third Quarters of 2018 in that more than 85% of the housing areas in all of the facilities had the self-referral forms.

The County's Seventh Self-Assessment also reports that in the Second Quarter of 2018, 100% of the self-referrals from CRDF, TTCF, MCJ, and NCCF were forwarded by the Department to DHS-CHS as required by Compliance Measure 39.4(b), and DHSCHS documented the timeliness and nature of its response in 83% of the CRDF referrals, 100% of the NCCF referrals, 67% of the TTCF referrals, and 63% of the MCJ referrals as required by Compliance Measure 39.4(c).16

16 Absent extenuating circumstances, Mental Health Services clinicians must respond to self-referrals within seven days of CHS's receipt of the self-referral from the Sheriff's Department. This is based upon the assumption that the Department is promptly forwarding the referral to the CHS within 24 hours of collecting the self-referral. In reviewing cases at CRDF, however, the Mental Health Subject Matter Expert found that the electronic health record on the self-referral form averaged 3.5 days after the patients dated the forms. If the inmate's self-referral is not forwarded to CHS within 24 hours of collection, CHS clinicians must respond within seven days of the inmate's self-referral.

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The County's Seventh Self-Assessment also reports that 100% of the self-referrals from three of the four buildings at PDC North in the Second Quarter of 2018 were forwarded and documented as required by this Compliance Measure, but there were no results for the MOH Building because "there were no designated Mental Health staff processing self-referrals in Second Quarter 2018, as the contracted staff previously responsible for this task no longer work at PDC."17 Finally, it reports that the County was unable to assess PDC South and PDC East during this quarter because "County records indicate that there were no self-referrals for these facilities" in this quarter, which is not surprising because, as the County notes, "those facilities have specialized preselected populations, and as such the County rarely, if ever, receives self-referrals from those facilities."
The County's Seventh Self-Assessment reports that for the Third Quarter of 2018, 100% of the self-referrals reviewed by the Department at CRDF were forwarded to CHS and that 88% of the time "CHS documented the timeliness and nature of CHS' response to the self-referrals received from the Department." The results for the other facilities were as follows: 100% and 46% for self-referrals at MCJ; 100% and 90% for TTCF; and 100% and 95% for PDC North. The County was unable to assess PDC South and PDC East for the same reasons as stated above.
The Substantial Compliance results reported by the County for NCCF for the Second Quarter of 2018 and for TTCF and PDC North for the Third Quarter of 2018 are subject to verification by the Monitor's auditors based upon an assessment of the timeliness of Mental Health's responses from the date the inmate's self-referral was received by Correctional Health Services and a qualitative assessment by the Mental Health Subject Matter Expert. As requested by DOJ, the auditors will also "examine whether self-referrals are being promptly forwarded to CHS" by Custody within 24 hours of collecting the self-referral and, if not, whether the CHS has responded timely within seven days of the inmate's self-referral (rather than from the CHS receipt of the selfreferral). See p. 39, n. 16, supra.
The Mental Health Subject Matter Expert and the clinicians conducted a qualitative assessment of the County's compliance with Paragraph 39 at TTCF in August 2018. They report that the County’s response to self-referrals at TTCF "is disorganized, incomplete, and frequently lacks any meaningful clinical response. Nursing staff frequently do not enter the self-referrals into the medical record, instead interpreting what they perceive the patient’s intent to be, often excluding important information and thereby rendering the medical record incomplete or inaccurate. There is rarely any notation in the medical record about which self-referrals are being responded to and notes rarely include any information from the self-referrals. In many cases, there is no clinical response at all, merely an appointment which may or may not be timely and may or may
17 In the County's response to the Monitor's draft of this Seventh Report, the County subsequently clarified that "there were no audited referrals during the randomly selected week" in the MOH Building, which the County believes "may be the result of temporary staffing issues." The County reported that "there were staff processing referrals for the MOH building during the Second Quarter of 2018."
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not result in an actual contact with the patient.”18 For these reasons, the Monitor is of the view that the Department has only achieved Partial Compliance at TTCF.
The Mental Health Subject Matter Expert reports that "response times and ability to track what the QMHP did and how it was tied to the [patient's self-referrals] was better at NCCF. . . likely due to lower volume." He reports that "the clinical responses are generally timely. . .and the response to real concerns was generally adequate." In light of the Department's reported results, the Monitor is of the view that the Department has maintained Substantial Compliance at NCCF for twelve consecutive months, subject to verification by the Monitor's auditors based upon an assessment of the timeliness of Custody's referrals and CHS's responses.19
18 In addition, the Mental Health Subject Matter Expert believes that too many of the responses are to staff driven requests (i.e., based upon a BOHMR or nurse referrals) rather than patient self-referrals. He also strongly recommends that County scan the actual self-referrals into the inmate's medical record "to assure the appropriate clinical data is getting to the QMHP." 19 The reported results for NCCF for the Third and Fourth Quarters of 2017 and the First Quarter of 2018, are also subject to verification by the Monitor’s auditors and an assessment of the timeliness of the referrals and responses.
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40. The County and the Sheriff will ensure a QMHP will be available on-site, by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County (1) to provide the Monitor with oncall schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week, and (2) randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify that a QMHP responded to all referrals, and 90% of the referrals within four hours.
The County’s Seventh Self-Assessment reports that for the Second Quarter of 2018, a QMHP responded 100% of the time and 90% of the responses were within four hours. The Augmented Seventh Self-Assessment reports that for the Third Quarter of 2018, a QMHP responded 100% of the time and 97% of the responses were within four hours.
The County's Substantial Compliance finding is subject to a qualitative review by the Mental Health Subject Matter Expert and the clinicians to assess whether the QMHP's are providing "clinically appropriate" services.20 The Mental Health Subject Matter Expert notes that "the County is meeting the timeliness for crisis response," but indicates that "the nature of the crisis response is not clinically adequate in the majority of cases. Most responses consist of placement in a new housing and/placement on risk precautions or other monitoring status. There is almost never any evidence of a clinical response to the crisis itself or a plan to follow-up or manage the crisis. In many cases, the notes refer to treatment being provided per the new unit staff, but there is rarely any subsequent treatment plan or follow-up of the crisis." Accordingly, the County has achieved Partial Compliance rather Substantial Compliance with Paragraph 40.
20 The County has voiced concerns about an expansion of Paragraph 40 and an undefined and subjective standard, but the Mental Health Subject Matter Expert has observed that "a crisis response would, at a minimum, characterize the cause of the crisis, conduct a relevant risk assessment, and create a plan of action based on that assessment."
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41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. Previously, the Monitor did not rate the County's compliance with Paragraph 41 because all FIP patients on suicide watch during the period either remained on suicide watch at the end of the period or "did not remain in the system (they were transferred to prison), and therefore did not go through the protocols."
During the Fifth Reporting Period, the parties agreed to revise the Compliance Measures to increase the number of inmates subject to the step-down protocols of Paragraph 41 and ensure that the implementation of step-down protocols for FIP patients on suicide watch "ameliorate the impact of the restrictions" and have the necessary "level of precautions based upon individual assessment[s]" of the patients. The revised Compliance Measures were reviewed by the Mental Health Subject Matter Expert.
The County's Seventh Self-Assessment reports that the "County recently finalized an EMR template to meaningfully assess the County's compliance with the application of this Compliance Measure to the relevant universe of patients and affiliated step-down protocols." The Augmented Self-Assessment reports that "68% -- rather than the required 95% -- of the inmates discharged from FIP during the [Third Quarter of 2018] after having been on suicide watch" met the Compliance Measures requirements. The Mental Health Subject Matter Expert noted "numerous problems in the documentation and scoring, some where the County did not give itself credit where it should have. . .and
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counting as compliant situations where they should not have." Further, "the documentation is often not clear and the nature of the precautions is often poorly characterized," and sometimes the County is relying on a nursing note with "no documentation of a QMHP assessment for step-down."
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42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement "step-down" procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: PARTIAL COMPLIANCE
The County’s Seventh Self-Assessment reports that for the Second Quarter of 2018 at CRDF, 100% of the medical records reviewed reflected that "inmates in HOH and placed on risk precautions were assessed by a QMHP"; "45% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and "0% -- rather than the required 85% -- of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 100%, 62%, and 25%.
The County's Augmented Seventh Self-Assessment reports that for the Third Quarter of 2018 at CRDF, 100% of the records "reflected that inmates in HOH and placed on risk precautions were assessed by a QMHP;" 40% "of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and 33% "of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 100%, 73%, and 12%.
As noted by the Mental Health Subject Matter Expert, the County has a working group developing "more individual risk-based approaches to removal and restoration of property that should improve compliance."
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43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
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STATUS (43):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 at NCCF and PDC North (verified))

PARTIAL COMPLIANCE (at CRDF, MCJ, and TTCF)

In response to comments by the Monitor and DOJ, the Department submitted proposed revisions to its discipline policies on May 30, 2017. After consulting with the Subject Matter Experts, the Monitor provided his written comments to the Department on June 29, 2017. The DOJ provided its comments to the Department the same day. The County's Seventh Self-Assessment reports that the Department is still "currently in the process of finalizing the revised policies related to discipline and the mentally ill," which were reviewed by the Monitor and DOJ nearly 18 months earlier.

The County's Sixth Self-Assessment reported the County "made changes in housing arrangements to develop mental health discipline pods, and implemented new guidelines and policy which reduce the number of patients eligible for discipline at TTCF and CRDF."

The County's Sixth Self-Assessment also reported on the practices regarding the discipline for inmates with P2, P3, and P4 designations in mental health housing locations. The Seventh Self-Assessment reports that the County has "continued its previously reported development of mental health discipline pods" and a "revised process for receiving notice of P1 inmates residing in General Population," but reiterates that "the County continues to experience staffing shortages that impact its ability to achieve Substantial Compliance" with this Provision.

The County's Seventh Self-Assessment reports that it achieved Substantial Compliance at NCCF in the Second Quarter of 2018 where a QMHP met with the one inmate receiving psychotropic medications who was transferred to disciplinary housing from an area outside mental health housing within 24 hours of the transfer as required by Compliance Measure 43-9(c) and "100% -- equal to the required 100% of the required weekly row walks through disciplinary units occurred pursuant to Compliance Measure 43.9(d)."21 Similarly, it achieved Substantial Compliance at PDC North where 100% of the required weekly walks through disciplinary units took place.

The results for MCJ also showed that 100% of the weekly row walks occurred, but MCJ did not achieve Substantial Compliance because only 41% of the meetings required pursuant to Compliance Measure 43-9(c) occurred, which is well-below the 90% threshold for Substantial Compliance when inmates receiving psychotropic medications are transferred to disciplinary housing from areas other than mental health housing.

Although not stated in the Self-Assessment, it appears that Compliance Measures

21 The County's Augmented Sixth Self-Assessment reported that it achieved Substantial Compliance at NCCF and PDC North in the First Quarter of 2018. These results were verified by the Monitor's auditors.

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43.9(b) and 43.9(e) are not applicable for NCCF, PDC North, and MCJ because these facilities did not have any prisoners transferred to disciplinary housing from mental health housing. In addition, it appears that Compliance Measure 43.9(c) is not applicable for PDC North because it did not have any inmates who were receiving psychotropic medications transferred from areas other than mental health housing.
The results for CRDF and TTCF for the Second Quarter of 2018 also showed that 100% of the weekly row walks occurred, but these facilities did not achieve Substantial Compliance because the consultations with QMHPs required pursuant to Compliance Measure 43-9(b) and the meetings required pursuant to Compliance Measure 43-9(c) did not meet the thresholds for Substantial Compliance.
The County's Augmented Seventh Self-Assessment reports that the County achieved Substantial Compliance at NCCF and PDC North in the Third Quarter of 2018 where "100% -- equal to the required 100% of the required weekly row walks through disciplinary units occurred pursuant to Compliance Measure 43.9(d)." There "were no inmate-patients falling within the parameters of Compliance Measure 43-9(c) (prisoners receiving psychotropic medications transferred to disciplinary housing from areas other than mental health housing) at NCCF during the relevant period." Apparently, this is also the case at PDC North. These results have been verified by the Monitor’s auditors and NCCF and PDC North will no longer be subject to monitoring for compliance with Paragraph 43.
The County's Augmented Seventh Self-Assessment also reports that for the Third Quarter of 2018, 59% of the required consultations at CRDF "occurred prior to transfers from mental health housing;" 75% of the required meetings occurred when inmates receiving psychotropic medications are transferred to disciplinary housing from areas other than mental health housing; and 100% of the weekly row walks through disciplinary units occurred. The results for TTCF were 58%, 81%, and 100%. For MCJ, 50% of the required meetings and 100% of the row walks occurred.
The Mental Health Subject Matter Expert and the clinicians reviewed random samples of inmates in HOH and MOH at CRDF and TTCF and concluded that a QMHP evaluated the inmate before discipline was imposed in 67% of the cases at CRDF, but only 10% of the cases at TTCF. The results for inmates in General Population on psychotropic medications were significantly better: 88% from CRDF and 92% from TTCF were evaluated by a QMHP prior to imposing discipline.
The Subject Matter Expert reports that he and clinicians "found no instances where a QMHP's recommendation was not followed. As before, no QMHP ever made a finding that discipline was contraindicated, and only occasionally did a QMHP recommend a higher level of care; a recommendation for a lower level of care was much more common, though these recommendations seemed reasonable." In addition, he notes that:
It does not seem that QMHPs have a clear sense of what might constitute a
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contraindication to discipline.22 While they address the patients’ mental health condition, there is rarely any discussion of the nature of discipline proposed and how this might affect the mental health of the patient. At TTCF, it was uncommon for a patient to be assessed prior to imposing discipline in MOH/HOH but there was more evidence of attending to contraindications, though it was usually just a statement that the patient could serve discipline.
* * * * The focus of these evaluations needs to be on the welfare and needs of the patient in light of proposed discipline (the nature of which was almost never discussed), not on whether mental illness contributed to the behavior. Many of these evaluations were done at cell front, compromising the quality of the assessment and making it unlikely that patients (especially when able to be heard by other inmates in the disciplinary setting) will be comfortable sharing their problems.
22 The County "strongly disagrees" with this assessment and asserts that "QMHPs engage in a detailed analysis and evaluation of inmate-patients whom custody is seeking to discipline and significant discussion with custody staff regarding the appropriateness of the discipline sought." It notes, however, that "there was some confusion among clinicians regarding how that analysis and evaluation should be documented."
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44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County has maintained Substantial Compliance with Paragraph 44 of the Agreement since January 1, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 44 was not subject to monitoring during the Seventh Reporting Period.
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45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at CRDF, NCCF, PDC EAST, PDC SOUTH, and TTCF)

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ and PDC North)

The County has maintained Substantial Compliance with Paragraph 45 for twelve consecutive months at all facilities as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 45 was not subject to monitoring during the Seventh Reporting Period.

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46. The County and the Sheriff will immediately interrupt, and if necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to review the documentation from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment. The County's Seventh Self-Assessment reports that for the Second Quarter of 2018, "96% -1% more than the required 95% -- of the records reviewed . . . reflected that appropriate aid and (when necessary) immediate interruption of self-injurious behavior was provided by the Department." In the Third Quarter of 2018, 95% of the records reflect that the Department provided appropriate aid and necessary interruption.
The County Seventh Self-Assessment notes that the "adaptation of the electronic BOMHR has ensured that staff immediately interrupt and provide appropriate aid to inmates who threaten or exhibit self-injurious behavior as required by this Provision[.]" The Monitor's Sixth Report noted that "[a]lthough the BOHMRs show when the inmate engaged in the self-injurious behavior, when the inmate was seen by a medical provider, and when a mental health clinician made an assessment, the BOHMRs do not always show what the County did to 'interrupt' the behavior or what aid the County provided to the inmate." In response, the County stated that "[t]he purpose of this provision is to ensure that the custody staff and QMHP's are immediately and properly responding to an inmate who threatens or exhibits self-injurious behavior to prevent self-harm or further self-harm. In this regard, the BOMHRs have been effectively used to ensure the prevention of suicides and suicide attempts. . . . Any information beyond what is provided in the BOHMHR can be found in response to other provisions."
The Mental Health Subject Matter Expert indicates that most of the BOHMRs involved expression of suicidal ideation, which do not involve threatened self-injurious behavior and thus "required no interruption. . . .The problem here is capturing a universe of patients where some custody intervention was needed." To establish Substantial Compliance, the County must either provide more detail in the BOHMRs what the Deputy did to interrupt the self-injurious behavior or rely on additional documentation reflecting the required information. By "capturing" a universe of inmates who actually threatened or engaged in self-injurious behavior,23 it may be possible to rely on BOHMRs to show what the Department did.
23 The Mental Health Subject Matter Expert suggests looking at the actual self-harm cases reviewed by CIRC, which are "more likely to be cases where some intervention may have been indicated," and then relying on BOHMRs or other documentation to show what Custody did to interrupt the behavior. DOJ "believes that the universe should include all instances of self-directed violence, and not be limited to those instances reviewed at the CIRC meeting based on their risk-rating score," but the County asserts that "[i]ncluding all incidents of self-directed violence. . .would be unduly burdensome" as there "roughly 800" such incidents in 2018. The Monitor agrees this would be unduly burdensome, but as noted by the Mental Health Subject Matter Expert, other cases may be needed "[i]f the CIRC cases are not sufficient in number."
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47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: NON-COMPLIANCE The County’s Seventh Self-Assessment states that the County has "provided a list of each critical incident between January 1 and June 30, 2018," for a total of 54 critical incidents during that period. It reiterates that the "County continues to work to develop a methodology to determine and assess whether staffing was a factor in any noncompliance with the Agreement, any critical incident, or the Department's handling of an incident."
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48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations ("CCR") Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County maintained Substantial Compliance with Paragraph 48 of the Agreement at all facilities for twelve consecutive months as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 48 was not subject Seventh Reporting Period, the Monitor observed "an acceptable level of cleanliness, sanitation, repair and safety" in each facility.
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49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016, through February 28, 2017)
The County maintained Substantial Compliance with Paragraph 49 of the Agreement at all facilities for twelve consecutive months as of February 28, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 49 was not subject to monitoring during the Seventh Reporting Period. Nevertheless, during inspections in the Seventh Reporting Period, the Monitor noted that the lighting systems, heating, ventilation and cooling systems in each facility were "adequately maintained and installed."
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50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at all facilities other than PDC South and PDC East)

SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at PDC South and PDC East)

The County maintained Substantial Compliance with Paragraph 50 of the Agreement at all facilities for twelve consecutive months as of March 31, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 50 was not subject to monitoring during Seventh Reporting Period.

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51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) for all facilities other than CRDF)

SUBSTANTIAL COMPLIANCE (as of July 1, 2016 through June 30, 2017 (verified) at CRDF)

The County maintained Substantial Compliance with Paragraph 51 of the Agreement at all facilities for twelve consecutive months as of June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 51 was not subject to monitoring during the Seventh Reporting Period.

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Case 2:15-cv-05903-DDP-JEM Document 148 Filed 02/28/19 Page 59 of 124 Page ID #:3227
52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52. All of the Compliance Measures have a 95% threshold for Substantial Compliance.
The County’s Seventh Self-Assessment reports that in the Second Quarter of 2018, 58% of the inmates initially placed in HOH at CRDF were provided the property required by Paragraph 52; 8% "of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP regarding allowable property;" 6% "of electronic medical records for inmates assigned to HOH reflect that property restrictions were based upon the clinical judgment of a QMHP;" and 95% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]" For the Second Quarter of 2018, the County reports that 94% of the inmates initially placed in HOH at TTCF were provided the property required by Paragraph 52; 50% of the electronic medical records "reflected a recommendation by a QMHP regarding allowable property;" 89% of the electronic medical records "reflect that property restrictions were based upon the clinical judgment of a QMHP"; and 94% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
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In the Third Quarter of 2018, 71% of the inmates initially placed in HOH at CRDF were provided the property required by Paragraph 52; and 97% of the inmates in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]" For TTCF, the Third Quarter results were 92% of the inmates initially placed in HOH were provided the property required by Paragraph 52; and 97% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
The County's Augmented Seventh Self-Assessment reports for the Third Quarter of 2018, "22% -- rather than the required 95% -- of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP" at CRDF, and 18% of the electronic medical records "reflect that property restrictions were based upon the clinical judgment of a QMHP[.]" The results for TTCF were 48% and 73%.
The Mental Health Subject Matter Expert and the clinicians reviewed the County's compliance with this provision in July and concluded that "the County continues to struggle with conducting and/or documenting assessments for property restrictions that are based on relevant risk factors." The Mental Health Subject Matter Expert notes that the basis (i.e., the risk assessment) for the property restrictions "is often absent or sorely lacking." The Department "is doing a reasonable job at providing property consistent with the recommendations of the QMHP's, but the quality of the assessments underlying these recommendations remains poor."
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53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to audit the records of prisoners who were eligible, but rejected or disqualified, for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone.
The County's Seventh Self-Assessment reports that 95% and 97% of the mentally ill prisoners who were eligible for and denied work in the Second and Third Quarters of 2018 were not denied the work due to a mental health diagnosis or prescription for psychotropic medication alone. Accordingly, the County concludes that it has achieved Substantial Compliance with Paragraph 53 as of the Second Quarter of 2018, and it maintained Substantial Compliance through the Third Quarter of 2018.
As noted in the Monitor's Sixth Report, the Mental Health Subject Matter Expert and clinicians previously reviewed documents posted by the County and noted that "[i]t is difficult to determine if . . . denials reflect lack of eligibility due to mental health diagnosis alone, or issues relating to housing placement of patients as a class, rather than individual determinations of eligibility." These concerns remained during the Seventh Reporting Period.
While the Mental Health Subject Matter Expert and the clinicians reviewed the County's "table of those refused programing and agreed with the County's 'scoring' of the individual cases selected for Compliance Measure 53-3(b)," they have found "it hard to assess [the County's] compliance based on the [available] documentation" and "have not been able to find a description of the [County's] methodology."
From a qualitative perspective, the Mental Health Subject Matter notes that "[t]he main problem is that those in HOH are effectively barred from programming because they are often too ill to go to settings where such programming is offered and yet no programming is being brought to them that some could avail themselves of. We have seen no HOH patients engaged in any programming, including on unit jobs (which some could do). Review of the movement history for those in HOH does not show attendance in any programming that I could find."
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Case 2:15-cv-05903-DDP-JEM Document 148 Filed 02/28/19 Page 62 of 124 Page ID #:3230
54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to audit the records of a maximum of 100 randomly selected prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. In the Fifth Reporting Period, the County reported that it achieved and maintained Substantial Compliance for the period from March 1, 2016 through December 31, 2016. The results were verified by the Monitor’s auditors.
The Mental Health Subject Matter Expert then expressed a concern that the randomly selected population "does not pre-select for patients on [mental health] rolls or on medication, so it is possible that all cases reviewed had no mental health problem that might have resulted in a denial." To address this concern, with the approval of the parties, the Monitor revised the Compliance Measures for Paragraph 54, effective January 1, 2018, to provide for an alternative pool of inmates proposed by the County. Because the Monitor's auditors had verified that the County has maintained Substantial Compliance under the existing Compliance Measures, the parties agreed that the County will only be required to maintain Substantial Compliance under the revised Compliance Measures for two additional quarters.
The County's Seventh Self-Assessment reports Substantial Compliance in the Second and Third Quarters of 2018. This is based upon posted results showing that, during two random weeks in the Second Quarter, none of the 18 inmates who requested, and were denied, programing were denied programing solely due to their prescriptions for psychotropic medication or mental health status. In the two random weeks in the Third Quarter of 2018, none of the five inmates who requested and were denied programing (e.g., work or education) were denied programing for these reasons.
In response to the Monitor's concerns that the County's results do not address whether inmates on psychotropic medications or mental health status were denied "privileges," the County's provided visitation records showing that none of the 36 inmates on psychotropic medication who received visits during these random weeks were denied visits for these reasons. The visitation records reflect inmates who received visits, rather than inmates who were denied visits, which is insufficient to determine if any inmates were denied this privilege because of their medications or mental health status. Further, the visitation records do not address whether these inmates were denied other privileges such as access to the dayroom and recreation. The County must either show that no inmates on psychotropic medications or mental health status (1) were denied privileges during the random weeks for any reasons or (2) were denied privileges during those weeks because of their medications or mental health status.
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55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through September 30, 2017 (verified) at CRDF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through March 31, 2018 (verified) at PDC North)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through June 30, 2018 (verified) and September 30, 2018 (unverified) at MCJ)
PARTIAL COMPLIANCE (at TTCF)
The County's Sixth Self-Assessment reported that the Department had maintained Substantial Compliance for twelve consecutive months through the Third Quarter of 2017 at CRDF and through the First Quarter of 2018 at PDC North. These results were verified by the Monitor's auditors and CRDF and PDC North were not subject to monitoring for compliance with Paragraph 55 in the Seventh Reporting Period.
The County's Seventh Self-Assessment reports Substantial Compliance for the Second and Third Quarters of 2018 at MCJ and for the Third Quarter of 2018 at TTCF for Compliance Measure 55-2. The Augmented Self-Assessment reports, however, that the Department only achieved Partial Compliance at TTCF; while the required TTCF staff attended all of the HOH meetings, they attended only 75% of the MOH meetings pursuant to Compliance Measures 55-6(a) and (b). The results at MJC for the Second Quarter of 2018 have been verified by the Monitor’s auditors. The results at MCJ for the Third Quarter of 2018 are subject to verification by the Monitor's auditors.
On January 8, 2019, the Department provided a semi-annual report "verifying the coordination and communication at the staff meetings" in HOH and/or MOH units at TTCF and MCJ during the first six months of 2018 as required by Compliance Measures 55.2, 55.4 and 55.6(c). DOJ is concerned "about the level of detail" in some huddle meeting minutes, and the Mental Health Subject Matter Expert notes that "it is very difficult to know [from the minutes] whether problem cases are being detected and discussed." The Monitor and Mental Health Subject Matter Expert will continue to attend huddle meetings during site visits to assess the efficacy of the meetings.
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56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH; and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing.
The County’s Substantial Compliance results for the twelve months from January 1, 2016, through December 31, 2016, were verified by the Monitor's auditors, and the County was not subject to monitoring for compliance with Paragraph 56 during the Seventh Reporting Period.
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Case 2:15-cv-05903-DDP-JEM Document 148 Filed 02/28/19 Page 65 of 124 Page ID #:3233
57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57):

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at MCJ)

PARTIAL COMPLIANCE (at PDC North, TTCF, and CRDF)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit in two randomly selected weeks to determine if the safety checks were staggered and conducted as required by Paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit for one randomly selected week to determine if a QMHP approved the new mental health housing assignments as required by Paragraph 57(e). The thresholds for achieving Substantial Compliance with these two Compliance Measures is 95%.

The County’s Sixth Self-Assessment reported that it maintained Substantial Compliance with Compliance Measure 57.5(b) in the Fourth Quarter of 2017 and the First Quarter of 2018 in the MOH unit at MCJ (the "Hope Dorm"). It also reported that all of the inmates at MCJ "analyzed pursuant to Compliance Measure 57-5(c) had received QMHP approval for their housing assignments" in both quarters. The results were verified by the Monitor's auditors and MCJ was not subject to monitoring for compliance with Paragraph 57 in the Seventh Reporting Period.

The County's Seventh Self-Assessment reports that the County achieved Partial Compliance in the HOH and MOH units at TTCF (88% and 83%) and CRDF (89% and 80%) in the Second and Third Quarters of 2018. It also reports that the County achieved Partial Compliance in the MOH units at PDC North in the Second Quarter of 2018 (93%) and Substantial Compliance in the Third Quarter of 2018 (99%). As noted by DOJ, and confirmed by the auditors, however, the safety checks at PDC North were not staggered as "custody staff [took] the same route through Module 2's four doors (A,B,C and D) in the same order every time they conduct[ed] the checks at almost identically spaced intervals." The County reports that the "Department expects the facility to show improved staggering by module in forthcoming audits."

The Self-Assessment also reports that 100% of the new mental health housing assignments in CRDF and in TTCF were approved by a QMHP in the Second and Third Quarters of 2018. This is consistent with the observations of the Mental Health Subject Matter Expert who notes that "a QMHP is almost always involved in MOH/HOH placement or release."

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58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells; (b) At least every 30 minutes in dormitory-style housing units where the unit
does not provide for unobstructed direct supervision of prisoners from a security control room; (c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes; (d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing; (e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner; (f) Custody staff will document their checks in a format that does not have pre-printed times; (g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and (h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
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STATUS (58):

SUBSTANTIAL COMPLIANCE (as of January 1, 2016 through December 31, 2016 (verified) at PDC South, PDC North, and PDC East)

SUBSTANTIAL COMPLIANCE ( as of July 1, 2017, through March 31, 2018 (verified) and through June 30, 2018 (unverified) at CRDF)

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018 (verified) and through September 30, 2018 (unverified) at IRC)

PARTIAL COMPLIANCE (at TTCF, NCCF, and MCJ)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by Paragraph 58. The thresholds for achieving Substantial Compliance is 90%.

The County maintained Substantial Compliance with Paragraph 58 for twelve consecutive months at PDC South, PDC North, and PDC East as of December 31, 2016. Pursuant to Paragraph 111, those facilities were not subject to monitoring in the Seventh Reporting Period.

The County's Sixth Self-Assessment reported that for the Fourth Quarter of 2017 and the First Quarter of 2018, the following percentages of safety checks were in compliance with Paragraph 58: CRDF (93% and 90%);24 TTCF (95% and 97%); MCJ (94% and 92%); NCCF (82% and 58.5%); and IRC (95% and 92%). Based upon the audit by the Monitor's auditors, however, it did not appear that the cell checks at MCJ and TTCF were staggered as required by Paragraph 58.

The County's Seventh Self-Assessment reports that 88% of the safety checks at CRDF and 89% of the checks at IRC in the Second Quarter of 2018 were in compliance with Paragraph 58, which is slightly below the 90% threshold for Substantial Compliance. It nevertheless requests a Substantial Compliance finding because "the safety checks on the relevant dates were timely conducted under Compliance Measure 58-2, however, there were technical difficulties uploading the scans from iPods" during the random weeks at both facilities. Excluding the one day (June 19, 2018) that the UDAL Main Report shows a problem with uploading iPod scans at CRDF, which accounted for 40 of the 42 missed rounds during the two random weeks, the percentage of compliant rounds at CRDF goes from 88.5% to 94.7%.

There was no single day with as significant a spike in missed (or non-compliant)

24 Substantial Compliance requires achieving the 90% threshold based upon the aggregate data for the two randomly selected weeks.

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rounds at IRC, but excluding the one day (May 12, 2018) on which it appears from the UDAL Main Report that the Title 15 scanner was not working, the percentage of compliance in the Second Quarter of 2018 goes from 89.4% to 91%. The Seventh SelfAssessment reports that 92% of the safety checks in the Third Quarter of 2018 at IRC were in compliance with Paragraph 58.
The County's Seventh Self-Assessment also reports that for the Second and Third Quarters of 2018, the following percentages of safety checks were in compliance with Paragraph 58 at the remaining facilities: MCJ (90% and 88%); TTCF (96% and 95%); and NCCF (60% and 54%). Based upon the audit by the Monitor’s auditors, however, it does not appear that the cell checks at TTCF are staggered in the Second and Third Quarters of 2018 as required by Paragraph 58.
The Substantial Compliance results at CRDF and IRC are subject to verification by the Monitor's auditors. If the results at CRDF and IRC (excluding the results for the days when the scanners were not working properly) are verified by the auditors,25 these facilities will no longer be subject to monitoring for compliance with Paragraph 58.
25 The Monitor’s auditors will review a few randomly selected videos for those days when the scanners were not working properly to verify that the safety checks occurred.
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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31, 2017 (verified) at PDC East and MCJ)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at NCCF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified) at CRDF)
SUBSTANTIAL COMPLIANCE (as of January 1, 2018, through September 30, 2018 (verified) at PDC North and PDC South)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through September 30, 2018 (verified) at TTCF)
Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. In response to the Monitor's comments, the Department's e-UDAL forms were modified to include a specific notation that the Supervisor verified that the safety checks were conducted. The threshold for achieving and maintaining Substantial Compliance is that 90% of the supervisor daily rounds were in compliance with the requirements of Paragraph 59.
The County's Sixth Self-Assessment reported that the Department had maintained Substantial Compliance at PDC East and MCJ for twelve consecutive months from January 1, 2017 through December 31, 2017 (and continuing to March 31, 2018). It also reported that the Department had maintained Substantial Compliance at NCCF for twelve consecutive months from April 1, 2017 through March 31, 2018. The results were verified by the Monitor's auditors and these facilities were not subject to monitoring for compliance with Paragraph 59 during the Seventh Reporting Period.
The County's Seventh Self-Assessment reports that the following percentage of rounds were in compliance with the provision in the Second and Third Quarters of 2018: CRDF (98% and 91%), PDC North (97% and 97%), PDC South (93% and 99%), and TTCF (98% and 91%). These results have been verified by the Monitor's auditors. CRDF has maintained Substantial Compliance for twelve consecutive months and is no longer subject to monitoring for compliance with Paragraph 59.
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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
Compliance Measures 60.2 and 60.3(b) require the County to prepare semi-annual reports setting forth (a) any identified clinical issues in the areas identified in Paragraph 61 that place prisoners at significant risk of suicide or self-injurious behavior; (b) corrective actions and systemic improvements taken by DMH and the Department to address any such issues during the reporting period; and (c) an assessment of the effectiveness of steps taken to address issues identified during earlier reporting periods.
The Mental Health Subject Matter Expert has stated that "CHS is clearly developing a sound QM system. It is based on well-established principles and methods of QM. They are taking appropriate and measured steps to implement their plan." The Monitor and Subject Matter Expert note the Department has continued to enhance its participation in the quality management process as required by Paragraphs 60 and 77.
On January 14, 2019, the County submitted CHS's Semi-Annual Report on Quality Improvement/Assurance, which covers the Second and Third Quarters of 2018. The Report discusses a number of items that will be implemented in the future. For example,
"[Custody Health Services] Compliance Team is currently developing a Mental Health Compliance Dashboard, which it expects to be in place by the first quarter of 2019. The new dashboard will track summary reports by facility, and nursing and mental health service, and outline trends, thresholds, and barriers to compliance and plans to resolve such barriers, as well as current and past compliance rates. The Mental Health Compliance Dashboard is expected to significantly improve CHS’s analysis of systemic data, ability to evaluate and compare current performance, identify key priorities, and focus on areas with the greatest need. Additionally, the dashboard will serve as a vehicle to improve communication with all levels of staff concerning our progress toward achieving compliance expectations."26
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26 As the Mental Health Subject Matter Expert previously observed, "[i]t is especially important for the county to develop and maintain on-going tracking (typically using a dashboard format) of aggregate data measuring critical aspects of these measures. . . .In each area, there needs to be an on-going analysis of key measures[.]" See Monitor's Sixth Report, p. 67.
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"CHS is in the process of revamping its Quarterly QI committee[;], beginning in 2019, the Committee will meet monthly with the purpose of promoting collaboration among facilities and service lines and improving quality of care and patient safety. The main focus will be to align the organizational quality and safety priorities, identify opportunities for improvement, and share best practices."
"Representatives from CHS Mental Health services will participate in these committee meetings on a quarterly basis beginning in January 2019. Mental Health services' participation is expected to focus on reports relating to quality and safety issues, as well as pertinent findings from the Critical Incident Review Committee ('CIRC') and Joint Quality Improvement Committee ('JQIC')."
****
"Going forward CCSB and CHS Compliance Team will work collaboratively to prepare reports and improve data analysis, including in monthly meetings expected to begin in 2019 to ensure that data used and parameters are identical."
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"[I]n January 2019, the County plans to start collecting additional readmission data, including discharge location, medication, compliance, use of long acting injectable (LAI), and whether appropriate dosages of psychotropic medications were given prior to discharge. The County's goal in collecting the data is to develop methods to evaluate whether or not patients were on the inpatient unit long enough to receive appropriate treatment, whether or not the percentage of medication compliance was adequate for discharge, and whether the patient was stable upon discharge[.]"
The County reports that the "shift" in the CIRC and JQIC meetings in the last reporting period to "discussion of system root causes" has "helped identify systemic concerns related to CIRC events.. . .rather than simply cataloging issues for future workgroups." The Mental Health Subject Matter Expert notes that:
The Department and CHS are collaborating in conducting sound investigations of episodes of serious self-harm. CHS is collecting aggregate data, though the scope needs to be expanded to cover essential aspects of the elements laid out in Provision 61. The Department is beginning to collect and analyze aggregate data but the integration of (or collaboration in developing) aggregate analytics jointly between CHS and LASD is just beginning.
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The County also reports that 12 staff members, including two from mental health have graduated from a Quality Academy at LAC+USC; "significant progress has been made in updating, customizing, and training staff in Safety Intelligence, CHS's patient safety incident reporting system;" "nearly all" CHS managers and supervisors and 78% of the "front-line staff" have been trained in Just Culture, which the County has adopted to replace "the historical custodial-style approach to medical and mental health care;" and it has established "a steering committee" and trained thirteen staff member as peer supporters in "the Helping Healers Heal (H3) program."
CHS's Semi-Annual Report summarizes the issues presented at the November 7, 2018 Bi-Annual Suicide Prevention meeting, including the access that mental health and medical staff now have to the County's "integrated behavior health information system," which "allows mental and medical health staff to more quickly and accurately care for inmates when they arrive at County jail facilities;" the access they are in the process of obtaining to the County's electronic medical records, which "is critical to the continuity of care" for inmates who go back and forth between County hospitals and jails; and the efforts of the Office of Diversion and Reentry (ODR) to divert inmates from jail. While reflecting the efforts that the County is making to improve the care of mentally ill inmates, it is not clear that these improvements are part of an integrated "quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide and self-injurious behavior."
The report discusses the efforts to "improve the use" of CIRC meetings "to identify and address systemic issues;" the changes in JQIC meetings introduced in November 2018 to "serve as a venue to present data on trends and/or themes in SDVs [Self-Directed Violence] and CIRCs that may inform system-wide improvements related to suicide prevention;" the efforts of CCSB and CHS to use the same data on SDV events; and the use of a new SDV review template by QMHP's "that streamlined the process and allowed raters to focus on the most salient information needed to determine the severity [of the SDV event] and the need for any immediate corrective action."
The County's report includes aggregate data on Suicides going back to 2014, and SDV incidents and CIRC incidents broken down on a monthly basis by age, race/ethnicity, gender, facility, proximity to court date method of attempt, prior SDV incidents, and risk rating. It also includes aggregate data on CIRC meetings and describes the efforts to "focus" the meetings "on improving overall identification of systemic issues, the process of tracking those issues, and analyzing trends and patterns," including the "categorization of issues" in CIRC summary tables to move "the County's analysis of issues toward detecting patterns and/or themes in [the] case reviews."
The Semi-Annual Report includes the following new sections:
 the Correctional Treatment Center – Mental Health Unit (CTC-MHU), including the significant decrease in use of clinical restraints in the unit, and its impact on
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staffing;27 admission and limited re-admission data; and the development of "a new Step-Down Assessment form that more clearly identifies the step-down process and helps inform patient care through improved documentation of patient status through treatment on the unit."
 Psychotropic Medication, including the STEP FORWARD program at CRDF "to provide early psychiatric intervention beginning at intake for those patients with severe mental illness (SMI)" and "Initial Psychiatric Evaluation and Medication Management for New Arrestees in MOH;" the tracking of patients refusing psychotropic mediations in MOH at TTCF; and the work of the Pill Call Working Group to revise and improve pill call procedures in all facilities.
 Other QI projects and health care services, including a summary of timelines of assessments and housing as a result of the new medical and mental health screening process at IRC; a summary of substance use services, including withdrawal management pods at TTCF and CRDF and group treatment sessions led by substance use disorder providers; mandatory training for suicide risk assessment, which commenced on August 23, 2018; and the work of an expanded Risk Precautions working group to address concerns about "the need for more individualized decisions regarding step down[.]"
The Monitor and Subject Matter Expert appreciate the many efforts that the Department and CHS have made to improve the quality of care afforded to address the needs of mentally ill inmates and prevent suicides and acts of self-directed violence in the jails. They believe that the County has made significant progress in the areas discussed in CHS's Semi-Annual Report, and is beginning to use aggregate data to recommend corrective action or systemic improvements. The quality management program is more organized with less fragmentation of processes, working groups, and projects, and CHS staff has benefitted from being trained in quality management.
Many of the elements of the quality improvement program were recently implemented or are scheduled to begin in the next reporting period. The County recognizes that much of the program is in the early stages, noting that "[i]n future reporting periods the County expects to demonstrate a more organized and structured approach to these types of work groups. The plan is to follow quality improvement principles that require a more formal approach and accountability." As stated by one of the clinicians, however, "developing the system is not the same as implementing and effectively using a QI program."
The Monitor and Mental Health Subject Matter Expert believe that the County will be able to achieve Substantial Compliance with a more formal approach and the implementation of the elements of the program set to begin in this next reporting period.
27 The County attributes this, in part, to changes in Custody's use of force policies and "an increase in using discussion and negotiation techniques to gain compliance from inmates/patients" and, in part, to the early use of "long-acting injectable (LAI) psychotropic mediations in CTC-MHU."
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It "will require the continued buildout of data collection and aggregation, analysis of aggregate data, general outcome measures (e.g., the dashboard), and coordination and engagement in these processes by the Department."
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts:
(i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints;
(c) Psychotropic medications;
(d) Access to care, timeliness of service, and utilization of the Forensic Inpatient Unit; and
(e) Elements of documentation and use of medical records.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County’s semi-annual reports to (a) review, collect, and aggregate data in the areas set forth in Paragraph 61; (b) recommend corrective actions and systemic improvements in those areas; and (c) assess the effectiveness of actions and improvements in prior reporting periods.
The CHS Semi-Annual Report sets forth aggregate data for suicides for the period 2014 through the Third Quarter of 2018, broken down by prior attempts or other serious self-injurious behavior, facility, method, demographics (age, ethnicity, and gender), and proximity to court date, which are the areas identified in Paragraph 61(a)(i) through (vi). Other than some very general conclusions, this section of the report does not analyze the data, recommend actions and improvements, or assess the effectiveness of prior actions and improvements.
The CHS Report also summarizes the process for QMHP reviews of SDV and the CIRC reviews of "moderate and high risk" cases at its monthly meetings. It reports that "[i]n August 2018, CHS officially began using the new template which streamlined the process and allowed raters to focus on the most salient information needed to determine severity and the need for any immediate corrective action." It then sets forth aggregate data for:
(1) SDV incidents for the second and third quarters of 2018 broken down by prior suicide attempts or other serious self-injurious behavior, ethnicity, gender, proximity to court date, and, on a monthly basis, by
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facility, method, CDC Risk Rating Score, and age; and
(2) serious self-injurious incidents that were reviewed at CIRC meetings broken down by systemic issues identified in each quarter, and by prior suicide attempts, facility, method, lethality (risk rating scores), age, ethnicity, gender, and proximity to court date.
As with the suicide data, with the exception of general conclusions regarding some of the aggregate data, the CHS Report does not set forth any analysis of the data, recommended "corrective actions and systemic improvements" in the areas in Paragraph 61, or "assess the effectiveness of actions and improvements in prior reporting periods."28 The report indicates that CHS intends to improve its analysis of the data in the future.29
Attached to the CHS Report is a summary for each of the 18 cases that breaks down each incident by the categories in Paragraph 61(a)(i) through (vi) of the Settlement Agreement, and then sets forth "issues" assigned by the categories in Paragraph 61(b) through (e), and the "response/status" of the issues.
The Semi-Annual Report also includes sections that "review, collect, and aggregate data" and in the areas required by Paragraph 61(b) through (e):
 aggregate data on the decrease in the use of clinical restraints in the Mental Health Unit of the CTC and analysis of the cause and effect of the decrease;
 aggregate comparative data on the admission, discharge, and readmission of patients in the CTC-MHU for the Second and Third Quarters of 2018 and historical data for admissions from 2014 through the Third Quarter of 2018.
 the development of a new Step-Down Assessment that more clearly identifies the step-down process and helps to inform patient care through improved documentation of patient status as they progress through treatment on the [CTCMHU].
 a summary of the quality improvement projects relating to the use of psychotropic medication, including the STEP FORWARD program at CRDF that addresses system shortcomings;
28 There is a cross-reference to the report of CCSB's activities, which provides a fairly detailed analysis of SDV incidents by age. See CHS Report, p. 25. 29 For example, based upon SDV incidents in the Second and Third Quarters of 2018, the CHS Report concludes that "a history of prior suicide attempts does not appear to be a significant factor as to whether or not inmates will engage in self-directed violence." It notes, however, that "this result may change when analyzing this category over a longer period of time and/or in conjunction with other categories[.]" Elsewhere, it notes that "[a]lthough the QI Category data [for CIRC incidents] provides only a very broad description it is a starting point for further analysis."
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 the implementation of a MOH intake team approach that has significantly reduced the wait time for patients/inmates with a P2 level of care housed in MOH to be see a psychiatrist;
 the development of a medication refuser list to track patients refusing psychotropic medications at MOH in TTCF;
 a pill call pilot program "to align pill call procedures with best practices" and address concerns expressed by the Monitor regarding these procedures;
 summaries of other quality improvement projects, including tracking the timeliness of suicidal patients being seen by mental health clinicians in IRC, and data showing a significant improvement in the flow of suicidal patients through IRC;
 comparative "admission," "discharge," and "re-admission" data for the Mental Health Unit of the Correctional Treatment Center for the Second and Third Quarters of 2017 and 2018.
Some of these targeted QI projects, such as the STEP FORWARD program and the pill call pilot program, may "be considered a CAP for an identified problem," but the Mental Health Subject Matter Expert notes that they do not reflect a "sufficient breadth of analysis of aggregate data to develop CAPs, which would set benchmarks and look at trends and patterns of usage." For example, there is no "analysis of general prescribing patterns or medication monitoring, both critical aspects of quality management of psychotropic prescribing." The Mental Health Subject Matter Expert notes:
The initiatives involving MOH psychiatric encounters, IRC QMHP assessments by QMHPs, and CTC utilization are good beginnings to assessing access to care. It will be important for the County to assess more general access to care such as individual contacts by patients with QMHPs and psychiatrists and group dosage according to established benchmarks. As access to care is determined by both CHS and the Department, collaboration on the analysis and correction of problems related to access to care are essential.
The most recent CHS semi-annual report is "a significant step forward."
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County's semi-annual Self-Assessments to set forth (a) the "development of corrective action plans to address the most recent recommendations of the quality improvement program;" and (b) the "implementation and tracking of corrective action plans to address recommendations of the program in prior quarters."
The reviews of the incidents discussed at CIRC meetings that are attached to CHS's Semi-Annual Report provide data responsive to the requirements of Paragraph 61(a)(i) through (vi), which is the basis of the aggregate data reported elsewhere, and set forth "issues" identified and assigned in the meetings about SDV incidents broken down by the categories set forth in Paragraph 61(b) through (e) and the "response/status" of those issues.
CCSB's Semi-Annual Report describes all of the corrective action plans identified during the Executive Inmate Death Reviews of suicides that occurred in the first six months of 2018 and the status of those CAPs as of December 2019.30
The Mental Health Subject Matter Expert reviewed these reports and has the following observations:
There is no central tracking of CAPs and progress towards their completion. The CIRC reviews track case-specific CAPs, although some CAPs address repeated problems having broader impact (such as closing gaps between furniture and walls and repairing speaker grates). The CHS Semi-Annual Report does not track CAPs in a well-organized manner and it generally limited to tracking "project" outcomes that may considered to be CAPs that address repeated defects.31 The CCSB semi-annual report does not separately track system-wide CAPs that are generated from aggregate data or on-going, system-wide problems (such as contraband being used for self-harm).
30 The CCSB Report also summarizes generally the CAP/Issues related to the serious suicide attempts reviewed during the CIRC meetings, broken down by CAP items issued to the Sheriff's Department and those issued to Correction Health Services. While the description of the CAPs at the suicide review meetings satisfies the requirements of Paragraph 77 for suicides, the general summary of the CAPs does not provide any specific information about the CAPs for the serious suicide attempts. The specific information is provided in the CIRC reviews attached to CHS's report. 31 Examples of this include the work on the intake process and the timeliness of MOH (P2) psychiatric encounters, which are also "important examples in that they reflect the use of aggregate data to identify systematic problems."
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Further, the County's reports do not discuss whether these CAPS/Issues raise systemic issues, recommend systemic improvements, or assess the effectiveness of such improvements from prior reporting periods. The County is clearly doing a good job in addressing specific CAPS/Issues; what appears to be missing is a programmatic analysis of these CAPS/Issues and the systemic impact on the quality of care provided to inmates. The Mental Health Subject Matter Expert states that "the steps the County is taking to improve the organization of the quality management program, the collaboration between CHS and the Department, and the development and use of more global aggregate data and its posting on a dashboard are appropriate next steps to achieve substantial compliance."
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63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.

STATUS: NON-COMPLIANCE

The Compliance Measures require that the County's Self-Assessment set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period; (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. In addition, for two random weeks, the Department is required to review the count sheets documenting the number of occupied and available beds in the MOH and HOH units at TTCF and CRDF. Substantial Compliance requires "the immediate availability of HOH and MOH beds at TTCF and CRDF 95% of the time."

The County reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the Second Quarter of 2018 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 0% 100%

The County also reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the Third Quarter of 2018 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 0% 50%

The average Daily Population in HOH at TTCF increased from 918 in the two randomly selected weeks in the Second Quarter of 2018 to 968 in the two randomly selected weeks in the Third Quarter of 2018, while the average number of HOH Beds was relatively constant (763.5 in the Second Quarter of 2018 to 759.7 in the Third Quarter).

The County's Augmented Seventh Self-Assessment reports that the Department "is not able to accurately assess bed availability electronically without reflecting erroneous results, and as such, the Department is not able to provide an accurate semiannual report at this time." The Mental Health Subject Matter Expert suggests a simple methodology using P levels as a proxy (P4 means FIP, P3 means HOH, P2 means MOH).

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64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in an initial 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed.
On July 14, 2017, the County submitted to the Monitor a Plan Regarding Availability of Licensed Inpatient Mental Health Care (Long Term and Short Term Plans) to provide "an update regarding the County's current efforts to meet the needs of the acutely mentally ill." The County reiterates in its Seventh Self-Assessment that "the County continues to pursue a dual strategy to increase inpatient beds and the resources necessary to obviate the need for these beds. With increased services to address the underlying mental health needs (both through appropriate medication and clinical treatment), and the County's strong effort to divert people from the jails, the need for inpatient services should decline."
The County's Seventh Self-Assessment reports that "the County also operates 18 inpatient beds at Olive View-UCLA Medical Center. These beds house individuals who are diverted from the County Jail, either pre-trial or once they have been brought into the jail and are awaiting trial. The County's Office of Diversion [began] managing these beds in early July 2018, and is responsible for identifying appropriate individuals for them." In addition, the Seventh Self-Assessment reports that the "County also continues to operate its Mental Health Unit-Correctional Treatment Center Inpatient Step-Down Unit, which increased the capacity of FIP-related housing to 64 beds."
The County's Seventh Self-Assessment also reports that the FIP waitlist "[c]urrently consists of approximately 46 patients," down from 64 patients reported for the Sixth Reporting Period. "Fourteen of these individuals are taking medications on a voluntary basis and are, therefore, not prioritized for admission to the FIP." Further, as in the prior reporting period, "the current average time from referral to admission for the most acute is approximately two days, and can be roughly 20 days for those on the FIP
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waitlist that are less acute." It appears that the County's plans are still not sufficient to "reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails."
The Monitor's Fourth Report stated that the County's long-term "plans must have a reasonable basis for projecting need in order to establish Substantial Compliance with Paragraph 64." As noted in the Monitor's Fifth Report, the County's "new level of care system that designates patients into categories based on acuity and treatment needs" and its "tracking system to monitor the number of patients who meet this criteria on any given day" "may provide a reasonable basis for projecting 'the number of licensed inpatient mental health beds necessary to serve the inmate population.'" The County needs to use this "methodology" to determine "the projected capacity required" in the long term and project how many beds will be required over several years. Without using this (or some other) methodology to project the number of FIP patients in the future, it is not possible to assess whether the County's plans for adding FIP beds are reasonable and sufficient. This remains an issue that needs to be addressed to achieve Substantial Compliance with Paragraph 64.
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires that (1) the County's Self-Assessments set forth the (a) the results of weekly medication audits documenting the visual observation of the administration of medication during the quarter; (b) unauthorized medications found as a result of cell searches during the reporting period; and (c) incidents involving confirmed prescription drug overdoses; and that (2) "the Monitor concludes, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner 85% of the time."
On April 6, 2018, the County provided a flow chart entitled "Provision 65 Pill Call – Ideal State Pod-Front Pill Call Procedures” (excluded HOH cell-to-cell procedure) that is the product of a work group convened to develop a "new method and practice of administering medications." The Monitor and Mental Health Subject Matter Expert concluded that the flow chart is a "reasonable approach," but that the "primary issue will be the nature of the interventions adopted by custody and healthcare staff in response to lack of cooperation" and "what happens if they are not able to verify that the inmate ingested the pills," which the flow chart partially addresses.
The County's Seventh Self-Assessment reports that a working group of representatives from Custody, Mental Health, and Nursing "initiated a pilot program in two modules at TTCF designed to test and improve pill call administration methods. To date, the pilot has increased cooperation between Custody and nursing through education, briefing, and increased supervision with the goal of increasing medication compliance by inmates and more quickly and more accurately identifying inmates who do not allow staff to verify medication ingestion and may be hoarding medication." The Mental Health Subject Matter Expert notes that this "is a good example of using quality management principles to improve system function[.]"
As in the past, medication was found during a significant number of searches during the Second 32 and Third Quarters33 of 2018. There were also six confirmed drug overdoses during the Third Quarter of 2018.
32 During the Second Quarter of 2018, 141 medications "not appropriately possessed by inmates" were found during 159 unannounced searches at CRDF, 456 medications were found during 89 searches at TTCF, 11 medications during 275 searches at MCJ, and 166 medications during 615 searches at NCCF. There were no medications found during searches at PDC South, PDC North, and PDC East. 33 During the Third Quarter of 2018, 181 medications "not appropriately possessed by inmates" were found during 160 unannounced searches at CRDF, 635 medications were found during 79 searches at TTCF, 193 medications during 200 searches at MCJ, 10 medications during 502 searches at NCCF, and 51 mediations during 196 searches at PDC North. There were no medications found at PDC South and PDC East.
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66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with a Serious Mental Illness ("SMI") to assess whether they have remained on an active mental health caseload and that 95% of HOH prisoners, 90% of MOH prisoners, and 85% of other prisoners with a serious mental illness been offered "clinically appropriate structured mental health treatment" and been seen by a QMHP at least monthly, regardless of whether they refuse medications. For the Second Quarter of 2018, the County posted results show that 22% of prisoners in HOH, 10% in MOH, and 41% with serious mental illness who reside in other housing areas were "offered clinically appropriate structured mental health treatment and were seen by a QMHP at least once a month." For the Third Quarter of 2018, the posted results for these categories are 28% of HOH prisoners, 6% of MOH prisoners, and 50% of others with serious mental illness. The County's Seventh Self-Assessment reports that "[t]he County continues to work towards increasing its capacity to offer clinically appropriate treatment, including structured mental health treatment" and "improved standardization of the intake assessment process performed in the reception centers" to better identify "inmates at intake who have a serious mental illness." The County also "continues to hire staff to replace those departing service in the jails, some 18 psychiatric social workers started at the jails during quarters two and three."
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings;
(c) the use of clinically appropriate interventions with such prisoners to encourage medication compliance;
(d) consideration of the need to transfer non-compliant prisoners to higher levels of mental health housing; and
(e) individualized consideration of the appropriateness of seeking court orders for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a).
STATUS: NON-COMPLIANCE
Substantial Compliance requires the County to "review the electronic medical records of 25% of the prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records [of 85% of the prisoners] reflect the documentation and consideration of the matters required by the terms of Paragraph 67."
The County's Seventh Self-Assessment reports acknowledges that the County "has historically experienced challenges implementing and assessing compliance with this Provision." It also reports that "[t]he County continues to work on ways to use technology to better and more accurately identify and assess compliance where patients have refused 50% of psychotropic medication within a seven day period."
The Mental Health Subject Matter Expert and the clinicians evaluated 15 cases from CRDF and 24 cases from TTCF for compliance with Paragraph 67. They found that a QMHP considered whether a higher level of care was indicated in 53% of the cases at CRDF and 25% of the cases at TTCF. They also found that 50% of the cases at CRDF and 22% of the cases at TTCF included "a reasonable determination of the reason for the recommendation for housing change." They were "concern[ed] to see that the interventions to improve adherence were rarely clinically appropriate at TTCF. There was also very rare consideration of whether involuntary treatment or FIP placement was indicated, even in severely ill patients with documentation strongly suggestive of dangerousness or grave disability. Many of these patients were being isolated in their cells in HOH with some refusing medical care."
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The County "strongly disagrees" with the Mental Health Subject Matter Expert's findings and conclusions. Although not directly addressing the Subject Matter Expert's qualitative assessment of the clinical judgements, the County notes that inmates in HOH
are frequently engaged by custody staff and psychiatric technicians, seen weekly by mental health clinicians, and are seen at least once a month by a psychiatrist. Inmate-patients who are of a P4 status are seen by a psychiatrist every other week. Moreover, psychiatrists evaluating inmatepatients in mental health housing who are refusing medications are trained to specifically consider FIST Orders, involuntary medication orders under Penal Code 2603, and/or admission to the mental health inpatient unit. In MOH, psychiatric technicians compile lists of inmate-patients refusing medication, and those lists are circulated and reviewed weekly by doctors and clinicians. The clinicians and psychiatrists evaluating inmate-patients in MOH regularly evaluate the patient's behavior regarding medication adherence in their assessments of P levels and other clinical matters. The Mental Health Subject Matter Expert notes, however, that "[t]here are rarely specific interventions targeting medication adherence; when adherence is mentioned, it is primarily encouragement to take medications, which is rarely a sufficient clinical intervention."
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ, NCCF, PDC East, PDC South, and PDC North)

SUBSTANTIAL COMPLIANCE (as of January 1, 2017 through December 31, 2017 (verified) at TTCF)

PARTIAL COMPLIANCE (at CRDF)

Substantial Compliance requires that "85% of the housing units are searched for contraband at least once in the previous quarter; and 95% of the HOH units visually inspected prior to housing prisoners in these units." Self-Assessments are to include a summary of searches conducted in the Second Quarter of the last reporting period and the First Quarter of the current reporting period and to randomly select and review 25 Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units.

The County’s posted results reflect that in the Fourth Quarter of 2017, 88% of the housing units at CRDF were searched at least once in the quarter, and 80% of the randomly selected HOH cells at CRDF were visually inspected before housing prisoners in these units. During the First Quarter of 2018, 93% of the housing units at CRDF were searched at least once in the quarter, and 92% of the randomly selected HOH cells at CRDF were visually inspected before housing prisoners in these units.

During the Sixth Reporting Period, the County provided additional records and CCTV footage to show that the HOH cells at TTCF were visually inspected more than 95% of the time in the Third Quarter of 2017. Where there was a date discrepancy in the source documents, the CCTV footage showed that the HOH cells were visually inspected before the prisoners were housed in these units. In the Fourth Quarter of 2017, 96% of the housing units at TTCF were searched at least once in the quarter, and 96% of the randomly selected HOH cells at TTCF were visually inspected before housing prisoners in these units. These results have been verified by the Monitor's auditors. The County has maintained Substantial Compliance with Paragraph 68 at TTCF for more than 12 consecutive months, and is no longer subject to monitoring with this provision at that facility. The County previously maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC South, and PDC North, and these facilities were not subject to monitoring for compliance with Paragraph 68 during this reporting period. As noted by DOJ, however, the "failure to conduct effective contraband searches as required by this provision, may implicate the County's ability to comply with other provisions related to medication hoarding, chiefly provisions 31 and 65."

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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through September 30, 2018 (unverified))
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved, and documented, and that the results of medical welfare checks on restrained prisoners were also documented.
The County’s Seventh Self-Assessment reports that for the Second Quarter of 2018, "77%. . . of electronic medical records reviewed. . .reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required by this Provision." The County’s Seventh Self-Assessment also reports that, for the Third Quarter of 2018, five of the six (83%) of the medical records reviewed "reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved, and documented as required by this Provision." The County's Self-Assessment notes that the "County has significantly reduced the number of times it uses clinical restraints" and that the "County tracks roughly 11 separate categories of information to assess compliance for each use of clinical restraints." It reports that it "failed to meet only 4 of the 198 items tracked—an effective compliance rate of more than 97%" in the Second Quarter of 2018, and "only 1" of 66 items tracked in the Third Quarter of 2018, or 98%."
The Monitor's Sixth Report notes that the Mental Health Subject Matter Expert believes that "the requirements of [this Compliance Measure] are excessive and do not match standards published by organizations such as the Centers for Medicare and Medicaid Services (CMS)[.]" For example, he "reviewed the one case that the County marked as non-compliant, which appeared to be because the patient was not seen by a psychiatrist prior to restraint even though the nurse obtained a proper telephone order. The psychiatrist assess the patient within 24 hours as well, in my view this should count as compliant." Based upon the Mental Health Subject Matter Expert's assessment, and with DOJ’s concurrence, the County achieved Substantial Compliance in the Third Quarter of 2018,34 subject to verification by the Monitor’s auditors.
34 The Mental Health Subject Matter Expert still recommends that the Compliance Measures be revised to allow for telephonic approval followed by a psychiatric assessment within 24 hours and that the County restructure its approach to the placement of inmates in clinical restraints as well as the monitoring of those in restraints.
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: PARTIAL COMPLIANCE
The Mental Health Subject Matter Expert and DOJ have expressed concern about the Department's Substantial Compliance with paragraph 70(c) if all inmates in HOH are routinely handcuffed when they are out of their cells "in a housing pod at the same time." One of the clinicians observed that "[o]ur recent onsite observations suggested that not all patients required such restraints all the time."35 The Mental Health Subject Matter Expert is of the view that the Department's own "policies impose other requirements for review of restraints that the Department is not following for this population."
As the County "previously reported[,] the Department routinely handcuffs inmates in HOH and HOH_MIST housing when more than one HOH inmates is out of the cell in a housing pod at the same time. This category of inmates, as a whole, is a safety concern as they are deemed unpredictable and potentially dangers."
In response to concerns expressed by the Mental Health Subject Matter Expert and DOJ, the County's Seventh Self-Assessment reports that:
Department has developed and continues to use alternative types of mental health housing with the goal of housing inmates with mental health concerns in the least restrictive manner appropriate, these models include Step-Down modules, the HOPE Dorm and the Living Module. As
35 The Mental Health Subject Matter Expert notes that paragraph 70(b) is also implicated because it required that restraint's "will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape."
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previously reported, the 'Living Module' concept at TTCF, whereby each patient begins their mental health treatment in an HOH pod and transitions into an MOH pod as their mental health improves. With each stage in the transition, the inmate-patient gains privileges and is less restricted in their movement. The Living Module now operates in two pods. Inmates in the Step-down modules and HOPE Dorm are not restrained when out of cell. The County's Seventh Self-Assessment also reports that "[t]he County continues to conduct weekly assessments of inmates in HOH housing. During those assessments, clinicians consider, among other things, whether an inmate is able to cohabitate with others. In addition, the County conducts daily huddle meetings to assess whether HOH inmates are suitable for a double man cell, or transfers to Enhanced Mental Health Housing or MOH." The Mental Health Subject Matter Expert notes, however, that while housing in a double-man cell is relevant, some inmates who need single-cell housing may still be able to come out unrestrained. The Subject Matter Expert notes that the "County has made some progress in implementing step-down units and the Living Module approach, but it is far from universally implemented and there is no formal policy or procedure in place to govern this and to reasonably assure continuation." To achieve Substantial Compliance with Paragraph 70(c), the County needs to conduct individual assessments to determine which inmates need to be restrained, throughout HOH and which inmates can be housed in less restrictive settings, as long as there are adequate beds at each level.
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71. The County and the Sheriff will ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (verified))
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71.
The County maintained Substantial Compliance with Paragraph 71 for twelve consecutive months during a prior reporting period and Paragraph 71 was not subject to monitoring in the Seventh Reporting Period.
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72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31, 2017) (subject to further verification)

Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings that review incidents of serious self-injurious behavior in the reporting period.

The Monitor's Sixth Report found that the County had maintained Substantial Compliance with Paragraph 72 for the twelve month period ending on December 31, 2018, but expressed the Monitor's concern that the information provided by the County was insufficient "for the Monitor 'to assess' whether the County is adequately reviewing potential non-custody staff misconduct.'"36 To address this concern, the County submitted a list of 2017 Performance Management cases reflecting the status and/or results of investigations Custody Health Services personnel in 2017. In includes whether the allegations were "substantiated" and, if so, the "Final Administrative and/or Disciplinary Action," but does not, as DOJ notes, "indicate to which suicides or suicide attempts the investigation and discipline listed correspond" or "how many of the investigations or disciplinary actions listed arose due to suicides or suicide attempts." The Monitor agrees that this information is needed to assess whether the County maintained Substantial Compliance for twelve consecutive months during the Fifth and Sixth Reporting Periods and, therefore, was not subject to monitoring for compliance with this provision during the Seventh Reporting Period.

36 See Monitor's Sixth Report, p. 84, note 44.
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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified))
Substantial Compliance requires the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicide during the reporting period.
The County’s Seventh Self-Assessment reports that for the Second Quarter of 2018, "96% -- 6% more than the required 90% -- of reports reviewed have all of the information required by Compliance Measure 73-4(a)." It also reports that the Office of Inspector General was notified of the one apparent or suspected suicide that occurred during this quarter.
The County’s Seventh Self-Assessment also reports that for the Third Quarter of 2018, "99% -- 9% more the required 90% -- of reports reviewed have all of the information required by Compliance Measure 73-4(a)" and there were "no incidents involving an apparent or suspected suicide" during the quarter. The Monitor’s auditors have verified the County’s results. Accordingly, the County has maintained Substantial Compliance for twelve consecutive months and will no longer be subject to monitoring for compliance with Paragraph 73.
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74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)
Substantial Compliance requires the Department to provide the Monitor with an Executive Suicide Death Review reflecting the results of the Department’s investigation of any suicide in the Jails within six months of the suicide. The review must reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded.
The County previously maintained Substantial Compliance with this provision for twelve consecutive months and it was not subject to monitoring during the Seventh Reporting Period. The County nevertheless continued to notify the Monitor of all inmate deaths, including suicides, and the subsequent death reviews. The Monitor continued to attend death reviews during the Seventh Reporting Period.
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75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
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STATUS (75):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified))

Substantial Compliance requires (a) DMH to review documentation of randomly selected suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (b) that the Department and DMH reviewed the relevant information known at that time and the status of any corrective actions taken, and they considered the need for additional corrective action if necessary; and (c) that the information is reflected in the Department's database for tracking and statistical analysis.
The County's Seventh Self-Assessment reported that for the Second Quarter of 2018, "85% -- equal to the required 85% -- of documents reviewed showed CHS staff considered the inmate's mental health status and need for immediate corrective action;" "100% -- 5% more than the required 95% -- of suicide attempts are reflected in the Department's database;" and "90% rather than the required 95% -- of the suicide attempts" were reviewed by "management and command-level personnel" from Custody, mental health, and medical. The County did not meet the 95% threshold for management and command level reviews of suicide attempts as required by Compliance Measure 755(b) because "due to a miscalculation," one of the ten serious suicide attempts "was reviewed 31 days after its occurrence – failing to meet the compliance requirement by only 1 day.” Because the delay was minimal and the "County is in Substantial Compliance with the other requirements of this Provision in the Second Quarter, the County requests a finding of Substantial Compliance." The Mental Health Subject Matter Expert concurs, and notes that the County is "doing a good job on these reviews, including some meaningful CAPs."

The County's Augmented Seventh Self-Assessment reports for the Third Quarter of 2018 "that 91%—6% more than the required 85%—of documents reviewed showed CHS staff considered the inmate's mental health status and need for immediate corrective action." The County also concluded that 100% - 5% more than the required 95% - of the suicide attempts were reviewed by "management and command-level personnel" from Custody, mental health, and medical; and 100% -- 5% more than the required 95%— of suicide attempts are reflected in the Department's database for tracking and statistical analysis. The Monitor’s auditors have verified the County’s results. Accordingly, the County has maintained Substantial Compliance for twelve consecutive months and will no longer be subject to monitoring for compliance with Paragraph 75.

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76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)

The County previously maintained Substantial Compliance with Paragraph 76 for twelve consecutive months and this provision was no longer subject to monitoring during the Seventh Reporting Period. Nonetheless, the County continued to conduct the reviews required by Paragraph 76 for the suicides that occurred during this period and invited the Monitor to attend these meetings.

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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
CCSB's Semi-Annual Report for the Second and Third Quarters of 201837 reports that "there were two (2) suicides within the jail facilities, nineteen (19) suicide attempts, and four hundred and twenty-six (426) Self-Directed Violence notifications in the jails. Each suicide was discussed in a Preliminary (24 hr), 7 and 30 Day Executive Review" as required by Paragraph 76. A third suicide that occurred at the end of the First Quarter of 2018 was also discussed within these timeframes in the Second Quarter of 2018.38 19 of the SDV incidents "were deemed serious suicide attempts." Of those 19, only nine of the serious incidents were discussed during six (6) Critical Incident Review Committee (CIRC) meetings.
37 Because the CCSB report covers the Second and Third Quarters of 2018, there is some overlap with CCSB's report for the Sixth Reporting Period, which covered the First and Second Quarters of 2018. 38 All of the suicides occurred in the Second Quarter of 2018 and were covered in CCSB's prior report.
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The Semi-Annual Report includes the following sections:
(a) "Administrative Review of Suicides." This summarizes the 24-hour, 7day, and 30-day suicide reviews that occurred during the Second and Third Quarters of 2018, which includes the corrective actions the Department took to mitigate suicide risks following these reviews. Based upon CCSB's Report and CHS's Semi-Annual Report, the Monitor remains satisfied that CCSB is ensuring that CHS and the Department are timely and thoroughly conducting administrative review of suicides and serious suicide attempts in the jails as required by Paragraphs 76 and Compliance Measure 77-2(a).
(b) "Patterns and trends and statistical analysis of suicides and serious suicide attempts in the jails." This section breaks down the suicides reviewed in the Second and Third Quarters of 2018 by age, ethnicity, days from arrest, time of day, location, method, and prior self-directed violence. Age and ethnicity are also reported as the rate per 100,000 inmates. In this report, CCSB "compare[s] the age distribution of inmates who committed or engaged in self-directed violence to that of the inmate population overall both by acts of self-directed violence more generally, and specifically, acts of selfdirected violence deemed to be 'critical incidents' by the Correctional Health Services (CHS) self-directed violence review team," and also calculates rates per thousand inmates in various age groups to "develop benchmarks by which incidents of self-directed violence can be tracked according to the age of the inmate[.]" The report analyzes the three suicides in the Second and Third Quarter of 2018, the 426 SDV incidents, and 18 CIRC incidents by age, compared to the inmate populations in each age group and per thousand inmates.39 It concludes "that inmates in the age categories 26-34 and 35-39 years old are at a higher risk of self-directed violence." This more detailed statistical analysis satisfies the requirements of Compliance Measure 77(b), but it is limited to age groups.40
(c) "Corrective actions taken by the department to mitigate suicide risks." This section summarizes the status of "a total of 74 CAP/Issues related to 19 serious suicide attempts that were reviewed during a Critical Incident Meeting,"41 and 24 corrective actions related to three suicides reviewed during the Second and Third Quarters of 2018. CCSB's report of the CAPs discussed at the Executive Inmate Review Committee meetings under the "Administrative Review of Suicides" section above and the CHS's Summary of Recent CIRC Incidents and Data in its Semi-Annual Report reflect that corrective actions are being "taken to mitigate suicide risks." The Mental Health Subject Matter Expert notes that "none of these CAPs were based on analysis of aggregate data or "patterns and trends and statistical analysis of suicides and serious suicide attempts."
39 As CCSB notes, since the CIRC sample size is only 18, "it is difficult to draw any conclusions as the margin of error is about 23%." Since the sample size of the suicides is only three, it is not possible to draw any conclusions from this data. 40 The report indicates that the County is continuing to develop its ability to "track trends and patterns in the area of inmate age groups and future reports may include analysis based on factors such as: the nature of the crime committed, . . . marital status, known gang affiliation and/or other identifying criteria." 41 See CCSB Report, p. 28. The County subsequently noted that there was an error in the CCSB Report and "[t]here were 18 CIRCs during the relevant period, each of which was reviewed in the normal course."
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(d) "Technical issues provided to, or obtained for other administrative units within the Custody Division to address suicide-risk issues." This section vaguely references "[v]arious projects and programs [that] have been developed to help address some of the [undefined] concerns" and notes that there are "incidents that include factors such as mental health, systemic issues, and facility layout/construction projects that will likely result in repeated behaviors until more long-term solutions are put into place." CCSB will be "responsible for monitoring the implementation and tracking of CAPs to address the issues identified." It does not appear, however, that CCSB provided any technical assistance to other administrative units within the Custody Division in this reporting period.
(e) "Analysis of staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts." This section summarizes, without any analysis, issues in these categories that were identified for the three suicides reviewed during the Second and Third Quarters of 2018.
(f) "Remedial measures, including policy revisions, re-training, or staff discipline, to address issues related to suicide and serious suicide attempts." This section consists of a table that summarizes the measures taken to address issues related to the three suicides reviewed during the Second and Third Quarters.
(g) "Summaries of meeting with DMH to develop, implement, and track corrective action plans." This section reports that "CCSB, and CHS (Mental and Medical Health) are involved in the CIRC and Joint Quality Improvement Committee (“JQIC”) meetings. Corrective action plans are primarily identified and discussed at CIRC meetings. At every JQIC meeting, there is follow up to verify that the CAP(s) have been addressed and assigned, also the individual assigned to the CAP should verify their effectiveness. CCSB tracks all suicide-related CAPs, whether they are CHS or LASD CAPs, and does so continuously outside of the CIRC and JQIC context." There were a total of 6 JQIC meetings during the Second and Third Quarters of 2018 that discussed 74 CAP/Issues identified during CIRC meetings.
Because the County is no longer subject to monitoring for compliance with Paragraph 24, which requires the County and the Sheriff "to review and inspect housing areas on at least an annual basis to identify suicide hazards," it is incumbent on CCSB to track the County's implementation of its Suicide Hazard Mitigation Plans and the corrective actions to address suicide hazards identified in the annual inspections. This is not, however, captured in either of CCSB's Semi-Annual Reports or other postings.
CCSB is to be commended for the work it has done to facilitate the implementation of various provisions of the Settlement Agreement. Paragraph 77 also requires the unit "to oversee the County's jail suicide prevention program in coordination with [CHS]" and Paragraphs 60 and 62 impose obligations on CCSB to work with CHS to "implement a quality improvement plan to identify and address clinical issues that
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place prisoners at significant risk of suicide and self-injurious behavior" and "develop, implement and track corrective action plans addressing recommendations of the quality improvement program."
Coordination between CCSB and CHS is improving, and they are tracking and sharing data related to suicides and self-directed violence, but not other measures. They are beginning to share and track suicide-related data (as per Paragraphs 61(a) and 77(b)), but not data related to other areas in which custody has some role, such as access to care, administration of psychotropic medications, and clinical restraints (as per Paragraph 61(b), (c), and (d)). Further, Custody's focus is primarily a matter of investigation and fixing case-specific problems, rather than gathering and analyzing aggregate data to detect system-wide problems. For example, the determination of whether an inmate can be brought out of his or her cell for therapy or must be seen by the clinician at the cell front instead is an access to care issue. While Custody necessarily has an important role in facilitating this clinical determination, there are HOH inmates who do not come out of their cells because they are deemed too dangerous, and therefore they are not receiving the access to care they need to treat their mental illness. The extent to which HOH inmates are not coming out of their cells and the reasons they are not coming out are not being tracked and assessed by Custody and CHS to ascertain the extent to which this is a significant access to care problem, and what systemic improvements can be identified, implemented and measured.
While CAPS identified at the CIRC and JQIC meetings are reviewed on a caseby-case basis, there is, as noted by the Mental Health Subject Matter Expert, "no evidence that aggregate data are being used to determine whether there are system-wide problems." He observes that:
There has been continued improvement in the tracking, coordination and follow through of case-specific CAPs. The use of Longitudinal Improvement Projects (LIPs) is also a sound development, but there needs to be more focused and targeted measures associated with these projects. A good example is the repeated problem of contraband associated with self-directed violence. The only reference to any effort to address this is repeated cell searches, but there are no targets, no method to determine efficacy, and no evidence that this problem has been reduced, despite being repeatedly identified as a problem.
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of May 11, 2016, through May 18, 2017)
Substantial Compliance requires (1) the Committee to meet twice per year and (2) "recommend coordinated approaches to suicide prevention in the Jails."
The County maintained Substantial Compliance with Paragraph 78 for twelve consecutive months as of May 18, 2017, and this provision was not subject to monitoring in the Seventh Reporting Period. The County has continued the Bi-Annual Suicide Prevention meetings and reports that 73 participants from various County departments attended the most recent meeting on November 7, 2018.
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; describe the medication support services available for prisoners not in mental health housing who are receiving psychotropic medications; and review electronic medical records of such to confirm that medication support services were provided to these prisoners.
The County’s Seventh Self-Assessment reports that in the Second Quarter of 2018, 56% of the prisoners who resided outside of mental health housing and were receiving psychotropic medications were "provided with medication support services," which is below the 85% threshold required by Compliance Measure 79.5(d) for Substantial Compliance. The County's Augmented Seventh Self-Assessment reports that in the Third Quarter of 2018, 51% of these prisoners were provided with medication support services.
As in the past, the County has "determined that a shortage of medical doctors treating patients in the general population hindered its ability to comply with this Provision." The County also acknowledges that, "[a]s noted in previous reports by the Monitor, the Subject Matter Expert determined that Compliance Measures 79-1(a-c) and 79-5(b), governing therapeutically appropriate treatment to inmates in HOH and MOH units, are not yet ripe for evaluation as the County is not yet able to render structured treatment according to methods reflected in treatment plans. The County continues to dedicate resources to improving treatment planning and the quality of individual and group therapeutic services."
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business workday. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

NON-COMPLIANCE

Paragraph 80 requires that, "no later than 18 months after the Effective Date [July 1, 2015]," 100% of the prisoners in HOH receive "ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week." The parties have agreed that up to five hours of the structured time can consist of education or work programs, but at least five hours of the time must be therapeutic.

The County's Seventh Self-Assessment reports that in the Second Quarter of 2018, 26% of the prisoners at CRDF and 84% of the prisoners at TTCF were offered the required 10 or more hours of unstructured, out-of-cell recreational time, which is wellbelow the 100% threshold for both unstructured recreational time and structured therapeutic or programming.

The County's Seventh Self-Assessment also reports that "[w]ith respect to the structured out-of-cell time, CHS is in the process of piloting an electronic system that allows clinicians, and not Custody staff, to track structured out-of-cell time offered. . . . The County also continues to work on expanding staffing so that it may offer additional group therapy sessions and a wider variety of group sessions such that patients receive clinically appropriate offerings."

The Mental Health Subject Matter Expert and the clinicians observed HOH pods at CRDF and TTCF in the Seventh Reporting Period, and they "coded" out-of-cell time for inmates in the pods. The Mental Health Subject Matter Expert "continues to have substantial concerns with the tracking of this data," and he also reports that:

Virtually all the structured out-of-cell activities were mental health groups and occasional meetings with mental health clinicians. The unstructured out-of-cell time mostly consisted of unstructured dayroom time with a minority of the time being constituted by showers, yard time, and stray activities.

As before, about half of the inmates did not come out of their cells, at all. . . .On average, out-of-cell time for structured activities remained about the same as [in the prior reporting period] at only about 25 minutes but unstructured time increased from an average of 88 minutes to 142 minutes per day.

The Department believes that increasing the "numbers of HOH pods allowing inmates out unrestrained. . .will likely continue to afford more unstructured out of cell time."

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81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
Policies approved by the Rosas Monitors and adopted by the Department in the First Reporting Period implemented the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
In the Second Reporting Period, the Rosas Monitors approved policies to implement the following provisions of the Rosas Implementation Plan: Paragraphs 6.16.20 (grievance system); Paragraph 8.2 (combining "Complaints of Retaliation"). They also approved revised policies to implement Paragraphs 13.1-13.2 (discipline for PREA violations, dishonesty, and failure to report force incidents).
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 of the Rosas Implementation Plan reflect training requirements that were supposed to be, but were not, completed by December 31, 2016. This is due in part to the delays that have occurred in the review and approval of the Department's use of force and investigations training program. The Monitor's auditors will review the Department's training records and verify the Department's compliance with the training requirement of the Rosas plan at CRDF, NCCF, PDC North, PDC South, and PDC East.
On July 10, 2018, the Department presented to the Rosas Monitors its Custody
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Operations Employee Review System it has implemented "to facilitate the identification, tracking, analysis, and review of specific employee-related incidents and issues." The system generates monthly reports reflecting use of force, grievances against staff, and Watch Commander Service Comment Reports for individual employees over a three month period to identify potentially problematic employees. The Rosas Monitors concluded that this system addresses the requirements of Paragraphs 19.1, 19.2, and 19.3 of the Rosas plan for an Early Warning System. The Department implemented the Employee Review System as a pilot program at the Downtown Jail Facilities on July 27, 2018, and expanded it throughout Custody Operations on October 25, 2018. As a result, the Department implemented all of the provisions of the Rosas Plan at NCCF, CRDF, PDC North, and PDC South and achieved Substantial Compliance with Paragraph 81 as of October 25, 2018. The Department is subject to monitoring of its compliance with the Rosas Plan at these facilities for the 18-month period required under the Rosas Settlement Agreement.
Paragraphs 4.10 and 9.1 of the Rosas Implementation Plan are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Accordingly, the Department has implemented all of the provisions of the Rosas Implementation Plan.
In the Seventh Reporting Period, the Monitor reviewed 31 randomly selected completed force packages for CRDF, NCCF, PDC North, and PDC South. Packages that the Monitor concluded raised an issue were also reviewed by the recently retained Use of Force Subject Matter Expert Susan McCampbell. Overall, the Monitor concluded that the Department is complying with its policies regarding the use and reporting of force incidents at NCCF, CRDF, PDC North, and PDC South,42 and that the force investigations are thorough and complete. There were two cases in which the Monitor concluded that the force was not in compliance with the applicable provisions of the Rosas Plan,43 and one case in which reporting and investigation of the force was not in compliance with the other applicable provisions of the plan. Of the two cases in which the Monitor concluded that the force was out of policy, one involved the use of a chemical spray against a naked inmate during the intake process and the other punches to the head of a restrained inmate. In the first case, the Monitor concluded that the reporting and investigation were also out of policy because the reports were not consistent with the video footage of the incident.44 In the latter case, the Department also found that the force was out of policy, but the Department determined that the Deputy Sheriff should receive additional training rather than discipline for the violation. Given that over 93%
42 With the exception of one force incident at South, all of the other force incidents reviewed by the Monitor during the Seventh Reporting Period were captured on the CCTVs at CRDF, NCCF, and PDC North. 43 In a third case at PDC South, the Monitor was not able to reach a conclusion regarding the force as the accounts of the involved deputy and the inmate were in conflict and the incident was not captured on the CCTV. 44 The Monitor's finding regarding the reporting and investigation of the force used in this case does not affect the Substantial Compliance finding with respect to Provision 84, which focuses on the timeliness of the completion of the investigations.
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of the force incidents complied with the Rosas use of force provisions and over 96% of the reports and investigations complied with the Rosas reporting and investigation provisions, the Monitor concluded that the Department achieved Substantial Compliance with these provisions at the facilities outside of the Downtown Jail Complex during the Seventh Reporting Period.
During the Seventh Reporting Period, the Monitor met with the Inmate Grievance Teams at CRDF and NCCF and with the Division Inmate Grievance Coordinator who has oversight responsibility for the implementation of the new grievance system. The grievance teams at both CRDF and NCCF have made significant improvements in the tracking of inmate grievances, reducing the back-log of overdue grievance investigations and closing out investigations that had been open for more than 30 days at their institutions. The Division Inmate Grievance Coordinator provided the Monitor with his Executive Reports: Statistical Analysis and Trends through the Third Quarter of 2018 (with a comparison to the Second Quarter of 2018) and for the months of November and December 2018, broken down by facility and with response times in compliance with the 15-day response required by the Rosas Plan. The Division Inmate Grievance Coordinator has done an outstanding job creating a new system for handling inmate grievances and in tracking and reporting on the effectiveness of this new system. The Monitor believes that the Department has achieved Substantial Compliance with the grievance provisions of the Rosas Plan at NCCF, CRDF, PDC North, and PDC South, which are the facilities covered by Paragraph 81.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 15, 2016, through December 31, 2017)
The Rosas Monitors have approved a de-centralized inmate grievance system, which includes an Inmate Grievance Team co-located at Century Regional Detention Facility. The Department published its new grievance policies on July 15, 2016.
CRDF has its own Inmate Grievance Team with the staffing required by CDM 801.020.00. The Monitor met with CRDF's Inmate Grievance Team during the Sixth Reporting Period and reviewed the operation of the grievance system at CRDF.
Pursuant to Paragraph 111 of the Settlement Agreement, the County was not subject to monitoring for Substantial Compliance with Paragraph 82 in the Seventh Reporting Period.
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83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement ("Common Areas"), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2015, through June 30, 2016 at MCJ and IRC)
SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at TTCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 at CRDF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through September 30, 2018, at NCCF and PDC North)
SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through September 30, 2018 at PDC South)
The Monitor visited NCCF and PDC North on April 4, 2018, and confirmed that the closed circuit security cameras were operational in Common Areas at those facilities. The Department subsequently ordered and installed an additional eight cameras to cover blind spots at PDC North. On July 12, 2018, the Department submitted a report showing all of the cameras requested were installed and operational at NCCF, PDC North, and PDC South.
Paragraph 83 also requires the Department to provide evidence that all video recordings of force incidents were adequately stored and retained for a period of at least one year after the force incident occurs. The County's Sixth Self-Assessment reported that it has achieved Substantial Compliance for this measure at CRDF in the Fourth Quarter of 2017.
The County's posted results for NCCF, PDC North, and PDC South reflect that the Department achieved Substantial Compliance at these facilities in that all of the video recordings of all force incidents at PDC North and South of randomly selected force incidents at NCCF in the Second and Third Quarters of 2018 "were stored and retained
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by the Department." The Monitor reviewed the video recordings and confirmed that the Department's videos depict the force incidents on the Department's inventory.45
In order to maintain Substantial Compliance, however, the Department must show that "90% of the force incidents on the quarterly lists. . . are on the inventory provided by the Department one year after the force incident." This requires the Department to show that force incidents that occurred in the first year after the cameras were installed be on the inventory one year after the incident. This means that NCCF and PDC North are subject to this requirement of Paragraph 83 until March 31, 2020, and PDC South is subject to it until June 30, 2020.
The County previously maintained Substantial Compliance with Paragraph 83 at IRC, MCJ, TTCF, and CRDF for twelve consecutive months and was not subject to monitoring at these facilities during the Seventh Reporting Period.
45 One force incident at PDC South in the Second Quarter was, however, too blurry to be able to see what actually happened. Since this was before all of the cameras were installed at PDC South, it occurred before the Department achieved Substantial Compliance at South.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:
(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and
(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through June 30, 2018 (verified))
Substantial Compliance under the Compliance Measures requires the Department to demonstrate that 95% of the investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies.46
The County’s Seventh Self-Assessment reports that the Department maintained Substantial Compliance in the Second Quarter of 2018. The Department concluded that "100% -- rather than the required 95% -- of investigations of force incidents which involved a violation of policy or misconduct were completed and administrative action was timely taken pursuant to 84-2." The reported results have been verified by the Monitor's auditors. As a result, the Department has maintained Substantial Compliance with Paragraph 84 for twelve months and is no longer subject to monitoring for compliance with this provision.
46 The Monitor's determination of the Department's compliance with Paragraph 84 is largely based upon the timeliness of the completion of the investigations, but the Monitor also previously reviewed several internal investigations, which appeared to be thorough and unbiased.
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85. The County and the Sheriff will ensure that Internal Affairs Bureau management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: NON-COMPLIANCE Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training. The County's posted results show that only 63% of the IAB investigators completed all three of the required courses as of the end of the Third Quarter of 2018.
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86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 at MCJ and CRDF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2017 at PDC North)
SUBSTANTIAL COMPLIANCE (as of February 1, 2017, through March 31, 2018 at PDC South and PDC East)
SUBSTANTIAL COMPLIANCE (as of March 1, 2017, through March 31, 2018 at NCCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 at IRC)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through December 31, 2018 at TTCF)
CDM 7-08/080 ACCOUNTABILITY OF SPECIALWEAPONS, effective October 14, 2016, requires each facility to have unit orders that "establish procedures for the storage, issuance, reissuance, accountability, maintenance, and periodic inventory of all weapons. . . stored at, or issued from, the facility," which includes detailed requirements for the "Inventory, Control, and Accountability of Aerosol Chemical Agents."
In addition to providing written policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment, Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with up-to-date Unit Orders for each jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons.
The Monitor and Use of Force Subject Matter Expert inspected the armories at TTCF on September 17, 2018, and noted the continued improvement and that the inventory logs were checked daily in the TTCF armories.
The Department previously maintained Substantial Compliance with Paragraph 86 for twelve consecutive months at MCJ, CRDF, PDC North, PDC South, PDC East, IRC, and NCCF. Pursuant to Paragraph 111, these were not subject to monitoring in the Seventh Reporting Period.
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PROVISION NO.

STATUS

SUBSTANTIAL COMPLIANCE DATES

18 Suicide Prevention Training Substantial Compliance (MCJ, NCCF, PDC South, PDC East, TTCF, IRC, PDC North, & CRDF)

(10/1/17 at MCJ & PDC South)1 (9/1/17 at NCCF) (12/1/17 at PDC East) (4/1/18 at TTCF, IRC, & PDC North) (6/1/18 at CRDF)

19 Crisis Intervention &

Substantial Compliance (MCJ,

Conflict Resolution Training NCCF, IRC, & TTCF)

Partial Compliance (CRDF)

(4/1/18 at MCJ, NCCF & IRC) (7/1/18 at TTCF)

20 Training at NCCF, PDC and Substantial Compliance (PDC

CRDF

East, PDC North, PDC South,

NCCF, & CRDF)

(8/1/17 at PDC East, PDC North, NCCF, & CRDF) (10/1/17 at PDC South)

21 CPR Certification

Substantial Compliance (NCCF, PDC East, PDC North, PDC South, TTCF, IRC, MCJ, & CRDF)

(10/1/15 – 9/30/16 at PDC East & PDC South) (1/1/16 – 12/31/16 at NCCF, PDC North, & IRC) (4/1/16 – 3/31/17 at TTCF) (10/1/17 – 9/30/18 at MCJ) (7/1/18 – 9/30/18 at CRDF)

22 Use of Arresting and Booking Documents

Substantial Compliance

(7/1/16 – 6/30/17)

1 Substantial Compliance Dates in bold reflect that the Department has achieved Substantial Compliance with the training requirements or maintained Substantial Compliance for twelve consecutive months with the other requirements; the results were verified by the Monitor's auditors when required; and the County or designated facilities are no longer subject to monitoring of this provision pursuant to Paragraph 111 of the Settlement agreement.

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23 Suicide Hazard Mitigation Plans

Substantial Compliance

24 Suicide Hazard Inspection Substantial Compliance

25 Transportation of Suicidal Inmates (station jails)

Partial Compliance

26 Identification and Evaluation Partial Compliance of Suicidal Inmates

27 Screening for Mental Health Partial Compliance Care and Suicide Risk

28 Expedited Booking of Suicidal Inmates

Substantial Compliance (IRC) Partial Compliance (CRDF)

29 Mental Health Assessments Substantial Compliance (of non-emergent mental health needs)

30 Initial Mental Health Assessments & Treatment Plans

Partial Compliance

31 Electronic Medical Records Partial Compliance Alerts

32 Electronic Medical Records Substantial Compliance – Suicide Attempts

33 Supervisor Reviews of

Substantial Compliance

Electronic Medical Records

34 Discharge Planning

Stayed Pending Litigation

35 Referral for Mental Health Care

Substantial Compliance

(7/12/18) (10/1/17 – 9/30/18)
(4/1/17 – 3/31/18 at IRC) (4/1/17 – 3/31/18)
(1/1/16 – 12/31/16) (7/1/16 – 6/30/17) (11/1/17 – 9/30/18)

36 Assessments After Triggering Events
37 Court Services Division Referrals

Partial Compliance Partial Compliance

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38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

(1/1/16 – 12/31/16)

39 Confidential Self-Referral

Substantial Compliance (NCCF & PDC North) Partial Compliance (TTCF, MCJ, & CRDF) Not Rated (PDC South & East)

(7/1/17 – 6/30/18 at NCCF) (7/1/18 – 9/30/18 at PDC North)

40 Availability of QMHPs

Partial Compliance

41 FIP Step-Down Protocols

Partial Compliance

42 HOH Step-Down Protocols Partial Compliance

43 Disciplinary Policies

Substantial Compliance (NCCF & PDC North) Partial Compliance (CRDF, MCJ, & TTCF)

(10/1/17 – 9/30/18 at NCCF & PDC North)

44 Protective Barriers

Substantial Compliance

(1/1/16 – 12/31/16)

45 Suicide Intervention and First Aid Kits

Substantial Compliance

(10/1/15 – 9/30/16 at CRDF, NCCF, TTCF, PDC East, & PDC South) (1/1/16 – 12/31/16 at MCJ & PDC North)

46 Interruption of Self-Injurious Partial Compliance Behavior

47 Staffing Requirements

Non-Compliance

48 Housekeeping and Sanitation Substantial Compliance

(1/1/16 – 12/31/16)

49 Maintenance Plans

Substantial Compliance

(3/1/16 – 2/28/17)

50 Pest Control

Substantial Compliance

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC North, TTCF, & CRDF) (4/1/16 – 3/31/17 at PDC South & PDC

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51 Personal Care & Supplies
52 HOH Property Restrictions 53 Eligibility for Education,
Work and Programs 54 Privileges and Programs2 55 Staff Meetings
56 Changes in Housing Assignments
57 Inmate Safety Checks in Mental Housing
58 Inmate Safety Checks in Non-Mental Housing

Substantial Compliance
Partial Compliance Partial Compliance

East)
(1/1/16 – 12/31/16 at MCJ, NCCF, PDC East, PDC North, PDC South, & TTCF) (7/1/16 – 6/30/17 at CRDF)

Partial Compliance

Substantial Compliance (CRDF, PDC North, & MCJ) Partial Compliance (TTCF)

(10/1/16 – 9/30/17 at CRDF) (4/1/17 – 3/31/18 at PDC North) (4/1/18 – 9/30/18 at MCJ)

Substantial Compliance

(1/1/16 – 12/31/16)

Substantial Compliance (MCJ) Partial Compliance (PDC North, TTCF, & CRDF)

(4/1/17 – 3/31/18 at MCJ)

Substantial Compliance (PDC South, PDC North, PDC East, CRDF, & IRC) Partial Compliance (TTCF, NCCF, & MCJ)

(1/1/16 – 12/31/16 at PDC South, PDC North, & PDC East) (7/1/17 – 6/30/18 at CRDF) (10/1/17 – 9/30/18 at IRC)

2 Per agreement of the parties, the County must maintain Substantial Compliance for two additional quarters under the revised Compliance Measures.

Case 2:15-cv-05903-DDP-JEM Document 148 Filed 02/28/19 Page 121 of 124 Page ID APP#E:3N2D8I9X A

59 Supervisor Rounds
60 Implementation of Quality Improvement Program
61 Requirements of Quality Improvement Program
62 Tracking of Corrective Action Plans

Substantial Compliance (at PDC North, PDC East, MCJ, CRDF, PDC South, NCCF, & TTCF)

(1/1/17 – 12/31/17 at PDC East & MCJ) (4/1/17 – 3/31/18 at NCCF) (10/1/17 – 9/30/18 at CRDF) (1/1/18 – 9/30/18 at PDC North & PDC South) (4/1/18 – 9/30/18 at TTCF)

Partial Compliance

Partial Compliance

Partial Compliance

63 Sufficient HOH and MOH Housing
64 Plans for Availability of Inpatient Health Care

Non-Compliance Partial Compliance

65 Administration of Psychotropic Medication
66 Active Mental Health Caseloads
67 Prisoner Refusals of Medication
68 Contraband Searches

Partial Compliance

Non-Compliance

Non-Compliance

Substantial Compliance (MCJ, NCCF, PDC East, PDC South PDC North, & TTCF) Partial Compliance (CRDF)

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC East, PDC South, & PDC North) (1/1/17 – 12/31/17 at TTCF)

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69 Clinical Restraints in CTC Substantial Compliance

70 Security Restraints in HOH Partial Compliance and MOH

71 Therapeutic Services for

Substantial Compliance

Inmates in Clinical Restraints

72 Administrative Reviews

Substantial Compliance

73 Reporting of Self-Injurious Behavior and Threats

Substantial Compliance

74 Law Enforcement Investigations of Suicides

Substantial Compliance

75 Management Reviews of Suicide Attempts

Substantial Compliance

76 Management Reviews of Suicides

Substantial Compliance

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Substantial Compliance Committee

79 Therapeutic Services in Mental Health Housing

Non-Compliance

80 Out-of-Cell Time in HOH Non-Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

82 Grievances at CRDF

Substantial Compliance

(7/1/18 – 9/30/18) (7/1/16 – 6/30/17) (1/1/17 – 12/31/17)3 (10/1/17 – 9/30/18) (9/1/16 – 12/31/17) (10/1/17 – 9/30/18) (9/1/16 – 12/31/17)
(5/11/16 – 5/18/17)
(7/15/16 – 12/31/17)

3 Subject to further verification.

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83 Closed Circuit Cameras
84 Investigation of Staff Misconduct
85 Internal Affairs Bureau Training
86 Maintenance and Inventory of Security Equipment

Substantial Compliance (MCJ, TTCF, IRC, CRDF, NCCF, PDC North, & PDC South)
Substantial Compliance

(7/1/15 – 6/30/16 at MCJ & IRC) (10/1/15 – 9/30/16 at TTCF) (4/1/16 – 3/31/17 at CRDF) (4/1/18 – 9/30/18 at NCCF & PDC North) (7/1/18 –9/30/18 at PDC South
(7/1/17 – 6/30/18)

Non-Compliance

Substantial Compliance (MCJ, CRDF, PDC North, PDC South, PDC East, NCCF, IRC, & TTCF)

(4/1/16 – 3/31/17 at MCJ & CRDF) (10/1/16 – 12/31/17 at PDC North) (2/1/17 – 3/31/18 at PDC South & PDC East)
(3/1/17 – 3/31/18 at NCCF) (4/1/17 – 3/31/18 at IRC) (4/1/18 – 12/31/18 at TTCF)

Case 2:15-cv-05903-DDP-JEM Document 148 Filed 02/28/19 Page 124 of 124 Page ID APP#E:3N2D9I2X B

First4 Second Third Fourth Fifth Sixth Seventh

Substantial Partial

Non-

Substantial

Compliance Compliance1 Compliance Compliance

(Provisions)

(Facilities)2

5

16

10

14

30

13

24

22

27(1)

10

29

24

26(1)

10

29

23

24(2)

7

34

32

22

7

38

31

22

7

39

No Longer Subject To Monitoring3
4(2) 10(2) 15(5) 18(9) 23(11)

1 The figure in parenthesis under Partial Compliance is the number of additional provisions where some facilities were in Partial Compliance and other facilities were in NonCompliance.
2 This represents the number of provisions where the Department is in Substantial Compliance at all or some of the facilities.
3 The figure in parenthesis under No Longer Subject to Monitoring is the number of additional provisions where some facilities are no longer subject to monitoring.
4 During the First Reporting Period, 43 provisions were not subject to monitoring.

 
 Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 1 of 127 Page ID #:3293

1 SCHEPER KIM & HARRIS LLP

2

RICHARD E. DROOYAN (Bar No. 65672) 601 West Fifth Street, 12th Floor

3 Los Angeles, CA 90071-2025

4

Telephone: (213) 613-4655 Facsimile: (213) 613-4656

5 Monitor
6

7

8

UNITED STATES DISTRICT COURT

9

CENTRAL DISTRICT OF CALIFORNIA

10

WESTERN DIVISION

11

12 UNITED STATES OF AMERICA,

13

Plaintiff,

14

15

v.

CV No. 15-05903 DDP (JEMX) MONITOR’S EIGHTH REPORT

16 COUNTY OF LOS ANGELES AND

17

LOS ANGELES COUNTY SHERIFF JIM MCDONNELL, in his Official

Capacity,

18

Defendants.

19

20

21

22

23

24

25

26

27

28

Case No. CV No. 15-05903 DDP (JEMX) MONITOR'S EIGHTH REPORT

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 2 of 127 Page ID #:3294

1

Pursuant to the Paragraph 109 of the Joint Settlement Agreement Regarding

2 Los Angeles County Jails, the Monitor appointed by this Court hereby submits the

3 attached Report “describing the steps taken” by the County of Los Angeles and the

4 Los Angeles County Sheriff during the six-month period from January 1, 2019,

5 through June 30, 2019, “to implement the Agreement and evaluating the extent to

6 which they have complied with this Agreement.” This Report takes into

7 consideration the advice and assistance I have received from the Subject Matter

8 Experts appointed by this Court and the comments from the parties in accordance

9 with Paragraph 110 of the Agreement. I am available to answer any questions the

10 Court may have regarding my Report at such times as are convenient for the Court

11 and the parties.

12

13 DATED: August 30, 2019

Respectfully submitted,

14

SCHEPER KIM & HARRIS LLP

15

RICHARD E. DROOYAN

16

17

18

By: /s/ Richard E. Drooyan Richard E. Drooyan

19

Monitor

20

21

22

23

24

25

26

27

28

1

Case No. CV No. 15-05903 DDP (JEMX)

MONITOR'S EIGHTH REPORT

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 3 of 127 Page ID #:3295
MONITOR’S EIGHTH REPORT
This Eighth Report sets forth the Monitor’s assessments of the implementation of the Settlement Agreement (the "Agreement") between the County of Los Angeles (the "County") and the United States Department of Justice ("DOJ") for the treatment of mentally ill inmates in the County’s jail facilities by the Los Angeles Sheriff’s Department (the "Department") and the County's Department of Health Services ("DHS").1 It covers the County's reported results for the period from January 1, 2019, through June 30, 2019 (the "Eighth Reporting Period").
As used herein, "Substantial Compliance" means that the County has "achieved compliance with the material components of the relevant provisions of this Agreement in accordance with the [agreed-upon Compliance Measures for assessing Substantial Compliance]," which it must maintain for twelve-consecutive months; "Partial Compliance" means that the County has achieved "compliance on some, but not all, of the material components of the relevant provision of this Agreement;" and "NonCompliance" means that the County has not met "most or all of the material components of the relevant provisions of this Agreement."
This Eighth Report is based upon the Monitor's review of the policies, procedures, and directives proposed and/or implemented by the Department and Correctional Health Services ("CHS") in the Eighth Reporting Period; tours of the jails by the Monitor; and assessments and observations of the Subject Matter Experts and the two clinicians retained by the Monitor to assist the Mental Health Subject Matter Expert. It takes into consideration the County’s Self-Assessment Status Report (the "Eighth SelfAssessment"), which was received on June 14, 2019; the Semi-Annual Report of the Department's Custody Compliance and Sustainability Bureau ("CCSB"), which was received on July 11, 2019; the County's Augmented Self-Assessment Status Report (the "Augmented Eighth Self-Assessment"), which was received on July 15, 2019; CHS's Semi-Annual Report on Quality Improvement/Assurance, which was received on July 15, 2019; and results reported by the County through July 15, 2019. It also takes into consideration the comments the Monitor received from the County and DOJ on the draft of this Report that was submitted to the parties on August 1, 2019.
During the Eighth Reporting Period, the Mental Health Subject Matter Expert, with the assistance of the clinicians, conducted additional qualitative assessments of the County's compliance with certain Substantive Provisions in the Settlement Agreement, and they again used different methodologies to test some of the County's reported results. The Monitor's determination of the County's compliance, with the advice of the Subject Matter Expert, is based upon the quantitative thresholds in the Compliance Measures (and any other applicable requirements in the Compliance Measures), unless the quality of the County's performance as determined by the qualitative assessment is plainly inadequate or the results reported by the Subject Matter Expert vary significantly from the results reported by the Department.
1 The Department of Health Services includes Correctional Health Services, which is responsible for Medical and Mental Health Services in the Los Angeles County jails.
1

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During the Eighth Reporting period, the County established compliance with additional provisions of the Settlement Agreement, and made progress in addressing the challenges to achieving and maintaining Substantial Compliance with respect to its quality improvement plans. It still faces significant challenges with respect to therapeutic services and out-of-cell time.
As in prior reports, this Eighth Report reflects the results of audits by the Monitor's auditors to verify results reported by the County. The Monitor has deemed the County to be in Substantial Compliance "as of" the beginning of the quarter reported by the County if the auditors have verified that the County has met the thresholds in the Compliance Measures. If the auditors were not able to verify the results reported by the County, the twelve-month period for maintaining Substantial Compliance will commence in a future period when the County's reported results are verified by the auditors. If the County maintains Substantial Compliance with a provision for twelve consecutive months, pursuant to Paragraph 111 of the Agreement, the Monitor and Subject Matter Experts will "no longer. . .assess or report on that provision" in future reporting periods.
Some of the Substantial Compliance results reported by the County in the Eighth Reporting Period have not been audited by the Monitor’s auditors and cannot be considered final until verified by the auditors. The County will not be deemed to be in Substantial Compliance as of the County's reported date for purposes of determining the twelve-month compliance period if the results are not verified by the auditors.
Appendix A to this Eighth Report shows the status of each of the 69 provisions of the Agreement that are subject to monitoring and the twelve-month triggering dates where the County is deemed to be in Substantial Compliance. Appendix B shows the County's progress from the Initial Reporting Period through the Eighth Reporting Period in achieving Substantial Compliance and in maintaining Substantial Compliance for twelve consecutive months on provisions that are no longer subject to monitoring.
As has been the case since the beginning of the Initial Reporting Period, the County cooperated completely with the Monitor and the Subject Matter Experts during the Eighth Reporting Period. The Department, CHS, and County Counsel facilitated our visits and inmate interviews, answered our questions, and responded to our requests for documents and information. We appreciate their responsiveness, transparency, professionalism, and courtesy in handling our monitoring requests.
Richard Drooyan, Monitor August 30, 2019
2

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EXECUTIVE SUMMARY
There are 69 provisions in the Settlement Agreement that are subject to monitoring by the Monitor and Subject Matter Experts. As of the date of this Report, the County and the Department are in Substantial Compliance with 36 provisions, in Partial Compliance with 18 provisions, and in Non-Compliance with seven provisions. In addition, there are six provisions in which the Department is in Substantial Compliance at some facilities and in Partial Compliance or Non-Compliance at other facilities. There is also one provision (Paragraph 34), that remained stayed pending litigation initiated by third party intervenors, and one provision (Paragraph 39) for which the Department is in Substantial Compliance at certain facilities, Partial Compliance at other facilities, and Not Rated at other facilities. There are 42 provisions for which the County and the Department are in Substantial Compliance at some or all of the facilities.2
There are 28 provisions that are no longer subject to monitoring because the County and Department maintained Substantial Compliance for twelve consecutive months as required by Paragraph 111 of the Settlement Agreement as verified by the Monitor's auditors as required.3 There are another nine provisions for which some facilities are no longer subject to monitoring because those facilities maintained Substantial Compliance for the required twelve consecutive months.4
As of the date of this Report, and subject to verification by the Monitor's auditors and qualitative assessments in some cases, the County and the Department are in Substantial Compliance at some or all of the facilities with the following provisions of the Settlement Agreement:
The County has achieved Substantial Compliance with Paragraph 18, which requires the training of Deputy Sheriffs and Custody Assistants on suicide prevention as follows: at Men's Central Jail ("MCJ") and Pitchess Detention Center ("PDC") South as of October 1, 2017, at North County Correctional Facility ("NCCF") as of September 1, 2017, at PDC East as of December 1, 2017; and at Twin Towers Correctional Facility ("TTCF"), the Inmate Reception Center ("IRC"), and PDC North as of April 1, 2018. The County has provided documentation reflecting that the County has achieved Substantial Compliance with Paragraph 18 at Century Regional Detention Facility ("CRDF") as of June 1, 2018. The results at CRDF are subject to verification by the Monitor's auditors.
The County has achieved Substantial Compliance at NCCF, MCJ, and IRC as of April 1, 2018; at TTCF as of July 1, 2018; at CRDF, PDC East, and PDC North as of December 1, 2018; and at PDC South as of March 1, 2019, with Paragraph 19, which
2 Under Paragraph 111 of the Agreement, the twelve-month period for which the County is required to maintain Substantial Compliance can be determined on a facility-by-facility basis. 3 This includes the initial training required by Paragraphs 19 and 20, which has been completed and is no longer subject to monitoring. The refresher training requirements are, however, still subject to monitoring. 4 The provisions that are no longer subject to monitoring at some or all of the facilities are highlighted in bold in Appendix A.
3

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 6 of 127 Page ID #:3298
requires the training of Deputy Sheriffs on Crisis Intervention and Conflict Resolution and the training of Deputy Sheriffs and Custody Assistants in working with mentally ill prisoners.
The County has achieved Substantial Compliance at PDC East, PDC North, NCCF, and CRDF as of August 1, 2017 and at PDC South as of October 1, 2017, with Paragraph 20, which requires the training of additional Deputy Sheriffs on Crisis Intervention and Conflict Resolution and on working with mentally ill prisoners.
The County has maintained Substantial Compliance for twelve consecutive months at PDC East, PDC South, PDC North, NCCF, IRC, and TTCF with Paragraph 21, which requires Custody personnel to maintain CPR certifications. The County also has provided documentation that it has maintained Substantial Compliance for twelve consecutive months at MCJ and for nine consecutive months at CRDF. The results for MCJ and CRDF are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months with Paragraph 22, which requires the County and the Sheriff to provide instructional material on the use of arresting and booking documents to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk.
The County has maintained Substantial Compliance for twelve consecutive months as of July 12, 2018, with Paragraph 23, which requires that the Department conduct a systematic review of prisoner housing to reduce the risk of self-harm and to identify and address suicide hazards, and to develop plans to reasonably mitigate suicide hazards identified in the review.
The County has maintained Substantial Compliance for twelve consecutive months as of September 30, 2018, with Paragraph 24, which requires the Department to conduct annual reviews and inspections of prisoner housing to identify suicide hazards.
The County has achieved Substantial Compliance as of October 1, 2018, through March 31, 2019, with Paragraph 27, which requires that all prisoners are individually and privately screened within 12 hours of their arrival at the jails.
The County has maintained Substantial Compliance for twelve consecutive months at IRC as of March 31, 2018, and for three consecutive months at CRDF as of March 31, 2019, with Paragraph 28, which requires the Department to expedite inmates having urgent or emergent mental health needs through the booking process. The results at CRDF are subject to further verification.
The County has maintained Substantial Compliance for twelve consecutive months as of March 31, 2018, with Paragraph 29, which requires mental health assessments of prisoners with non-emergent mental health needs within 24 hours of the intake nursing assessment.
4

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 7 of 127 Page ID #:3299
The County has provided documentation that it has maintained Substantial Compliance as of January 1, 2019, through March 31, 2019, with Paragraph 30, which requires initial mental health assessments. The results are subject to verification by the Monitor’s auditors.
The County achieved Substantial Compliance at NCCF as of January 1, 2019, through March 31, 2019, with Paragraph 31, which requires that all prisoners are individually and privately screened within 12 hours of their arrival at the jails.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 32, which requires that a serious suicide attempt be entered in the prisoner’s electronic medical record in a timely manner.
The County has maintained Substantial Compliance for twelve consecutive months as of June 30, 2017, with Paragraph 33, which requires mental health supervisors to review electronic medical records on a quarterly basis to assess their accuracy.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2018, with Paragraph 35, which requires the Department to ensure that custody staff refer prisoners who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 38, which requires mental health staff or JMET teams to make weekly cell-by-cell rounds in restricted non-mental health housing modules to identify prisoners with mental illnesses and grant prisoner's requests for out-of-cell interviews.
The County has maintained Substantial Compliance at NCCF as of July 1, 2017, through March 31, 2018, and at PDC South as of October 1, 2018 through March 31, 2019, with Paragraph 39, which requires the County to use a confidential self-referral system for prisoners to request mental health care. The County has also provided documentation reflecting that it achieved Substantial Compliance at NCCF as of April 1, 2018 through June 30, 2018 and at PDC North as of July 1, 2018, through March 31, 2019. The results NCCF and PDC North are subject to verification by the Monitor's auditors and a qualitative assessment by the Subject Matter Expert.
The County has maintained Substantial Compliance at NCCF and PDC North for twelve consecutive months, as of September 30, 2018, with Paragraph 43, which requires the Department to develop and implement policies for discipline of prisoners with serious mental illnesses.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 44, which requires the Department to install protective barriers in High Observation Housing and other mental health housing
5

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 8 of 127 Page ID #:3300
areas.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 45, which requires Suicide Prevention Kits and first-aid kits in control booths in all facilities.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 48, which requires the Department to have written housekeeping, sanitation, and inspection plans to ensure proper cleaning.
The County has maintained Substantial Compliance for twelve consecutive months as of February 28, 2017, with Paragraph 49, which requires the Department to have maintenance plans to respond to routine and emergency maintenance needs.
The County has maintained Substantial Compliance for twelve consecutive months as of March 31, 2017, with Paragraph 50, which requires pest control in the jails.
The County has maintained Substantial Compliance for twelve consecutive months as of June 30, 2017, with Paragraph 51, which requires the Department to ensure that all prisoners have access to basic hygiene supplies in accordance with state regulations.
The County has maintained Substantial Compliance for twelve consecutive months at CRDF and PDC North with Paragraph 55, which requires custody, medical and mental health staff to meet daily in High Observation Housing and weekly in Moderate Observation Housing. The County has also maintained Substantial Compliance as of April 1, 2018, through September 30, 2018 at MCJ. The County also has provided documentation reflecting that it achieved Substantial Compliance as of October 1, 2018, through March 31, 2019, at MCJ. The results at MCJ are subject to verification by the Monitor’s auditors.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2016, with Paragraph 56, which requires custody, medical, and mental health staff to communicate regarding any change in a housing assignment following a suicide attempt or serious change in mental health condition.
The County has maintained Substantial Compliance for twelve consecutive months as of March 31, 2018, at MCJ with Paragraph 57, which requires safety checks in mental health housing.
The County has maintained Substantial Compliance for twelve consecutive months at PDC South, PDC North, and PDC East as of December 31, 2016, at CRDF as of June 30, 2018, and at IRC as of September 30, 2018, with Paragraph 58, which requires safety checks in non-mental health housing.
6

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 9 of 127 Page ID #:3301
The County has maintained Substantial Compliance for twelve consecutive months as of March 31, 2019, with Paragraph 59, which requires unannounced daily supervisory rounds to verify safety checks.
The County has achieved Substantial Compliance with Paragraph 60, which requires the implementation of a quality improvement plan.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, NCCF, PDC East, PDC North, PDC South, and TTCF with Paragraph 68, which requires staggered contraband searches in housing units.
The County has achieved Substantial Compliance as of July 1, 2018, through March 31, 2019, with Paragraph 69, which requires the County and the Sheriff to use clinical restraints only in the Correctional Treatment Center with the approval of a licensed psychiatrist who performed an individualized assessment.
The County has maintained Substantial Compliance for twelve consecutive months as of June 30, 2017, with Paragraph 71, which requires the County and the Sheriff to ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the restraints.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 72, which requires the Department and the County to report on meetings to review suicides and incidents of serious self-injurious behavior.
The County has maintained Substantial Compliance for twelve consecutive months as of September 30, 2018, with Paragraph 73, which requires the Department to prepare detailed reports of prisoners who threaten or exhibit self-injurious behavior.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 74, which requires the Department to have an objective law enforcement investigation of every suicide that occurs in the jails.
The County has maintained Substantial Compliance for twelve consecutive months as of September 30, 2018, with Paragraph 75, which requires the Department and the County to review every serious suicide attempt that occurs in the jails.
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 76, which requires the Department to follow certain procedures whenever there is an apparent or suspected suicide.
The County has maintained Substantial Compliance for twelve consecutive months as of May 18, 2017, with Paragraph 78, which requires the Suicide Prevention Advisory Committee to meet twice a year.
7

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 10 of 127 Page ID #:3302
The County has maintained Substantial Compliance for twelve consecutive months as of December 31, 2017, with Paragraph 82, which requires the Department to co-locate personnel responsible for collecting prisoners' grievances at CRDF.
The County has maintained Substantial Compliance for twelve consecutive months at MCJ, IRC, TTCF, and CRDF with Paragraph 83, which requires it to install closed circuit security cameras throughout all of the common areas in the jails. The County has also achieved Substantial Compliance at NCCF and PDC North as of April 1, 2018, through March 31, 2019, and at PDC South as of July 1, 2018, through March 31, 2019.
The County has maintained Substantial Compliance for twelve consecutive months as of June 30, 2018, with Paragraph 84, which requires investigations of force incidents and administrative actions to be completed timely.
The County has maintained Substantial Compliance for twelve consecutive months as of March 31, 2019, with Paragraph 86, which requires inventory and control of weapons.
8

Case 2:15-cv-05903-DDP-JEM Document 150 Filed 08/30/19 Page 11 of 127 Page ID #:3303
EIGHTH REPORT
18. Within three months of the Effective Date, the County and the Sheriff will develop, and within six months of the Effective Date will commence providing: (1) a four-hour custody-specific, scenario-based, skill development training on suicide prevention, which can be part of the eight-hour training described in paragraph 4.8 of the Implementation Plan in Rosas to all new Deputies as part of the Jail Operations Continuum and to all new Custody Assistants at the Custody Assistants academy; and (2) a two-hour custody-specific, scenario-based, skill development training on suicide prevention to all existing Deputies and Custody Assistants at their respective facilities, which can be part of the eight-hour training described in paragraph 4.7 of the Implementation Plan in Rosas, through in-service Intensified Formatted Training, which training will be completed by December 31, 2016.
These trainings will include the following topics:
(a) suicide prevention policies and procedures, including observation and supervision of prisoners at risk for suicide or self-injurious behavior;
(b) discussion of facility environments and staff interactions and why they may contribute to suicidal behavior;
(c) potential predisposing factors to suicide;
(d) high-risk suicide periods and settings;
(e) warning signs and symptoms of suicidal behavior;
(f) case studies of recent suicides and serious suicide attempts;
(g) emergency notification procedures;
(h) mock demonstrations regarding the proper response to a suicide attempt, including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance;
(i) differentiating between suicidal and self-injurious behavior; and
(j) the proper use of emergency equipment.
9

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STATUS (18):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (verified) at MCJ and PDC South)

SUBSTANTIAL COMPLIANCE (as of September 1, 2017 (verified) at NCCF)

SUBSTANTIAL COMPLIANCE (as of December 1, 2017 (verified) at PDC East)

SUBSTANTIAL COMPLIANCE (as of April 1, 2018 (verified) at TTCF, IRC, and PDC North)

SUBSTANTIAL COMPLIANCE (as of June 1, 2018 (unverified) at CRDF)

The Monitor, in consultation with the Mental Health Subject Matter Expert, concluded in the First Reporting Period that the Department's training on suicide prevention, together with the Department’s De-escalation and Verbal Resolution Training ("DeVRT"), meets the requirements of Paragraph 18. The DeVRT curriculum was approved by the Rosas Monitors and the Monitor, in consultation with the Mental Health Subject Matter Expert, on November 4, 2015. On May 30, 2017, the Monitor, in consultation with the Subject Matter Expert, approved a revision to the two-hour course on suicide prevention for existing Deputy Sheriffs and Custody Assistants.

The County's Initial Self-Assessment Status Report delivered on December 14, 2015, reported that the Department commenced its suicide prevention training for new Deputy Sheriffs and Custody Assistants on July 1, 2015, and for existing Deputy Sheriffs and Custody Assistants before the Effective Date of the Settlement Agreement.

Substantial Compliance is achieved when the Department reaches the 85% threshold for existing personnel at a facility, provided that it has achieved the 95% threshold for new personnel during the entire time from July 1, 2015 until it has reached the 85% threshold for existing personnel.

In the Fifth Reporting Period, the County reported that the Department achieved Substantial Compliance at MCJ and PDC South as of October 1, 2017, and at NCCF as of September 1, 2017. The County's Augmented Fifth Self-Assessment reported Substantial Compliance at PDC East as of November 1, 2017.5 The results at MCJ, PDC South, and NCCF have been verified by the Monitor’s auditors.

The County's Sixth Self-Assessment reported that the County had achieved Substantial Compliance at TTCF (91% of existing personnel), IRC (93%), and PDC North (97%) as of April 1, 2018. The results at TTCF, IRC, and PDC North have been verified by the Monitor’s auditors.

5 All two-hour training of existing Deputy Sheriffs and Custody Assistants occurred after the revision of the suicide prevention course was approved by the Monitor on May 30, 2017.

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The County's posted results report for the Seventh Reporting Period reflected that it had achieved Substantial Compliance at CRDF as of June 1, 2018. The results at CRDF are still subject to verification by the Monitor's auditors.
The Department is no longer subject to monitoring for the training of new Deputies in the Jail Operations Continuum and new Custody Assistants in the Custody Assistant Academy as required by Paragraph 18. The County's Eighth Self-Assessment reiterates, however, that "the Department continuously provides the required training for new Deputies in the Jail Operations Continuum and new Custody Assistants in the Custody Assistants Academy."
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19. Commencing July 1, 2015, the County and the Sheriff will provide:
(a) Custody-specific, scenario-based, skill development training to new Deputies during their Jail Operations training, and to existing Deputies assigned to Twin Towers Correctional Facility, Inmate Reception Center, Men’s Central Jail, the Mental Health Housing Units at Century Regional Detention Facility, and the Jail Mental Evaluation Teams ("JMET") at North County Correctional Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed within the time frames established in that case (currently December 31, 2016). Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2016. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
(b) Commencing July 1, 2015, the County and the Sheriff will ensure that new Custody Assistants receive eight hours of training in the Custody Assistant academy, and that all existing Custody Assistants receive eight hours of training related to identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas. This training will be completed by December 31, 2016. Custody Assistants will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.
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STATUS (19):

SUBSTANTIAL COMPLIANCE (as of April 1, 2018, (verified) at NCCF, MCJ, and IRC)

SUBSTANTIAL COMPLIANCE (as of July 1, 2018, (verified) at TTCF)

SUBSTANTIAL COMPLIANCE (as of December 1, 2018 (verified) at CRDF, PDC East, and PDC North)

SUBSTANTIAL COMPLIANCE (as of March 1, 2019 (verified) at PDC South)

As of November 4, 2015, the Monitor, in consultation with the Mental Health Subject Matter Expert and the Rosas Monitors, approved the curriculum for DeVRT, which provides for 32 hours of Crisis Intervention and Conflict Resolution training and includes eight hours identifying and working with mentally ill prisoners. The DeVRT curriculum meets the requirements of Paragraph 19 of the Settlement Agreement and Paragraphs 4.6, 4.7, and 4.9 of the Rosas Implementation Plan. The Mental Health Subject Matter Expert and the Rosas Monitors approved the training materials developed by the Department for the DeVRT on March 4, 2016.

Substantial Compliance requires the County to show that 95% of the new Deputies hired after July 1, 2015 and 85% of the existing Deputies as of that date received the required DeVRT training. It also requires that 95% of the new Custody Assistants hired after that date and 85% of the existing Custody Assistants as of that date received the required training in working with mentally ill inmates.

The County's Sixth Self-Assessment reported that the Department had achieved Substantial Compliance with respect to the training of existing Deputies and Custody Assistants at IRC, MCJ, CRDF, TTCF, and NCCF (JMET) in the First Quarter of 2018. The Department trained 95% of the existing Deputy Sheriffs and 89% of the existing Custody Assistants at TTCF by the end of the First Quarter of 2018; 100% of existing Deputies and 98% of existing Custody Assistants at IRC; 99% of existing Deputies and 92% of existing Custody Assistants at MCJ; and 100% of the existing Deputies in the JMET unit at NCCF.6

Using the Monitor's approved definition of "unavailable" personnel,7 the Department's revised results for the Sixth Reporting Period reflected that it had trained 98% of the existing Deputies and 88% of the existing Custody Assistants at IRC through March 2018; 99% of the existing Deputies and 85% of the existing Custody Assistants at MCJ through March 2018; and 95% of existing Deputies and 89% of existing Custody Assistants at TTCF through June 2018. These results have been verified by the Monitor's auditors and the Department is no longer subject to monitoring at these Downtown Jail

6 There were no Custody Assistants assigned to the unit. 7 Deputies and Custody Assistants are not deemed "unavailable" unless they have been on leave or
otherwise unavailable for more than six months as of the date of the assessment.

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facilities for the initial training required by Paragraph 19. The County's Seventh Self-Assessment reported that the Department achieved
Substantial Compliance at all facilities for new Deputies and new Custody Assistants through the Third Quarter of 2018. The Eighth Self-Assessment reports that it has achieved Substantial Compliance for the training of new Deputies and new Custody Assistants through the First Quarter of 2019.8 These reported results have been verified by the Monitor's auditors.
The County's Eighth Self-Assessment reports that it trained 100% of the "existing" Deputies at CRDF through the October of 2018, using the approved definition of "unavailable" personnel, and 94% of the existing Custody Assistants through November 2018. These results have been verified by the Monitor's auditors and the Department is no longer subject to monitoring at CRDF for the initial training required by Paragraph 19.
Finally, the Department reports that it trained 93% of the existing Custody Assistants at PDC South as of February 2019, and 94% at PDC North, 100% at PDC East, and 97% at NCCF as of January 2019. These results have been verified by the Monitor's auditors and the Department is no longer subject to monitoring at NCCF, PDC East, PDC South, or PDC North for the initial training of existing Custody Assistants required by Paragraph 19.
The Department is still subject to monitoring in future periods for Substantial Compliance with the refresher course requirements; the Department's reported results will be subject to verification by the Monitor's auditors.
8 The Eighth Self-Assessment reports that "PDC East, South, North and NCCF did not have any staff required to be audited under the [relevant] Compliance Measures[.]"
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20. provide:
(a)

Commencing no later than July 1, 2017, the County and the Sheriff will
Custody-specific, scenario-based, skill development training to existing Deputies assigned to North County Correctional Facility, Pitchess Detention Center, and the non-Mental Health Housing Units in Century Regional Detention Facility as follows:
(i) 32 hours of Crisis Intervention and Conflict Resolution as described in paragraphs 4.6 and 4.9 of the Implementation Plan in Rosas to be completed by December 31, 2019. Deputies at these facilities will receive an eight-hour refresher course consistent with paragraph 4.6 of the Implementation Plan in Rosas every other year until termination of court jurisdiction in that case and then a four-hour refresher course every other year thereafter.
(ii) Eight hours identifying and working with mentally ill prisoners as described in paragraph 4.7 of the Implementation Plan in Rosas to be completed by December 31, 2019. This training requirement may be a part of the 32-hour training described in the previous subsection. Deputies at these facilities will receive a four-hour refresher course consistent with paragraph 4.7 of the Implementation Plan in Rosas every other year thereafter.

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STATUS (20):

SUBSTANTIAL COMPLIANCE (as of August 1, 2017 (verified) at CRDF, PDC East, PDC North, and NCCF)

SUBSTANTIAL COMPLIANCE (as of October 1, 2017 (verified) at PDC South)

As of November 4, 2015, the Monitor, in consultation with the Subject Matter Experts and the Rosas Monitors, approved the curriculum for the Department’s Deescalation and Verbal Resolution Training ("DeVRT"), which provides for 32 hours of Crisis Intervention and Conflict Resolution training that meets the requirements of Paragraph 20 of the Settlement Agreement.

Substantial Compliance requires that 85% of existing Deputies at the facilities designated in Paragraph 20(a) as of July 1, 2017, receive the required DeVRT training. The County reported that as of August 1, 2017, 85% of the Deputies assigned to PDC East, 89% of the Deputies assigned to PDC North, 85% of the Deputies assigned to NCCF, and 91% of the Deputies assigned to the non-mental housing units at CRDF, had received the required training, and as of October 1, 2017, 96% of the Deputies assigned to PDC South had received the training. The results at CRDF, PDC East, PDC North, PDC South, and NCCF have been verified by the Monitor's auditors, and these facilities were not subject to monitoring for the initial training for existing Deputies during the Eighth Reporting Period.

While Paragraph 20 is no longer subject to monitoring for the initial training courses, the Department is still subject to monitoring in future periods for Substantial Compliance with the refresher course requirements; the Department's reported results for the refresher course will be subject to verification by the Monitor's auditors.

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21. Consistent with existing Sheriff’s Department policies regarding training requirements for sworn personnel, the County and the Sheriff will ensure that existing custody staff that have contact with prisoners maintain active certification in cardiopulmonary resuscitation and first aid.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at PDC East and South)
SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at NCCF, PDC North, and IRC)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at TTCF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through March 31, 2018 (verified) and through September 30, 2018 (unverified) at MCJ)
SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through September 30, 2018 (verified) and through March 31, 2019 (unverified) at CRDF)
The Compliance Measures provide that the Department will demonstrate Substantial Compliance when 95% of the designated custody staff have the required CPR and first aid certifications for twelve consecutive months.
Pursuant to Paragraph 111 of the Settlement Agreement, PDC South, PDC East, PDC North, NCCF, IRC, and TTCF were not subject to monitoring for Substantial Compliance with Paragraph 21 in the Eighth Reporting Period.
The County's Fifth Self-Assessment reported that it achieved Substantial Compliance at MCJ in October 2017, which it maintained through the remainder of 2017. These results have been verified by the Monitor's auditors. The County's Sixth SelfAssessment reported that the Department continued to maintain Substantial Compliance at MCJ through the First Quarter of 2018. These results have been verified by the Monitor's auditors. The County's Seventh Self-Assessment reported that it continued to maintain Substantial Compliance at MCJ through the Third Quarter of 2018. These results are subject to verification by the Monitor's auditors. If verified, Paragraph 21 is no longer subject to monitoring at MCJ.
The County's Seventh Self-Assessment reflected that it achieved Substantial Compliance with Paragraph 21 at CRDF in June 2018. The County's Eighth SelfAssessment reflects that it has maintained Substantial Compliance with Paragraph 21 at CRDF through the end of the First Quarter of 2019. These results are subject to verification by the Monitor's auditors.
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22. Within six months of the Effective Date and at least annually thereafter, the County and the Sheriff will provide instructional material to all Sheriff station personnel, Sheriff court personnel, custody booking personnel, and outside law enforcement agencies on the use of arresting and booking documents, including the Arrestee Medical Screening Form, to ensure the sharing of known relevant and available information on prisoners’ mental health status and suicide risk. Such instructional material will be in addition to the training provided to all custody booking personnel regarding intake.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017)
The Justice Data Interface Controller ("JDIC") message the Department has been using since June 29, 2016, is sufficient to establish Substantial Compliance with Paragraph 22, and the County maintained Substantial Compliance for twelve consecutive through June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, the County was not subject to monitoring for Substantial Compliance with Paragraph 22 in the Eighth Reporting Period.
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23. Within three months of the Effective Date, the County and the Sheriff will commence a systematic review of all prisoner housing, beginning with the Mental Health Unit of the Correctional Treatment Center, all High Observation Housing areas, all Moderate Observation Housing areas, single-person discipline, and areas in which safety precautions are implemented, to reduce the risk of self-harm and to identify and address suicide hazards. The County and the Sheriff will utilize a nationally-recognized audit tool for the review. From this tool, the County and the Sheriff will:
(a) develop short and long term plans to reasonably mitigate suicide hazards identified by this review; and
(b) prioritize planning and mitigation in areas where suicide precautions are implemented and seek reasonable mitigation efforts in those areas.
STATUS: SUBSTANTIAL COMPLIANCE The Monitor has verified, with the advice of the Subject Matter Expert, that the Department's Suicide Hazard Inspection Check List tool is a nationally recognized audit tool for this review. The Department reports that it inspected all of the housing units by January 14, 2016, and it has provided the Monitor with completed checklists documenting the inspections. The County submitted an updated Suicide Hazard Mitigation plan to the Monitor on January 18, 2018. After consultation with the Mental Health Subject Matter Expert, the Monitor concluded that the updated Plan satisfies the requirements of Paragraph 23. The Department submitted another updated plan to the Monitor on July 12, 2018. After consultation with the Mental Health Subject Matter Expert, the Monitor concluded that the updated Plan satisfies the requirements of Paragraph 23. The County has maintained Substantial Compliance with Paragraph 23 for twelve consecutive months and this provision is no longer subject to monitoring.
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24. The County and the Sheriff will review and inspect housing areas on at least an annual basis to identify suicide hazards.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018)
CDM 3-06/020.00 FACILITIES INSPECTIONS requires Custody Support Services (CSS) to "review and inspect housing areas on a least an annual basis to identify suicide hazards."
The Monitor and Subject Matter reviewed a revised annual suicide hazard inspection tool that was submitted by the Department on December 13, 2016, and approved it with the caveat that, in order to achieve Substantial Compliance, the sample sizes of randomly selected cells must be large enough to ensure that the cells are representative of each housing type at a facility. Further, if a problem is found in the randomly selected cells, a complete inspection or remediation of the area or setting should then be conducted. An updated tool was submitted by the Department on February 9, 2017; it also was approved with the same caveats.
The Department conducted an Annual Suicide Hazard Inspection at each of its jail facilities during the Sixth and Seventh Reporting Periods. The Department maintained Substantial Compliance with this provision for twelve consecutive months in the Sixth and Seventh Reporting Periods, and it was not subject to monitoring during the Eighth Reporting Period. As the Monitor has noted, however, implementation and tracking of corrective actions must be addressed by the Custody Compliance and Sustainability Bureau ("CCSB") under Paragraph 77(c), which requires CCSB to "ensure that corrective actions are taken to mitigate suicide risk. . . obtaining where appropriate, technical assistance. . .when such assistance is needed to address suicide-risk issues."
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25. The County and the Sheriff will ensure that any prisoner in a Sheriff’s Department station jail who verbalizes or who exhibits a clear and obvious indication of current suicidal intent will be transported to IRC, CRDF, or a medical facility as soon as practicable. Pending transport, such prisoners will be under unobstructed visual observation, or in a suicide resistant location with safety checks every 15 minutes.
STATUS: PARTIAL COMPLIANCE A provision of the Station Jail Manual adopted in March 2018 requires that any arrestee who "displays obvious suicidal ideation or exhibits unusual behavior that clearly manifest[s] self-injurious behavior or other clear indication of mental health crisis shall be transported to the Inmate Reception Center (IRC), Century Regional Detention Facility (CRDF), or a medical facility as soon as practicable. Pending transport, such inmates . . . shall be under unobstructed visual observation or in a suicidal restraint location with safety checks every 15 minutes." The Compliance Measures require the Department to randomly select and analyze Arrestee Medical Screening Forms from station jails identifying prisoners who verbalize or exhibit a clear and obvious indication of current suicidal intent to determine compliance with Paragraph 25 of the Agreement. The County's Eighth Self-Assessment reports that 71% of the records reviewed for the Fourth Quarter of 2018, and 65% of the records reviewed for the First Quarter of 2019 reflect the information required to establish Substantial Compliance with Paragraph 25, which is slightly lower than the previous three quarters.9
9 As noted by the Mental Health Subject Matter Expert, "[s]ome station jails are doing a good job of monitoring, but others continue to show 15 minute checks exactly every 15 minutes over several hours. This raises questions about the accuracy of the data and/or reflects poor practice as it is important to vary the time of checks somewhat."
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26. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will follow established screening procedures to identify prisoners with emergent or urgent mental health needs based upon information contained in the Arrestee Medical Screening Form (SH-R-422) or its equivalent and the Medical/Mental Health Screening Questionnaire and to expedite such prisoners for mental health evaluation upon arrival at the Jail Reception Centers and prior to routine screening. Prisoners who are identified as having emergent or urgent mental health needs, including the need for emergent psychotropic medication, will be evaluated by a QMHP as soon as possible but no later than four hours from the time of identification.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to "review Arrestee Medical Screening Forms (SH-R-422) (or its equivalent) and the Medical/Mental Health Screening Questionnaires of 100 randomly selected prisoners during one randomly selected week per quarter at CRDF and at IRC." Substantial Compliance requires that (1) 95% of the forms "include the required mental health information" and (2) 90% of the prisoners having urgent or emergent needs were "seen by a QMHP within four hours."
The County’s Eighth Self-Assessment reports that for the one randomly selected week in the Fourth Quarter of 2018, 94% of the screening forms reviewed had the required mental health information, and 72% of the prisoners were seen by a QMHP within four hours, which is a significant improvement from the Third Quarter of 2018, when only 45% of the prisoners were seen within four hours. The County "believes these improvements are the result of the IRC restructuring" whereby the initial and nursing assessments are conducted at the windows in the IRC clinic. For the First Quarter of 2019, 89% of the forms had the required information and 86% of the prisoners were seen within four hours, a continued improvement.10
The Mental Health Subject Matter Expert and the clinicians did a qualitative assessment of the Department's results during a site visit in March 2019. They assessed the "completeness of intake documentation" and "whether patients with emergent or urgent needs were missed at intake[.]" They "found that 95% of the intake documentation was complete and available," and that only 5% "of urgent/emergent cases that should have been detected at admission were not." They reported "seeing consistent sound performance in the screening and detection processes for urgent and emergent cases. It appears that the change to having nurses conduct initial screening has been effective."
10 The Mental Health Subject Matter Expert notes, however, that Paragraph 26 encompasses patients with "emergent or urgent mental health needs, including the need for emergent psychotropic medications," and is not limited to suicidal patients.
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27. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that all prisoners are individually and privately screened by Qualified Medical Staff or trained custody personnel as soon as possible upon arrival to the Jails, but no later than 12 hours, barring an extraordinary circumstance, to identify a prisoner’s need for mental health care and risk for suicide or self-injurious behavior. The County and the Sheriff will ensure that the Medical/Mental Health Screening Questionnaire, the Arrestee Medical Screening Form (SH-R-422), or its equivalent, and/or the Confidential Medical Mental Health Transfer Form are in the prisoner’s electronic medical record or otherwise available at the time the prisoner is initially assessed by a QMHP.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2018, through March 31, 2019 (verified)).
The Compliance Measures require the Department to review the records of "randomly selected prisoners who were processed for intake during one randomly selected week at CRDF and at IRC" to determine compliance with this provision. Substantial Compliance requires that 90% of the records reviewed reflected that the prisoners were screened for mental health needs within 12 hours and that the required documentation was available to the QMHP for 90% of the mental health assessments conducted by the QMHP.
The County's Eighth Self-Assessment reflects that it achieved Substantial Compliance with Paragraph 27 in the Fourth Quarter of 2018, when "90% -- equal to the required 90% -- of inmates" were timely assessed by qualified personnel, and "93% -- 3% more than the required 90% -- of required documents were available for assessments conducted by QMHPs[.]" It maintained Substantial Compliance through the First Quarter of 2019, when 96% of the inmates were timely assessed and 100% "of the required documents were available for [the] assessments." These results are a significant improvement over the results in the Third Quarter of 2018, and have been verified by the Monitor's auditors.
The Mental Health Subject Matter Expert and the clinicians did a qualitative assessment of the "completeness of intake documentation" and "focused on whether patients with routine needs were missed at intake[.]" They found "that 96% of the intake documentation was completed and available," and only 12% "of routine cases that should have been detected were not." The Subject Matter Expert reports that they "found the inconsistencies and errors in intake materials were less than previously" and that this "demonstrates clear improvement in the process."11
11As noted in the Monitor's Seventh Report, see p. 21, nurses at CRDF now conduct the assessments in a room off a hallway near the booking front and nurses at IRC now conduct the assessments at windows behind the inmate seating areas in the IRC clinic.
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28. The County and the Sheriff will ensure that any prisoner who has been identified during the intake process as having emergent or urgent mental health needs as described in Paragraph 26 of this Agreement will be expedited through the booking process. While the prisoner awaits evaluation, the County and the Sheriff will maintain unobstructed visual observation of the prisoner when necessary to protect his or her safety, and will conduct 15-minute safety checks if the prisoner is in a cell.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at IRC)
SUBSTANTIAL COMPLIANCE (as of January 1, 2019, through March 31, 2019 (subject to further verification) at CRDF)
The Compliance Measures require the Department to review the records of randomly selected prisoners at CRDF and IRC who have urgent or emergent mental health needs to determine whether they were expedited through the booking process.
The County's Eighth Self-Assessment reflects that in the Fourth Quarter of 2018, 55% of the inmates with urgent or emergent mental health needs were expedited through the booking process at CRDF as required by Compliance Measure 28.2 and 80% of the inmates identified as having urgent or emergent mental health needs were observed or checked as required by Compliance Measure 28.4. In the First Quarter of 2019, 100% of these inmates were expedited through booking and 100% were observed or checked. The Substantial Compliance results for the First Quarter of 2019 are subject to further verification by the Monitor's auditors.12
Although Compliance Measure 28.2 requires the County to "review the records of 25 randomly selected prisoners at CRDF. . .who have been identified as having urgent or emergent mental health needs" in one randomly selected week per quarter, there were only seven such prisoners identified in the week selected for the First Quarter of 2018. The County reported that all seven inmates were expedited through booking and it posted supporting source documents for all seven. The County then reported on video reviews of a randomly selected sample of five of these seven prisoners to establish that they were observed or checked as required by Compliance Measure 28.4.13
12 The County's posted summary suggests that it is assessing whether the inmates were "under unobstructed observation" or checked until they were expedited to Module 1200, where they were evaluated by mental health clinicians. The second sentence of Paragraph 28, however, requires that inmates remain under unobstructed observation or be subject to 15 minute checks in 1200 "[w]hile [they] await[] evaluation[s]" by the clinicians. The County's report "that inmates housed, even temporarily, in CRDF Module 1200 are placed under 15 minute checks as the module is an HOH-type unit" is subject to verification by the Monitor's auditors. 13 In August 2017, the Monitor agreed that the County could review three (later five) randomly selected videos in lieu of unannounced visits because inmates with urgent or emergent mental health needs were rarely in the CRDF reception center during the visits. This is similar to what the parties agreed could be used for Compliance Measures 36.3 and 36.4(a). Accordingly, the County is only required to post the
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The County previously maintained Substantial Compliance with Paragraph 28 at IRC for twelve consecutive months, and IRC was not subject to monitoring for compliance with Paragraph 28 in the Eighth Reporting Period.
source documents for five randomly selected inmates to establish compliance with Compliance Measure 28.2
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29. The County and the Sheriff will ensure that a QMHP conducts a mental health assessment of prisoners who have non-emergent mental health needs within 24 hours (or within 72 hours on weekends and legal holidays) of a registered nurse conducting an intake nursing assessment at IRC or CRDF.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified))
The Compliance Measures require the Department to review randomly selected records of the prisoners identified in the intake nursing assessment as having nonemergent mental health needs to determine if the Department completed mental health assessments for 85% of the prisoners within the required time periods.
The County’s Sixth Self-Assessment reported that in the Fourth Quarter of 2017 the County completed mental health assessments for 99% of the inmates at CRDF and IRC within the required time periods, and in the First Quarter of 2018, it completed 95% of the assessments within the required time periods. The Monitor's auditors verified the County's results. Accordingly, the County previously maintained Substantial Compliance for twelve consecutive months and was not subject to monitoring for compliance with Paragraph 29 in the Eighth Reporting Period.
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30. Consistent with existing DMH policies, the initial mental health assessment will include a brief initial treatment plan. The initial treatment plan will address housing recommendations and preliminary discharge information. During the initial assessment, a referral will be made for a more comprehensive mental health assessment if clinically indicated. The initial assessment will identify any immediate issues and determine whether a more comprehensive mental health evaluation is indicated. The Monitor and SMEs will monitor whether the housing recommendations in the initial treatment plan have been followed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2019, through March 31, 2019 (unverified))
The Compliance Measures require the Department to review randomly selected initial mental health assessments and report on (1) the percentage of assessments that have (i) included an initial treatment plan that addresses housing recommendations and preliminary discharge information and (ii) identified any immediate issues and whether a more comprehensive evaluation was indicated; and (2) whether the housing recommendations were followed.
The County's Eighth Self-Assessment reports that 100% of the housing assignments reviewed in the Fourth Quarter of 2018 followed the housing recommendations in the initial treatment plans, which exceeds the 95% threshold for Substantial Compliance, but only 68% of the initial mental health assessments included an initial treatment plan that had the information required by Paragraph 30, which is below the 85% threshold for Substantial Compliance. The results for the First Quarter of 2019 were that 100% of the housing assignments followed the housing recommendations and 90% of the initial mental health assessments had the required information.14 The results for the First Quarter of 2019 are subject to verification by the Monitor’s auditors.
The Mental Health Subject Matter Expert and the clinicians again evaluated "whether the determination of immediate issues [in the random sample of mental health assessments] was reasonable in light of available information. . . [and] whether the initial treatment plan covered the elements required by existing County policy, which goes beyond the content of the formal compliance measure." They found that 96% of the cases "identified immediate issues," and that the determination of the immediate issues "was reasonable from a qualitative perspective" in 96% of the cases. The Subject Matter Expert concludes that the County has shown continued "improvement" and "should achieve substantial compliance," if the County's Self-Assessment shows that it has satisfied the required quantitative thresholds.
14 The County reports that "[d]uring the Fourth Quarter, the County created a quality improvement project related to improving its initial mental health assessments and provided three separate targeted training sessions to IRC staff at TTCF[.]"
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31. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will maintain electronic mental health alerts in prisoners’ electronic medical records that notify medical and mental health staff of a prisoner’s risk for suicide or self-injurious behavior. The alerts will be for the following risk factors:
(a) current suicide risk;
(b) hoarding medications; and
(c) prior suicide attempts.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2019 through March 31, 2019 at NCCF (unverified))
PARTIAL COMPLIANCE (at CRDF, TTCF, MCJ and PDC North)
The Compliance Measures require the Department to review randomly selected electronic medical records for prisoners in certain at-risk groups to determine if the required mental health alerts are in 85% of the records reviewed, which is the threshold for Substantial Compliance, for prisoners who report suicidal thoughts during the intake process; were removed from risk precautions in the prior quarter; or were identified as hoarding medicine.
The County's Eighth Self-Assessment reports the following results for the Fourth Quarter of 2018: at CRDF, 60% (current suicide risk), 96% (removed from risk precautions),15 and 33% (hoarding) of the records had the required mental health alerts; at TTCF, 75% (current suicide risk), 92% (removal from risk precautions), and 54% (hoarding) of the records had the alerts; at MCJ, 57% of the records had the alerts for hoarding; at NCCF, 66% of the records had the alerts for hoarding, and at PDC North, 100% of the records had the alerts for hoarding.16
The County's Eighth Self-Assessment reports that the County has "previously changed its universe [of inmates who may be hoarding medication], which now includes. . . . inmate segregation reports that refer to inmates disciplined for having contraband pills." The report states that the County "is concerned with the consistency with which those inmates are referred to nursing for consideration of whether a hoarding alert is
15 As noted in the Monitor's Seventh Report, p. 27, n. 13, in order to achieve Substantial Compliance, the County will need to provide some explanation for the clinical judgment that no alert is required for an inmate who has been removed from risk precautions or that the inmate "did not meet the clinical criteria for risk precautions in the first place." 16 The County did not report any results for the other mental health alerts for prisoners at MCJ, NCCF or PDC North because "Compliance Measures 31-1(a) and 31-1(b) refer to the intake and HOH populations respectively." Although mental health alerts are required for all prisoners who have a "risk of suicide or self-injurious behavior," the County does not have to randomly select prisoners at MCJ, NCCF, or PDC North as long as it can show that these "alerts are not being discontinued inappropriately" or it has "processes that are likely to prevent that from occurring."
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appropriate or necessary" and it "anticipates revising its assessment approach, with a particular focus on how suspected instances of hoarding are communicated between medical and custody staff." The Mental Health Subject Matter Expert indicates that County's reliance, in part, on segregation reports is "reasonable," "as long as it is understood that any detection of contraband medications [by Custody] must result in notice to healthcare staff." The County's Augmented Eighth Self-Assessment reports, however, that in the First Quarter of 2019, "the County experienced documentation concerns regarding communications between custody staff and medical staff when inmates are disciplined for having contraband pills and whether sufficient information is provided to medical staff to enable them to accurately identify inmates who might be hoarding medications."
The County's Augmented Eighth Self-Assessment reports the following results for the First Quarter of 2019: at CRDF, 92% (current suicide risk), 88% (removed from risk precautions), and 88% (hoarding) of the records had the required mental health alerts; at TTCF, 93% (current suicide risk), 84% (removal from risk precautions), and 81% (hoarding) of the records had the alerts; at MCJ, 63% of the records had the alerts for hoarding; at NCCF, 100% of the records had the alerts for hoarding, and at PDC North, none of the records had the alerts for hoarding.17
17 Where the County experienced documentation concerns discussed above, the County counted those instances as non-compliant. It reports that it did not experience these documentation issues at NCCF.
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32. Information regarding a serious suicide attempt will be entered in the prisoner’s electronic medical record in a timely manner.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require that 95% of the electronic medical records of prisoners who had a serious suicide attempt reflect information regarding the attempt, and 85% of the records reflect that the information was entered into the record within one day of the attempt.
The County maintained Substantial Compliance with Paragraph 32 for twelve consecutive months as of December 31, 2016, and this provision was not subject to monitoring in the Eighth Reporting Period.
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33. The County will require mental health supervisors in the Jails to review electronic medical records on a quarterly basis to assess their accuracy as follows:
(a) Supervisors will randomly select two prisoners from each clinician’s caseload in the prior quarter;
(b) Supervisors will compare records for those prisoners to corroborate clinician attendance, units of service, and any unusual trends, including appropriate time spent with prisoners, recording more units of service than hours worked, and to determine whether contacts with those prisoners are inconsistent with their clinical needs;
(c) Where supervisors identify discrepancies through these reviews, they will conduct a more thorough review using a DMH-developed standardized tool and will consider detailed information contained in the electronic medical record and progress notes; and
(d) Serious concerns remaining after the secondary review will be elevated for administrative action in consultation with DMH’s centralized Human Resources.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (verified))
The Compliance Measures require the County to provide the Monitor and the Subject Matter Experts with the DMH-developed standardized tool required by Paragraph 33(c), and to report the results of its analysis of the electronic medical records of two randomly selected prisoners from each clinician’s caseload. The County has provided the required tool, and previously reported Substantial Compliance for the Third and Fourth Quarters of 2016, and the First and Second Quarters of 2017.
The Monitor’s auditors have verified the County’s previously reported results. Accordingly, the County maintained Substantial Compliance for twelve consecutive months and was no longer subject to monitoring for compliance with Paragraph 33 during the Eighth Reporting Period.
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34 (Revised). Consistent with existing Correctional Health Services policy, the County and the Sheriff will conduct clinically appropriate release planning for all prisoners who are being released to the community and who have been identified by a QMHP as having a mental illness and needing mental health treatment, or as having a DSM-5 major neuro-cognitive disorder that caused them to be housed in the Correctional Treatment Center at any time during their current incarceration. For prisoners with mental illness and needing mental health treatment, the release planning services will be guided by the prisoner’s level of care. Specifically, prisoners who any time during their incarceration meet mental health level of P3, or P4 will be presumptively referred for release planning services, and prisoners who meet mental health level of care P2 will receive release planning services upon referral by a clinician or upon their request. Prisoners who have a DSM-5 major neuro-cognitive disorder that caused them to be housed in the Correctional Treatment Center will also be referred for release planning services consistent with the Correctional Health Services policy applying to prisoners with mental illness.
(a) Release planning will consider the need of the prisoner for housing; transportation to the prisoner's community-based provider, residence, or shelter within the County; bridge psychotropic medications; medical/mental health/substance abuse services; income/benefits establishment; and family/community/social supports (“Release Planning Areas”).
(b) Release planning will be based on an individualized assessment of the prisoner's needs and, unless the prisoner is unable or unwilling to participate, will be undertaken in collaboration with the prisoner. For prisoners referred for release planning services, those services will include:
(i) An Initial Release Plan that will be created at intake or no later than ten days after the referral for release planning, which referral shall normally occur at the time of intake. The Initial Release Plan will include preliminary identification of needs in each of the Release Planning Areas and preliminary recommendations for services to address those needs, and a referral for assistance in obtaining California identification when needed and when the prisoner is eligible; and/or
(ii) A Comprehensive Release Plan that will be initiated no later than thirty days after the referral for release planning. The Comprehensive Release Plan will include (A) collecting information regarding the prisoner’s needs; (B) coordinating with community-based providers to identify available services that meet the prisoner's needs; (C) facilitating the transition of care to community-based providers, and (D) assisting in obtaining identification and/or benefits when needed, when the prisoner is eligible, and as offered by the Sheriff’s Community Transition Unit.
(c) The County will maintain a re-entry resource center with staff supervised by a QMHP. The re-entry resource center will:
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(i) Provide information appropriate to the released prisoner about available housing, transportation, medical/mental health/substance abuse services, income/benefits establishment, community/social supports, and other community resources; and (ii) Provide released prisoners with copies of their release plans, as available. (d) All prisoners who are receiving and continue to require psychotropic medications will be offered a clinically appropriate supply of those medications upon their release from incarceration. Unless contraindicated, this will be presumed to be a 14-day supply or a supply with a prescription sufficient so that the prisoner has the psychotropic medication available during the period of time reasonably necessary to permit the prisoner to consult with a doctor and obtain a new supply. (e) Nothing in Paragraph 34 will require prisoners to accept or participate in any of the services provided under this Paragraph. (f) Neither the County nor the Sheriff shall be in violation of this paragraph if after reasonable efforts as set forth in Correctional Health Services Policy M380.01, Release Planners are unable to identify available post-release services.
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STATUS (34):

STAYED PENDING LITIGATION

During the Seventh Reporting Period, the parties and the Intervenors reached an agreement on the provisions of revised Paragraph 34 ("Revised Paragraph 34") set forth above. They also agreed on revised Compliance Measures and a revised policy to implement Revised Paragraph 34.

On December 10, 2018, the Court issued an order pursuant to the parties' joint stipulation revising Paragraph 34. The County expects to report the status of its compliance with Revised Paragraph 34 beginning in January 2020.

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35. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody staff, before the end of shift, refer prisoners in general or special populations who are demonstrating a potential need for routine mental health care to a QMHP or a Jail Mental Evaluation Team ("JMET") member for evaluation, and document such referrals. Custody staff will utilize the Behavior Observation and Referral Form.
STATUS: SUBSTANTIAL COMPLIANCE (as of November 1, 2017, through December 31, 2018 (verified))
The Compliance Measures require the Department to review, for a randomly selected month each quarter, the Behavior Observation and Mental Health Referral ("BOMHR") records for prisoners referred by custody staff to a QMHP or JMET member for "routine" mental health care to determine the timeliness of the referrals. Substantial Compliance requires that "85% of the BOMHR forms reflect that the referral occurred before the end of the shift in which the potential need for mental health care is identified."
The County's Sixth Self-Assessment reported that the Department "has developed an electronic version of the BOMHR" and it "concluded that 100% -- 15% more than the required 85% -- of BOMHR forms reflected that referrals occurred prior to the end of the shift in which the potential need for mental health care is identified" in the last two months of the Fourth Quarter of 2017 and in the First Quarter of 2018. These results were verified by the Monitor's auditors.
The County's Seventh Self-Assessment reported that the 100% of BOMHR forms reviewed in both the Second and Third Quarters of 2018 "reflected that referrals occurred prior to the end of the shift in which the potential need for mental health care is identified." These results have been verified by the Monitor's auditors.
The County's Eighth Self-Assessment reports that 100% of BOMHR forms reviewed in the Fourth Quarter of 2018 reflected timely referrals. These results have been verified by the Monitor's auditors and the County is no longer subject to monitoring for compliance with Paragraph 35.
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36. Consistent with existing DMH policies, the County and the Sheriff will ensure that a QMHP performs a mental health assessment after any adverse triggering event, such as a suicide attempt, suicide threat, self-injurious behavior, or any clear decompensation of mental health status. For those prisoners who repeatedly engage in such self-injurious behavior, the County will perform such a mental health assessment only when clinically indicated, and will, when clinically indicated, develop an individualized treatment plan to reduce, and minimize reinforcement of, such behavior. The County and the Sheriff will maintain an on-call system to ensure that mental health assessments are conducted within four hours following the notification of the adverse triggering event or upon notification that the prisoner has returned from a medical assessment related to the adverse triggering event. The prisoner will remain under unobstructed visual observation by custody staff until a QMHP has completed his or her evaluation.
STATUS: PARTIAL COMPLIANCE
The Compliance Measures require the Department to review randomly selected records of prisoners newly admitted to mental health housing from a lower level of care due to an adverse triggering event during two randomly selected weeks per quarter; and provide a staffing schedule for on-call services.
The County's Eighth Self-Assessment reports that during the Fourth Quarter of 2018, (a) "86% -- rather than the required 95% -- of inmates" identified in the two randomly selected weeks received an assessment by a QMHP within four hours as required by Compliance Measure 36-4(a); (b) 80% of the selected prisoners at CRDF, and 80% at TTCF were on videos "under unobstructed visual observation pending assessment," which is also below the 95% threshold for Substantial Compliance;18 and (c) the County achieved 100% compliance with a staffing schedule that provides on-call services 24 hours a day, 7 days a week.
The County's Augmented Eighth Self-Assessment reports that during the First Quarter of 2019, (a) "85% of the inmates" identified in the two randomly selected weeks received an assessment by a QMHP within four hours; (b) 100% of the selected prisoners at CRDF and TTCF were on videos "under unobstructed visual observation pending assessment," and (c) the County achieved 100% compliance with a staffing schedule that provides on-call services 24 hours a day, 7 days a week.
Based upon a January 2019 site visit, the Mental Health Subject Matter Expert and clinicians found that 77% of the identified prisoners received an assessment by a QMHP within four hours, and 47% had an adequate assessment of the event, but "in only 38% was there a safety plan or crisis response to address those risk factors." He reports that the "County is detecting cases reasonably reliably, but response times are falling a bit short. Adequate risk assessments are being done about half the time but a corresponding
18 DOJ and the County previously agreed that "the Department will randomly select five BOMHRS" from a randomly selected date, to "review videos to determine how the inmate was being observed while waiting for the QMHP," and "produce screen shots and movement records as part of their self-assessment."
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response or plan to address those risks is present in only a minority of cases."19 Based upon record reviews and discussions with staff, the Mental Health Subject Matter Expert and clinicians note that there are times when the mental health staff cannot go to the housing unit to conduct the mental health assessment.20 Thus, while the County may have a "staffing schedule that provides on-call services 24 hours a day, 7 days a week," as reflected in the County's own reported results, it is not clear that the system is adequate.21
19 The County's response to the draft of this Eighth Report notes that the Compliance Measures "establish quantitative thresholds" while the related provision in Paragraph 40 "contains a qualitative element[.]" Accordingly, the "County's view is that Substantial Compliance with Provision 36 should be determined according to the County's ability to meet the qualitative thresholds[.]" The Monitor does not disagree unless, as noted earlier, "the quality of the County's performance as determined by the qualitative assessment is plainly inadequate or the results reported by the Subject Matter Expert vary significantly from the results reported by the Department." See p. 1, supra. 20 DOJ recommends that the County "consider targeted staffing interventions to address these challenges." 21 Compliance Measure 36-2 requires the Monitor, in consultation with the Subject Matter Experts, to "review" the staffing schedule "to verify the adequacy of the on-call system."
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37. Sheriff’s Court Services Division staff will complete a Behavioral Observation and Mental Health Referral ("BOMHR") Form and forward it to the Jail’s mental health and/or medical staff when the Court Services Division staff obtains information that indicates a prisoner has displayed obvious suicidal ideation or when the prisoner exhibits unusual behavior that clearly manifests self-injurious behavior, or other clear indication of mental health crisis. Pending transport, such prisoner will be under unobstructed visual observation or subject to 15-minute safety checks.
STATUS: PARTIAL COMPLIANCE The Compliance Measures require the Department to randomly select nine courts from among the three Court Divisions each quarter, review written communications and orders that refer to a suicide risk or serious mental health crisis for a prisoner and incident reports for self-injurious behavior by prisoners appearing in the selected courts, and determine if these incidents are reflected in BOMHR forms completed by the Court Services Division staff in the selected courts. The County’s Eighth Self-Assessment reports that 100% of the incidents covered by Paragraph 37 in six randomly selected courts were reflected on BOMHRs in the Fourth Quarter of 2018, but only 71% of the incidents in six other courts were reflected on BOMHRs in the First Quarter of 2019, which is below the 90% threshold for Substantial Compliance.
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38. Consistent with existing DMH policies and National Commission on Correctional Health Care standards for jails, the County and the Sheriff will ensure that mental health staff or JMET teams make weekly cell-by-cell rounds in restricted nonmental health housing modules (e.g., administrative segregation, disciplinary segregation) at the Jails to identify prisoners with mental illness who may have been missed during screening or who have decompensated while in the Jails. In conducting the rounds, either the clinician, the JMET Deputy, or the prisoner may request an out-of-cell interview. This request will be granted unless there is a clear and documented security concern that would prohibit such an interview or the prisoner has a documented history of repeated, unjustified requests for such out-of-cell interviews.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
The Compliance Measures require the Department to review the documentation of the weekly cell-by-cell rounds and the JMET Logs for a randomly selected week each quarter to confirm that the required cell-by-cell checks were conducted and out-of-cell interviews were handled in accordance with this provision.
The County's reported results, which were verified by the Monitor's auditors, showed that it had maintained Substantial Compliance with Paragraph 38 for twelve consecutive months as of December 31, 2016. Accordingly, pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 38 was not subject to monitoring in the Eighth Reporting Period.
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39. The County and the Sheriff will continue to use a confidential self-referral system by which all prisoners can request mental health care without revealing the substance of their requests to custody staff or other prisoners.

STATUS

SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through March 31, 2018 (verified) and through June 30, 2018 (unverified) at NCCF)

SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through March 31, 2019 (unverified) at PDC North)

SUBSTANTIAL COMPLIANCE (as of October 1, 2018, through March 31, 2019 (verified) at PDC South)

PARTIAL COMPLIANCE (at TTCF, CRDF, and MCJ)

NOT RATED (PDC East)

Substantial Compliance requires the Department to (a) verify that housing areas have the required forms and (b) review randomly selected self-referrals for mental health care from prisoners to confirm that (i) the referrals "were forwarded to DMH" by the Department, and (ii) that "DMH documented the timeliness and nature of DMH's response to the self-referrals[.]" The thresholds for Substantial Compliance are that 85% of the housing areas have the required forms and 90% of the self-referrals must be forwarded by the Department to the Department of Health Services – Custody Health Services (DHS-CHS) and 90% must contain the required documentation of DHS-CHS's response.

The County's Eighth Self-Assessment reports that it achieved Substantial Compliance with Compliance Measure 39.4(a) in the Fourth Quarter of 2018 and the First Quarter of 2019 in that more than 85% of the housing areas in all of the facilities had the self-referral forms. Based upon a review of the County’s policies and procedures, multiple tours of the facilities by the Monitor, site visits by the Subject Matter Expert and the clinicians, interviews, and the County’s Eighth Self-Assessment, the Monitor is satisfied that the Department has adequate processes and procedures for inmates to make confidential self-referrals for mental health care.

The County previously reported Substantial Compliance with Compliance Measures 39.4(b) and 4(c) at NCCF for twelve consecutive months from July 1, 2017, through June 30, 2018. The results for the three-month period ending on June 30, 2018 have not been verified by the Monitor's auditors.22

22 Notwithstanding that the County's previously reported Substantial Compliance at NCCF for twelve consecutive months, the County's Eighth Self-Assessment reports Substantial Compliance at NCCF for the Fourth Quarter of 2018 and the First Quarter of 2019. The County reports that in the Fourth Quarter of 2018, 100% of the self-referrals from NCCF were forwarded to CHS as required by Compliance Measure 39.4(b) and CHS documented 94% of the NCCF referrals. It also reports that, in the First Quarter of 2019,
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The Mental Health Subject Matter Expert and clinicians conducted a qualitative assessment of the County's handling of self-referrals at NCCF as part of a January 2019 site visit that raises concerns about the adequacy of the QMHP responses. They report that there was a QMHP response in 88% of the cases; the response was timely in 85% of the cases, but clinically appropriate in only 48% of the cases. They found that "many of the responses consisted of a brief assessment and a transfer to a higher level of care and/or placement on restrictive conditions, but with almost no evidence of a clinical crisis intervention." They also found that "QMHPs place inmates on 'risk precautions,' despite assessments finding low suicide risk and without explaining why such restrictive conditions were necessary."23
The County's Eighth Self-Assessment reports Substantial Compliance at PDC North and PDC South in the Fourth Quarter of 2018 in that 100% of the self-referrals from each facility were forwarded to CHS as required by Compliance Measure 39.4(b) and DHS-CHS documented 95% of the PDC North referrals and 100% of the PDC South referrals as required by Compliance Measure 39.4(c). It reports that there were no relevant referrals from PDC East during the period as "inmates are pre-screened for mental health issues before being housed there."
The Eighth Self-Assessment also reports Substantial Compliance at PDC North and PDC South for the First Quarter of 2019 as follows: 100% and 95% for PDC North; and 100% and 100% for PDC South. The County was again unable to assess PDC East for the same reasons.24
The Substantial Compliance results reported by the County for NCCF for the Second Quarter of 2018 and for PDC North are subject to verification by the Monitor's auditors to whether self-referrals are being promptly forwarded to CHS by Custody within 24 hours of collecting the self-referral and, if so, whether CHS has responded within seven days. If the self-referral is not promptly forwarded by Custody, CHS must respond within seven days of the inmate's self-referral (rather than CHS's receipt of the self-referral from Custody). See Monitor's Seventh Report, p. 38, n. 16.
The County's Eighth Self-Assessment reports that in the Fourth Quarter of 2018, 100% of the self-referrals from CRDF, TTCF, and MCJ, were forwarded by the Department to DHS-CHS, and DHS-CHS documented the timeliness and nature of its
100% of the referrals were forwarded to CHS and CHS documented all of the referrals. The County's posted results for the Third Quarter of 2018 reflects that 100% of the referrals were forwarded to CHS and CHS documented 100% of the referrals. 23 DOJ has expressed a concern about the Substantial Compliance rating for NCCF in light of the findings of the Subject Matter Expert and the clinicians. Subject to verification by the auditors, NCCF maintained Substantial Compliance with Paragraph 39 for twelve consecutive months as of June 30, 2018, which is over six months before the Qualitative Assessment by the Subject Matter Expert and the clinicians. The Monitor does not believe that he can retroactively downgrade the Substantial Compliance finding under these circumstance. If, however, the auditors are unable to verify the County's reported results at NCCF for the three months ending on June 30, 2018, the County will have to achieve and maintain for twelve consecutive months Substantial Compliance at NCCF after the First Quarter of 2019. 24 If there are no relevant referrals from PDC East, it will deemed to be in Substantial Compliance once the other PDC facilities have maintained Substantial Compliance for twelve consecutive months.
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response in 80% of the CRDF referrals, 76% of the TTCF referrals, and 40% of the MCJ referrals. These results were below the 90% threshold for Substantial Compliance. The County's Eighth Self-Assessment reports that for the First Quarter of 2019, 100% of the self-referrals reviewed by the Department at CRDF were forwarded to CHS, but "CHS documented the timeliness and nature of CHS' response to the self-referrals received from the Department" only 46% of the time. The results were 100% and 60% for MCJ and 100% and 56% for TTCF.
The Mental Health Subject Matter Expert and the clinicians conducted a qualitative assessment of the County's compliance with Paragraph 39 at TTCF and CRDF, in March 2019. They report that it "was very difficult to track the response to self-referrals [at CRDF and TTCF], with CRDF being the most well-organized. . . . [C]linical notes often did not address the content of the self-referral, [the] self-referrals are often not scanned into the record, [and the summaries of the self-referrals are sometimes] inaccurate or [do] not include important information." The Mental Health Subject Matter Expert and the clinicians found a "QMHP response in 89% of cases; the response was timely in 67% of the cases, and clinically adequate in 74% of the cases."
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40. The County and the Sheriff will ensure a QMHP will be available on-site, by transportation of the prisoner, or through tele-psych 24 hours per day, seven days per week (24/7) to provide clinically appropriate mental health crisis intervention services.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County (1) to provide the Monitor with oncall schedules for two randomly selected weeks reflecting that a QMHP was assigned 24 hours a day, seven days per week, and (2) randomly select referrals for mental health crisis intervention received by a QMHP per quarter to verify that a QMHP responded to all referrals, and 90% of the referrals within four hours.
The County’s Eighth Self-Assessment reports that for the Fourth Quarter of 2018, a QMHP responded 100% of the time and 93% of the responses were within four hours and that for the First Quarter of 2019, a QMHP responded 100% of the time and 95% of the responses were within four hours.
As in prior reporting periods, the County's Substantial Compliance finding is subject to a qualitative review by the Mental Health Subject Matter Expert and the clinicians to assess whether the QMHP's are providing "clinically appropriate" services. They conducted their review during a March 2019 site visit, in which they found that a QMHP responded in 98% of the cases and the response was also within four hours in 98% of the cases. They found, however, that there was a "clinically appropriate crisis response" in only 35% of the cases. They are of the "view that both of [these] measures address potentially high risk situations" and they "found that the majority of responses are inadequate, often consisting only in transfer and/or imposing restrictive conditions on patients with little or no evidence of a clinical crisis intervention."25 What is needed is "evidence that the clinician assessed the nature of the crisis and made a reasonable attempt to work with the patient to resolve the crisis."26 Accordingly, the County has achieved Partial Compliance rather Substantial Compliance with Paragraph 40.27
25 The Mental Health Subject Matter Expert has observed that "a crisis response would, at a minimum, characterize the cause of the crisis, conduct a relevant risk assessment, and create a plan of action based on that assessment." 26 The Mental Health Subject Matter Expert and clinicians have "seen some limited improvement," with one clinician noting that "they provided some support, problem-solving, or other limited short-term intervention." The County reports that it "is currently developing a template for clinicians to use as a guide in documenting their crisis intervention to ensure more thorough clinical responses and better document the same." 27 DOJ has expressed a concern about the number of exclusions from the randomly selected referrals in the First Quarter of 2019 (27) as opposed to the Fourth Quarter of 2018 (seven). In response, the County notes the number of exclusions is less than in the Second and Third Quarters of 2018. The County also explained that it "has excluded from its assessment, items initially captured in the universe that do not relate to crisis intervention services and that extraction evaluations "are separate and distinct" from a mental health crisis evaluation that is done if the inmate is "being extracted as a result of a mental health crisis."
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41. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols that provide clinically appropriate transition when prisoners are discharged from FIP after being the subject of suicide watch. The protocols will provide:
(a) intermediate steps between highly restrictive suicide measures (e.g., clinical restraints and direct constant observation) and the discontinuation of suicide watch;
(b) an evaluation by a QMHP before a prisoner is removed from suicide watch;
(c) every prisoner discharged from FIP following a period of suicide watch will be housed upon release in the least restrictive setting deemed clinically appropriate unless exceptional circumstances affecting the facility exist; and
(d) all FIP discharges following a period of suicide watch will be seen by a QMHP within 72 hours of FIP release, or sooner if indicated, unless exceptional circumstances affecting the facility exist.
STATUS: NON-COMPLIANCE
Substantial Compliance requires DMH to review the medical records of all prisoners on suicide watch in FIP for one randomly selected month each quarter, and submit a report regarding the implementation of the step-down protocols and the results of its review of the medical records. Previously, the Monitor did not rate the County's compliance with Paragraph 41 because all FIP patients on suicide watch during the period either remained on suicide watch at the end of the period or "did not remain in the system (they were transferred to prison), and therefore did not go through the protocols."
During the Fifth Reporting Period, the parties agreed to revise the Compliance Measures to increase the number of inmates subject to the step-down protocols of Paragraph 41 and ensure that the implementation of step-down protocols for FIP patients on suicide watch "ameliorate the impact of the restrictions" and have the necessary "level of precautions based upon individual assessment[s]" of the patients. The revised Compliance Measures were reviewed by the Mental Health Subject Matter Expert.
The County's Eighth Self-Assessment reports that the "County finalized a revised EMR template to more meaningfully assess the County's compliance with this [revised] Compliance Measure." It reports that "56% -- rather than the required 95% -- of the prisoners discharged from FIP during the [Fourth Quarter of 2018 after having been on suicide watch] met the requirements set forth in Compliance Measure 41-4." The County's Augmented Eighth Self-Assessment reports that only 27% of the prisoners discharged from FIP during the First Quarter of 2019 met these requirements.
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42. Consistent with existing DMH policies, the County and the Sheriff will implement step-down protocols to ensure that prisoners admitted to HOH and placed on risk precautions are assessed by a QMHP. As part of the assessment, the QMHP will determine on an individualized basis whether to implement "step-down" procedures for that prisoner as follows:
(a) the prisoner will be assessed by a QMHP within three Normal business work days, but not to exceed four days, following discontinuance of risk precautions;
(b) the prisoner is counseled to ameliorate the negative psychological impact that any restrictions may have had and in ways of dealing with this impact;
(c) the prisoner will remain in HOH or be transferred to MOH, as determined on a case-by-case basis, until such assessment and counseling is completed, unless exceptional circumstances affecting the facility exist; and
(d) the prisoner is subsequently placed in a level of care/housing as determined by a QMHP.
STATUS: PARTIAL COMPLIANCE
The County’s Eighth Self-Assessment reports that for the Fourth Quarter of 2018 at CRDF, 100% of the medical records reviewed reflected that "inmates in HOH and placed on risk precautions were assessed by a QMHP;" "23% -- instead of the required 90% -- of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and "75% -- rather than the required 85% - of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 98%, 68%, and 25%. There was a slight overall improvement at both facilities from the prior quarter.
The County's Augmented Eighth Self-Assessment reports that for the First Quarter of 2019 at CRDF, 100% of the records "reflected that inmates in HOH and placed on risk precautions were assessed by a QMHP;" 34% "of the records reflected that the QMHP determined on an individualized basis whether to implement step-down procedures;" and 33% "of the records reflected that step-down procedures were implemented per the QMHP assessment, where applicable." For this quarter at TTCF, the results in these categories were 100%, 89%, and 60%.
The Eighth Self-Assessment reports that a working group has
met frequently, and also met specifically with the Mental Health Subject Matter Expert during the Reporting Period, to ensure the County follows a clear and clinically sound approach [to risk precaution step-down
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protocols]. Among other things, the County’s new risk precaution process incorporates additional supervisory consultation and input, required implementation of the step-down process for all inmates being removed from risk precaution and the establishment of a clearer treatment plans and goals. The County also revised the Risk Assessment for Suicide tool (formerly the SRAC) to ensure risk precaution criteria were consistent with that tool and allowed for risk assessment independent of risk precaution criteria and P-level. The Mental Health Subject Matter Expert noted that the County has "taken appropriate steps to improve the criteria, process, and management of risk precautions." Notwithstanding the quantitative results at CRDF, the Monitor finds that the County is in Partial Compliance at both facilities based upon the Mental Health Subject Matter Expert's assessment.
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43. Within six months of the Effective Date, the County and the Sheriff will develop and implement written policies for formal discipline of prisoners with serious mental illness incorporating the following:
(a) Prior to transfer, custody staff will consult with a QMHP to determine whether assignment of a prisoner in mental health housing to disciplinary housing is clinically contraindicated and whether placement in a higher level of mental health housing is clinically indicated, and will thereafter follow the QMHP's recommendation;
(b) If a prisoner is receiving psychotropic medication and is placed in disciplinary housing from an area other than mental health housing, a QMHP will meet with that prisoner within 24 hours of such placement to determine whether maintenance of the prisoner in such placement is clinically contraindicated and whether transfer of the prisoner to mental health housing is clinically appropriate, and custody staff will thereafter follow the QMHP's recommendation;
(c) A QMHP will participate in weekly walks, as specified in paragraph 38, in disciplinary housing areas to observe prisoners in those areas and to identify those prisoners with mental health needs; and
(d) Prior to a prisoner in mental health housing losing behavioral credits for disciplinary reasons, the disciplinary decision-maker will receive and take into consideration information from a QMHP regarding the prisoner’s underlying mental illness, the potential effects of the discipline being considered, and whether transfer of the prisoner to a higher level of mental health housing is clinically indicated.
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STATUS (43):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified) at NCCF and PDC North)

PARTIAL COMPLIANCE (at CRDF, MCJ, and TTCF)

In response to comments by the Monitor and DOJ, the Department submitted proposed revisions to its discipline policies on May 30, 2017. After consulting with the Subject Matter Experts, the Monitor provided his written comments to the Department on June 29, 2017. The DOJ provided its comments to the Department the same day. The County's Eighth Self-Assessment reports that the Department is still "in the process of finalizing the revised policies related to discipline and the mentally ill."

The County's Eighth Self-Assessment reports "no inmates with mental illness lost behavioral credits for disciplinary reasons" during the Fourth Quarter of 2018 or the First Quarter of 2019. The Eighth Self-Assessment again summarizes the practices regarding the discipline for inmates with P2, P3, and P4 designations in mental health housing locations.28 It also reports that the County "continues to use its revised process for receiving notice of P1 inmates residing in General Population who are scheduled to receive discipline," but reiterates that "the County continues to experience staffing shortages that impact its ability to achieve Substantial Compliance" with this provision.

The County previously reported that that it had achieved Substantial Compliance at NCCF and PDC for twelve consecutive months. These results were verified by the Monitor's auditors, and NCCF and PDC North were not subject to monitoring in the Eighth Reporting Period.

The Eighth Self-Assessment reports that for the Fourth Quarter of 2018, 100% of the weekly row walks required by Compliance Measure 43-9(d) occurred at MCJ, but only 70% of the meetings required pursuant to Compliance Measure 43-9(c) occurred, which is well-below the 90% threshold for Substantial Compliance when inmates receiving psychotropic medications are transferred to disciplinary housing from areas other than mental health housing.29

The County's Eighth Self-Assessment reports that for the Fourth Quarter of 2018, 58% of the required consultations at CRDF "occurred prior to transfers from mental health housing;" 87% of the required meetings occurred when inmates receiving psychotropic medications are transferred to disciplinary housing from areas other than mental health housing; and 100% of the weekly row walks through disciplinary units occurred. The results for TTCF were 81%, 95%, and 100%. For MCJ, 70% of the required meetings and 100% of the row walks occurred.

28 The Mental Health Subject Matter Expert and clinicians report that they "have not seen any evidence of
mentally ill [inmates] transferred from HOH to disciplinary housing[.]" 29 It appears that Compliance Measure 43.9(b) was not applicable to MCJ during this period because it did
not have any prisoners transferred to disciplinary housing from mental health housing.

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The County's Eighth Self-Assessment also reports that for the First Quarter of 2019, 70% of the required consultations at CRDF "occurred prior to transfers from mental health housing;" 88% of the required meetings occurred when inmates receiving psychotropic medications are transferred to disciplinary housing from areas other than mental health housing; and 100% of the weekly row walks through disciplinary units occurred. The results for TTCF were 89%, 88%, and 100%30 and for MCJ were 100%, 47%, and 80%.
During a May 2019 site visit, the Mental Health Subject Matter Expert and the clinicians reviewed the records of inmates in HOH and MOH at CRDF and TTCF who were subject to discipline to assess the Department's compliance with Paragraph 43. They found that in 67% of the cases the QMHP evaluated the inmate before discipline was imposed; in 61% of the cases "the QMHP considered whether a higher level of housing was indicated;" and 67% of the cases "demonstrated evidence of the recommendations being based on the clinical condition of the patient." They also found that in 74% of the cases, the QMPH considered "whether discipline was contraindicated." They also reviewed the records of inmates in General Population on psychotropic medication who were subject to discipline and found that 88% of the inmates "were evaluated by a QMHP" before discipline was imposed; 76% were seen by the QMHP within 24 hours; and "89% were considered for a higher level of mental health housing." They also found that in 81% of the cases the QMHP considered "contraindications to discipline" and in 85% of the cases there was evidence that the QMHP's recommendations were "based on the clinical condition of the [inmate]."
In conclusion, the Subject Matter Expert and clinicians found that "Some QMHP's are doing a good job addressing [the requirements of Paragraph 43], especially those who are assigned this task specifically." Nevertheless,
there are still many cases where QMHP's are assessing whether the patient's mental health condition contributed to the problem behavior, which is not what they should be doing. It is also highly concerning that there are no instances where contraindications to discipline were identified, despite a number of those assessed having very severe mental illnesses. It does not seem that QMHPs have a clear sense of what might constitute a contraindication to discipline. While they address the patient's mental health condition, there is rarely any discussion of the nature of discipline proposed and how it might affect the patient's mental health.
Moreover, "the nature of the discipline is unclear in most instances. It is also not being addressed by the QMHPs conducting these assessments."
30 The Mental Health Subject Matter Expert and the clinicians have expressed a concern that the County's compliance "methodology may still be a mechanical exercise in determining whether contacts were made and documented rather than whether they are conducting a meaningful mental health assessment pertaining to their disciplinary practices."
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44. Within six months of the Effective Date, the County and the Sheriff will install protective barriers that do not prevent line-of-sight supervision on the second floor tier of all High Observation Housing areas to prevent prisoners from jumping off of the second floor tier. Within six months of the Effective Date, the County and the Sheriff will also develop a plan that identifies any other areas in mental health housing where such protective barriers should be installed.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County has maintained Substantial Compliance with Paragraph 44 of the Agreement since January 1, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 44 was not subject to monitoring during the Eighth Reporting Period.
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45. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will provide both a Suicide Intervention Kit that contains an emergency cut-down tool and a first-aid kit in the control booth or officer’s station of each housing unit. All custody staff who have contact with prisoners will know the location of the Suicide Intervention Kit and first-aid kit and be trained to use their contents.

STATUS:

SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 (verified) at CRDF, NCCF, PDC East, PDC South, and TTCF)

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ and PDC North)

The County maintained Substantial Compliance with Paragraph 45 for twelve consecutive months at all facilities as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 45 was not subject to monitoring during the Eighth Reporting Period.

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46. The County and the Sheriff will immediately interrupt, and if necessary, provide appropriate aid to, any prisoner who threatens or exhibits self-injurious behavior.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to review the documentation from randomly selected incidents involving prisoners who threaten or exhibit selfinjurious behavior, and include an assessment of the timeliness and appropriateness of the Department’s responses to these incidents in its semi-annual Self-Assessment. The County's Eighth Self-Assessment reports that for the Fourth Quarter of 2018, "96% -- 1% more than the required 95% -- of the records reviewed . . . reflected that appropriate aid and (when necessary) immediate interruption of self-injurious behavior was provided by the Department." It also reports that for the First Quarter of 2019, 97% of the records reflect that the Department provided appropriate aid and necessary interruption.
The County's Eighth Self-Assessment notes that the "Department has continuously reported Substantial Compliance with this Provision beginning in Second Quarter 2018" based upon the use of the electronic BOMHR. The Monitor and the Mental Health Subject Matter reviewed the source documents posted by the County for the randomly selected incidents involving prisoners who threatened or exhibited selfinjurious behavior in Fourth Quarter of 2018 and the First Quarter of 2019. Many of the BOMHRs involved expression of suicidal ideation, which, as previously noted by the Mental Health Subject Matter Expert,31 do not involve threatened self-injurious behavior and thus "required no interruption."
For many of the cases involving inmates who threatened or exhibited selfinjurious behavior (i.e., more than suicidal ideation), the BOMHRs reflect what the Department did to "interrupt" the behavior and what aid the County healthcare personnel provided to the prisoners. In some cases where the BOMHR does not specifically state what the Department did to interrupt the behavior, it can be inferred what the Department did. And in some cases where the BOMHR does not specifically state what aid was provided, the County provided additional documentation consisting of medical records, incident reports, or injury assessments that provided this information. In a number of cases, however, it is not possible to tell from the BOMHR if the interruption was "immediate."
With additional information regarding the timing and the nature of the "interruption," the BOMHRs (as supplemented by medical records if necessary) can be used to achieve Substantial Compliance with Paragraph 46, subject to random reviews of videos to confirm the information on the BOMHRs.32
31 See Monitor's Seventh Report, p. 51. 32 The Monitor suggests that the Department revise the BOMHR as follows: delete the OBERVED BEHAVIORS LINE under OBSERVATIONS, change the COMMENTS block to INMATE'S BEHAVOR, and add a block entitled TIME AND NATURE OF DEPARTMENT'S RESPONSE. It will then be readily apparent from the BOMHR what the Department did to interrupt the behavior and the timing of the interruption. In the alternative, the Department could rely on other source documents such as incident reports
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47. The County and the Sheriff will ensure there are sufficient custodial, medical, and mental health staff at the Jails to fulfill the terms of this Agreement. Within six months of the Effective Date, and on a semi-annual basis thereafter, the County and the Sheriff will, in conjunction with the requirements of Paragraph 92 of this Agreement, provide to the Monitor and DOJ a report identifying the steps taken by the County and the Sheriff during the review period to implement the terms of this Agreement and any barriers to implementation, such as insufficient staffing levels at the Jails, if any. The County and the Sheriff will retain staffing records for two years to ensure that for any critical incident or non-compliance with this Agreement, the Monitor and DOJ can obtain those records to determine whether staffing levels were a factor in that critical incident and/or non-compliance.
STATUS: NON-COMPLIANCE The County has provided a list of each critical incident during the Eighth Reporting Period, but has not assessed "whether staffing was a factor in any noncompliance with the Agreement, any critical incident, or the Department's handling of an incident." The County's Augmented Eighth Self-Assessment reports that CCSB has "developed a program to assist facilities in identifying how staffing levels may have impacted assaults on staff and/or Category 3 uses of force[.]"
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48. Within three months of the Effective Date, the County and the Sheriff will have written housekeeping, sanitation, and inspection plans to ensure the proper cleaning of, and trash collection and removal in, housing, shower, and medical areas, in accordance with California Code of Regulations ("CCR") Title 15 § 1280: Facility Sanitation, Safety, and Maintenance.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016)
The County maintained Substantial Compliance with Paragraph 48 of the Agreement at all facilities for twelve consecutive months as of December 31, 2016. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 48 was not subject to monitoring during the Eighth Reporting Period, but the Monitor did observe "an acceptable level of cleanliness, sanitation, repair and safety" during tour of each facility. The Monitor and the Use of Force Subject Matter Expert were impressed with the conditions and cleanliness in TTCF and NCCF during this period.
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49. Within three months of the Effective Date, the County and the Sheriff will have a maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, sink, and lighting units, and heating, ventilation, and cooling system are adequately maintained and installed. The plan will also include steps to treat large mold infestations.
STATUS: SUBSTANTIAL COMPLIANCE (as of March 1, 2016, through February 28, 2017)
The County maintained Substantial Compliance with Paragraph 49 of the Agreement at all facilities for twelve consecutive months as of February 28, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 49 was not subject to monitoring during the Eighth Reporting Period. Nevertheless, during inspections in the Eighth Reporting Period, the Monitor noted that inmates at NCCF in particular complained about the heating and cooling systems at that facility.
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50. Consistent with existing Sheriff’s Department policies regarding control of vermin, the County and the Sheriff will provide pest control throughout the housing units, medical units, kitchen, and food storage areas.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at all facilities other than PDC South and PDC East)

SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 (verified) at PDC South and PDC East)

The County maintained Substantial Compliance with Paragraph 50 of the Agreement at all facilities for twelve consecutive months as of March 31, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 50 was not subject to monitoring during Eighth Reporting Period.

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51. Consistent with existing Sheriff’s Department policies regarding personal care items and supplies for inmates, the County and the Sheriff will ensure that all prisoners have access to basic hygiene supplies, in accordance with CCR Title 15 § 1265: Issue of Personal Care Items.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) for all facilities other than CRDF)

SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (verified) at CRDF)

The County maintained Substantial Compliance with Paragraph 51 of the Agreement at all facilities for twelve consecutive months as of June 30, 2017. Pursuant to Paragraph 111 of the Settlement Agreement, Paragraph 51 was not subject to monitoring during the Eighth Reporting Period.

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52. The County and the Sheriff will implement policies governing property restrictions in High Observation Housing that provide:
(a) Except when transferred directly from FIP, upon initial placement in HOH:
(i) Suicide-resistant blankets, gowns, and mattresses will be provided until the assessment set forth in section (a)(ii) below is conducted, unless clinically contraindicated as determined and documented by a QMHP.
(ii) Within 24 hours, a QMHP will make recommendations regarding allowable property based upon an individual clinical assessment.
(b) Property restrictions in HOH beyond 24 hours will be based on clinical judgment and assessment by a QMHP as necessary to ensure the safety and well-being of the prisoner and documented in the electronic medical record.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to (1) randomly inspect the cells of prisoners placed in HOH (except from FIP) within the previous 24 hours to confirm that they have been provided with suicide-resistant blankets, gowns and mattresses unless clinically contraindicated, and document the results of the inspection; (2) randomly inspect the cells of prisoners placed in HOH (except from FIP) for more than 24 hours to confirm that they have been provided with allowable property as recommended by a QMHP; and (3) review the electronic medical records of prisoners assigned to HOH on the days of those inspections to verify compliance with the provisions of Paragraph 52. All of the Compliance Measures have a 95% threshold for Substantial Compliance.
The County’s Eighth Self-Assessment reports that in the Fourth Quarter of 2018, 100% of the inmates initially placed in HOH at CRDF were provided the property required by Paragraph 52 and 100% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.];" but only 14% "of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP regarding allowable property;" and 16% "of electronic medical records for inmates assigned to HOH reflect that property restrictions were based upon the clinical judgment of a QMHP."
Also for the Fourth Quarter of 2018, the County reports that 89% of the inmates initially placed in HOH at TTCF were provided the property required by Paragraph 52; and 96% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP;" 35% of the electronic medical records "reflected a recommendation by a QMHP regarding allowable property;" and 77% of the records "reflect that property restrictions were based upon the clinical judgment of a QMHP."
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The County's Augmented Eighth Self-Assessment reports that for the First Quarter of 2019, 95% of the inmates initially placed in HOH at CRDF were provided the property required by Paragraph 52; 28% "of the electronic medical records for inmates assigned to HOH reflected a recommendation by a QMHP;" 15% of the records "reflect that property restrictions were based upon the clinical judgment of a QMHP;" and 93% of the inmates in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
For TTCF, in the First Quarter of 2019, 92% of the inmates initially placed in HOH were provided the property required by Paragraph 52; 44% of the records "reflected a recommendation by a QMHP;" 71% of the records reflect that the "property restrictions were based upon the clinical judgment of a QMHP;" and 92% of the inmates placed in HOH "for more than 24 hours" had "allowable property as recommended by a QMHP[.]"
During a January 2019 site visit, the Mental Health Subject Matter Expert and the clinicians reviewed "[w]hether there was an assessment by a QMHP within 24 hours" and "qualitatively evaluated whether the restrictions were based on an analysis of relevant risks." They found that a QMHP provided an initial assessment in 96% of the cases reviewed, and within 24 hours in 84% of those cases. The Subject Matter Expert reports that their qualitative evaluation showed that the allowable property was based on the relevant risks in 50% of the cases. While this is "an improvement," he notes that "there was often no discussion of why certain items were restricted or even why restrictions were needed at all. Restrictions were often put in place when the structured suicide risk assessment indicated low risk and there was no documentation or analysis demonstrating that restrictions were needed." They also found that there were "current assessments" in 78% of the cases. They concluded that "the County is doing a reasonable job at providing property consistent with the recommendations of the QMHPs, but that the quality of the assessments underlying these recommendations remains inconsistent and often poor." Based upon the qualitative assessment by the Mental Health Subject Matter Expert and the clinicians, the Monitor is of the view that the Department has achieved Partial Compliance with Paragraph 52.
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53. If otherwise eligible for an education, work, or similar program, a prisoner’s mental health diagnosis or prescription for medication alone will not preclude that prisoner from participating in said programming.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to audit the records of prisoners who were eligible, but rejected or disqualified, for education and work programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for medication alone. The County's Eighth Self-Assessment reports that 80% and 61% of the mentally ill prisoners who were eligible for and denied work in the Fourth Quarter of 2018 and the First Quarter of 2019 were not denied the work due to a mental health diagnosis or prescription for psychotropic medication alone. The County's Eighth Self-Assessment also reports that in the First Quarter of 2019 "staffing and other issues caused a number of requests to be unanswered in a timely manner per Department policy. The Department counted requests that were not answered in a timely manner as 'denied' for purposes of its assessment whether or not those requests were ultimately granted or denied for a reason unrelated to an inmates mental health diagnosis or prescription medication. The Department hopes to have these timeliness issues resolved in the coming quarters."33
33 The Mental Health Subject Matter Expert and clinicians noted that "[o]verall, the organization of the information posted [by the Department] remains somewhat difficult to follow and interpret." They suggest using aggregate data (e.g., comparing the rate of denials for the mentally ill with the denials for the nonmentally ill) to establish "proof of practice."
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54. Prisoners who are not in Mental Health Housing will not be denied privileges and programming based solely on their mental health status or prescription for psychotropic medication.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the Department to audit the records of a maximum of 100 randomly selected prisoners who were eligible and denied privileges or programs to confirm that they were not rejected or disqualified because of a mental health diagnosis or prescription for psychotropic medication alone. In the Fifth Reporting Period, the County reported that it achieved and maintained Substantial Compliance for the period from March 1, 2016 through December 31, 2016. The results were verified by the Monitor’s auditors.
The revised Compliance Measures for Paragraph 54, effective January 1, 2018, provide for an alternative pool of inmates proposed by the County. Because the Monitor's auditors had verified that the County has maintained Substantial Compliance under the original Compliance Measures, the parties agreed that the County will only be required to maintain Substantial Compliance under the revised Compliance Measures for two additional quarters.
The County's Eighth Self-Assessment reports Substantial Compliance in the Fourth Quarter of 2018, but only Partial Compliance in the First Quarter of 2019. The Self-Assessment reports that "[n]o inmates were denied requests based on their mental health status or receipt of a prescribed psychotropic medication" in the Fourth Quarter of 2018. Similarly, no inmates were denied visits for those reasons in the First Quarter of 2019.
According to the results posted by the Department, 40% of the inmate requests that were denied in the in the First Quarter of 2019 were deemed to be non-compliant because they "were not answered timely or not answered and have no disposition." The results also reflect that no inmates were denied visits solely due to their medications or mental health status.
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55. Relevant custody, medical, and mental health staff in all High Observation Housing units will meet on Normal business work days and such staff in all Moderate Observation Housing units will meet at least weekly to ensure coordination and communication regarding the needs of prisoners in mental health housing units as outlined in Custody Services Division Directive(s) regarding coordination of mental health treatment and housing. When a custody staff member is serving as a member of a treatment team, he or she is subject to the same confidentiality rules and regulations as any other member of the treatment team, and will be trained in those rules and regulations.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through September 30, 2017 (verified) at CRDF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017 through March 31, 2018 (verified) at PDC North)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through September 30, 2018 (verified) and through March 31, 2019 (unverified) at MCJ)
PARTIAL COMPLIANCE (at TTCF)
The Department maintained Substantial Compliance for twelve consecutive months through the Third Quarter of 2017 at CRDF and through the First Quarter of 2018 at PDC North. These results were verified by the Monitor's auditors, and CRDF and PDC North were not subject to monitoring for compliance with Paragraph 55 in the Eighth Reporting Period.
The County's Eighth Self-Assessment reports Substantial Compliance for the Fourth Quarter of 2018 and for the First Quarter of 2019 at MCJ for Compliance Measures 55-2, 55-6(a) and 55-6(b), which require daily staff meetings in HOH and weekly meetings in MOH attended by representatives from custody, medical, and mental health. The County posted results for TTCF reflect that only 80% of the required meetings in MOH were held during the randomly selected month, which is below the thresholds for Substantial Compliance required by Compliance Measures 55-6(a) and 556(b). The results at MCJ for the Fourth Quarter of 2018 and the First Quarter of 2019 are subject to verification by the Monitor's auditors.
The County has submitted a report "verifying the coordination and communication at the staff meetings" in HOH and/or MOH units at TTCF and MCJ during the last six months of 2018.34 If the results for MCJ for the Fourth Quarter of 2018 and the First Quarter of 2019 are verified by the Monitor's auditors, MCJ will no longer be subject to monitoring for compliance with Paragraph 55.
34 Although, as noted by DOJ, some of the MOH minutes from MCJ are lacking in detail, the County's report of the meetings attended by CCSB "verify the coordination and communication" between the Department and DHS personnel at those meetings as required under the Settlement Agreement.
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56. Consistent with existing DMH and Sheriff’s Department policies, the County and the Sheriff will ensure that custody, medical, and mental health staff communicate regarding any change in a prisoner’s housing assignment following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified))
Substantial Compliance requires the Department to review in randomly selected periods the electronic medical records of (1) prisoners admitted to HOH following a suicide threat, gesture, or attempt, or other indication of an obvious and serious change in mental health condition to determine if the medical and/or mental health staff approved the placement of the prisoner in HOH; and (2) prisoners who were the subject of a suicide attempt notification to determine if the prisoners were clinically assessed and that clinical staff approved the post-incident housing.
The County’s Substantial Compliance results for the twelve months from January 1, 2016, through December 31, 2016, were verified by the Monitor's auditors, and the County was not subject to monitoring for compliance with Paragraph 56 during the Eighth Reporting Period.
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57. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks to ensure a range of supervision for prisoners housed in Mental Health Housing. The County and the Sheriff will ensure that safety checks in Mental Health Housing are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner;
(b) Custody staff will document their checks in a format that does not have pre-printed times;
(c) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks;
(d) Video surveillance may not be used to replace rounds and supervision by custodial staff unless new construction is built specifically with constant video surveillance enhancements and could only be used to replace 15 minute checks in non-FIP housing, subject to approval by the Monitor;
(e) A QMHP, in coordination with custody (and medical staff if necessary), will determine mental health housing assignments; and
(f) Supervision of prisoners in mental health housing will be conducted at the following intervals: (i) FIP: Custody staff will perform safety checks every 15 minutes. DMH staff will perform direct constant observation or one-to-one observation when determined to be clinically appropriate; (ii) High Observation Housing: Every 15 minutes; (iii) Moderate Observation Housing: Every 30 minutes.
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STATUS (57):

SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at MCJ)

PARTIAL COMPLIANCE (at PDC North, TTCF and CRDF)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records if the Title 15 scanner was not working) for all shifts for each module in each mental health housing unit in two randomly selected weeks to determine if the safety checks were staggered and conducted as required by Paragraph 57 of the Agreement, and to audit the housing records for each mental health housing unit for one randomly selected week to determine if a QMHP approved the new mental health housing assignments as required by Paragraph 57(e). The thresholds for achieving Substantial Compliance with these two Compliance Measures is 95%.

The County’s Sixth Self-Assessment reported that it maintained Substantial Compliance with Compliance Measure 57.5(b) in the Fourth Quarter of 2017 and the First Quarter of 2018 in the MOH unit at MCJ (the "Hope Dorm"). It also reported that all of the inmates at MCJ "analyzed pursuant to Compliance Measure 57-5(c) had received QMHP approval for their housing assignments" in both quarters. The results were verified by the Monitor's auditors and MCJ was not subject to monitoring for compliance with Paragraph 57 in the Eighth Reporting Period.

The County's Eighth Self-Assessment reports that the County achieved Partial Compliance with the safety checks in the mental health housing units at TTCF (63% and 48%) and CRDF (69% and 66%) in the Fourth Quarter of 2018 and the First Quarter of 2019. These results are significantly below the results in the prior reporting period. The Self-Assessment also reports that 100% of the new mental health housing assignments in CRDF were approved by a QMHP in the Fourth Quarter of 2018, but only 93% in the First Quarter of 2019, which is below the 95% threshold for Substantial Compliance. The results for TTCF were 98% and 96% in these quarters.

The Self-Assessment also reports that the County achieved Substantial Compliance in the MOH units at PDC North in the Fourth Quarter of 2018 (96%) which it maintained in the First Quarter of 2019 (98%). As noted by DOJ, and confirmed by the auditors, the safety checks at PDC North were not staggered as "safety checks have been almost always in Module 2's A-dorm and end in the D-dorm, and the safety checks begin almost on the dot every 24 minutes."

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58. Within three months of the Effective Date, the County and the Sheriff will revise and implement their policies on safety checks. The County and the Sheriff will ensure that safety checks in non-mental health housing units are completed and documented in accordance with policy and regulatory requirements as set forth below:
(a) At least every 30 minutes in housing areas with cells; (b) At least every 30 minutes in dormitory-style housing units where the unit
does not provide for unobstructed direct supervision of prisoners from a security control room; (c) Where a dormitory-style housing unit does provide for unobstructed direct supervision of prisoners, safety checks must be completed inside the unit at least every 60 minutes; (d) At least every 60 minutes in designated minimum security dormitory housing at PDC South, or other similar campus-style unlocked dormitory housing; (e) Custody staff will conduct safety checks in a manner that allows staff to view the prisoner to assure his or her well-being and security. Safety checks involve visual observation and, if necessary to determine the prisoner’s well-being, verbal interaction with the prisoner; (f) Custody staff will document their checks in a format that does not have pre-printed times; (g) Custody staff will stagger checks to minimize prisoners’ ability to plan around anticipated checks; and (h) Video surveillance may not be used to replace rounds and supervision by custodial staff.
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STATUS (58):

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at PDC South, PDC North, and PDC East)

SUBSTANTIAL COMPLIANCE ( as of July 1, 2017, through June 30, 2018 (verified) at CRDF)

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified) at IRC)

PARTIAL COMPLIANCE (at TTCF, NCCF, and MCJ)

Substantial Compliance requires the Department to audit the Title 15 Dashboard records (or UDAL records) for all shifts for each module in each housing unit to determine if the safety checks were staggered and conducted as required by Paragraph 58. The threshold for achieving Substantial Compliance with each of the Compliance Measures is 90%.

The County maintained Substantial Compliance with Paragraph 58 for twelve consecutive months at PDC South, PDC North, and PDC East as of December 31, 2016. Pursuant to Paragraph 111, those facilities were not subject to monitoring in the Eighth Reporting Period.

The County's Sixth Self-Assessment reported that for the Fourth Quarter of 2017 and the First Quarter of 2018, the following percentages of safety checks were in compliance with Paragraph 58: CRDF (93% and 90%); TTCF (95% and 97%); MCJ (94% and 92%); NCCF (82% and 58.5%); and IRC (95% and 92%). Based upon the audit by the Monitor's auditors, however, it did not appear that the cell checks at MCJ and TTCF were staggered as required by Paragraph 58.

The County's Seventh Self-Assessment reported that 88% of the safety checks at CRDF and 89% of the checks at IRC in the Second Quarter of 2018 were in compliance with Paragraph 58, which is slightly below the 90% threshold for Substantial Compliance. It nevertheless requested a Substantial Compliance finding because "the safety checks on the relevant dates were timely conducted under Compliance Measure 58-2, however, there were technical difficulties uploading the scans from iPods" during the random weeks at both facilities. Excluding the one day (June 19, 2018) that the UDAL Main Report showed a problem with uploading iPod scans at CRDF, the percentage of compliant rounds at CRDF was 94.7%.

Excluding the one day (May 12, 2018) on which it appears from the UDAL Main Report that the Title 15 scanner was not working at IRC, the percentage of compliance in the Second Quarter of 2018 was 91%. The Seventh Self-Assessment reported that 92% of the safety checks in the Third Quarter of 2018 at IRC were in compliance with Paragraph 58. The County's Eighth Self-Assessment also reports that for the Fourth

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Quarter of 2018 and the First Quarter of 2019, the following percentages of safety checks were in compliance with Paragraph 58 at the remaining facilities: MCJ (78% and 75%); TTCF (92% and 73%); and NCCF (74% and 75%).
The Substantial Compliance results at IRC have been confirmed by the Monitor’s auditors and IRC was not subject to monitoring for compliance with Paragraph 58 in the Eighth Reporting Period.
The Substantial Compliance results at CRDF have been by the Monitor's auditors,35 and CRDF was not subject to monitoring for compliance with Paragraph 58 in the Eighth Reporting Period.
35 The Monitor’s auditors reviewed a few randomly selected videos for those days when the scanners were not working properly and verified that the safety checks occurred.
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59. Consistent with existing Sheriff’s Department policies regarding uniform daily activity logs, the County and the Sheriff will ensure that a custodial supervisor conducts unannounced daily rounds on each shift in the prisoner housing units to ensure custodial staff conduct necessary safety checks and document their rounds.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31, 2017 (verified) at PDC East and MCJ)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 (verified) at NCCF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified) at CRDF)
SUBSTANTIAL COMPLIANCE (as of January 1, 2018, through December 31, 2018 (verified) at PDC North and PDC South)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018. through March 31, 2019 (verified) at TTCF)
Substantial Compliance requires the Department to audit e-UDAL records for housing units in each facility to determine if supervisors are conducting unannounced daily rounds in accordance with Paragraph 59. In response to the Monitor's comments, the Department's e-UDAL forms were modified to include a specific notation that the Supervisor verified that the safety checks were conducted. The threshold for achieving and maintaining Substantial Compliance is that 90% of the supervisor daily rounds were in compliance with the requirements of Paragraph 59.
The County's Sixth Self-Assessment reported that the Department had maintained Substantial Compliance at PDC East and MCJ for twelve consecutive months from January 1, 2017 through December 31, 2017 (and continuing to March 31, 2018). It also reported that the Department had maintained Substantial Compliance at NCCF for twelve consecutive months from April 1, 2017 through March 31, 2018. The results were verified by the Monitor's auditors and these facilities were not subject to monitoring for compliance with Paragraph 59 during the Eighth Reporting Period.
The County's Seventh Self-Assessment reported that the following percentage of rounds were in compliance with the provision in the Second and Third Quarters of 2018: CRDF (98% and 91%), PDC North (97% and 97%), PDC South (93% and 99%), and TTCF (98% and 91%). These results were verified by the Monitor's auditors and CRDF was not subject to monitoring for compliance with Paragraph 59 during the Eighth Reporting Period.
The County's Eighth Self-Assessment reports that the following percentage of rounds were in compliance with the provision in the Fourth Quarter of 2018 for PDC
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North (100%) and PDC South (96%), and for the Fourth Quarter of 2018 and the First Quarter of 2019 for TTCF (95% and 94%). These results have been verified by the Monitor's auditors. PDC North, PDC South, TTCF, and NCCF have maintained Substantial Compliance for twelve consecutive months and are no longer subject to monitoring for compliance with Paragraph 59.
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60. Within six months of the Effective Date, the Department of Mental Health, in cooperation with the Sheriff’s Unit described in Paragraph 77 of this Agreement, will implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior.
STATUS: SUBSTANTIAL COMPLIANCE
Paragraph 60 requires the County to "implement a quality improvement program to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior." This is, as the County notes, "separate and distinct" from the requirements of Paragraphs 61 and 62 (although related to the requirements of Paragraph 77). The Compliance Measures for Paragraph 60, however, require the County to "identify and address . . . clinical issues" in the areas identified in Paragraph 61 of the Agreement" and corrective actions are taken to address "such issues." See Compliance Measures 60.1, 60.2(a), and 60.3(b).
On July 15, 2019, the County submitted CHS's Semi-Annual Report on Quality Improvement/Assurance, which includes data through the end of the First Quarter of 2019.36 The Report discusses "components" of a "multipronged plan to improve quality" that were developed or in use during these quarters as follows:"
"15 staff members graduated from the Quality Academy at LAC+USC . . . .Graduates of this program serve as QI leads and advisors at their home CHS facilities and service lines[.]"37
* * * *
CHS's Quality Improvement Committee ("QIC") now "meets monthly to work on improving the quality of care delivered across ICHS [Integrated Correctional Health Services]. Members represent departments, facilities, and service lines across ICHS." The "purpose" of the QIC "is to promote collaborative relationships" and "align organizational priorities[.]"
* * **
CHS's Department of Quality Improvement and Patient Safety ("QIPS") expanded its monthly Quality Dashboard so that it "now covers 41 metrics." CHS's Mental Health management is "in the process of reviewing" the metrics "that are specific to mental health matters to ensure that essential components of mental health service delivery are represented and tracked and that trends are established from which point QI projects are generated."
36 CHS submitted an amended report on July 18, 2019. 37 This report does not indicate how many of these graduates are from mental health.
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QIPS "developed a QI project template" that "serves as a road map to ensure all aspects of QI work are captured and reported." The Custody Health Services "Compliance Team developed a Mental Health Compliance Dashboard that tracks compliance with relevant DOJ Settlement Agreement provisions." It is "used at monthly [Quality Improvement Committee] QIC meetings to communicate progress towards compliance and assist with identifying key priorities."38
* * * *
CHS also invested "significant resources in updating, customizing, and training staff in its Safety Intelligence program, a patient safety incident reporting system."
The CHS Report includes recent activities of the Critical Incident Review Committee ("CIRC") and the Joint Quality Improvement Committee ("JQIC"). CHS's compliance team conducts "reviews of all self-directed violence (SDV) incidents occurring within the jail system and from those reviews [it] selects serious self-harm incidents and quality improvement cases to be presented at monthly CIRC meetings."39 Recently, SDV's with a lower "risk rating score" with "potentially systemic issues" have been reviewed at CIRC meetings and "tracked in the same manner as issues identified in standard CIRC cases." In addition, "standardized categories of terms" have been developed "to better identify and prioritize similar and repeated systematic issues," and "better enable [the County] to aggregate data and identify trends over a longer period of time."
Beginning in November 2018, JQIC meetings included reviews of "aggregate data in addition to follow-up and review of matters identified in the previous month's CIRC." The purpose is "to improve data analysis and the identification of trends" that could "inform QI projects or [CAPs] to address clinical or systemic issues placing inmates at risk for suicide or serious self-injurious behaviors." The CHS Compliance Team and CCSB, including "command level staff," meet monthly, "to discuss issues and data analysis to be presented to JQIC."
The Semi-Annual Report includes the following sections:
 the Correctional Treatment Center – Mental Health Unit (CTC-MHU), which reports a continuing decrease in use of clinical restraints in the unit through the First Quarter of 2019, which has "reduced demands on staffing" and "concerns for medical complications that may occur when an inmate/patient is placed in restraints."
38 CHS previously indicated that the dashboard would "track summary reports by facility, and nursing and mental health service, and outline trends, thresholds, and barriers to compliance and plans to resolve such barriers, as well as current and past compliance rates." See Monitor's Seventh Report, p. 69. 39 Summaries of the 11 cases reviewed at the monthly CIRC meetings in the Fourth Quarter of 2018 and First Quarter of 2019 are attached to the CHS Report.
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 A summary of the results of the STEP FORWARD program at CRDF that provides "early psychiatric intervention at intake for patient[s] with severe mental illness," which has resulted in a significant drop in the number of post-intake referrals for psychiatric services over the First Quarter of 2019, although it does not appear that the wait times between the date of the remaining post-intake referrals until the date the patient is seen have been reduced;
 the results of the MOH intake approach that has continued to reduce the wait time for patients/inmates with a P2 level of care housed in MOH to see a psychiatrist;
 a Pill Call Pilot program "to align pill call procedures with best practices" that has been expanded to cover all MOH housing units at TTCF in February 2019; and40
 Other QI projects and health care services, which reports on (a) a "significant improvement in the timeliness of processing patients with urgent/emergent needs through IRC" beginning in the Fourth Quarter of 2018; (b) substance use services, including withdrawal management pods at TTCF and CRDF and aggregate alcohol withdrawal management/detoxification data collected during the Fourth Quarter of 2018 and the First Quarter of 2019;41 (c) the County's "effort to establish a clear and clinically sound approach in addressing risk precaution (sic) and inmates at increased risk for serious self-harm and/or suicide," which included the development of a "new Risk Assessment for Suicide" that was activated on June 11, 2019; (d) a Quality Improvement Project that involved the creation of "a teaching tool" designed "to assist clinicians to better understand the intention of the Release Planning Section" of the Initial Mental Health Evaluation form, which resulted in a reported reduction "in non-compliant bookings" from 26 in the Third Quarter of 2018 to eight in the First Quarter of 2019; and (e) an analysis of aggregate data, identifying systemic issues and developing corrective action plans relating to "(i) transitions of care involving inmates returning to jail on a 5150 and (ii) an evaluation of individuals with multiple SDVs in TTCF pod 132F."42
40 The report does not indicate what impact, if any, improvements from the Pill Call Pilot Program had on addressing the problem of inmates hoarding medication. The County did, however, report a significant reduction from discovering 1,023 unauthorized medications found as a result of searches in the Fourth Quarter of 2018 at TTCF to 381 medications in the First Quarter of 2019, which was when the Pill Call Pilot program was expanded. See p. 84, n. 52 and n. 53, infra. It is also not clear what the County's plan is for expanding the program to CRDF. 41 The report does not, however, analyze this data or draw any conclusions regarding the efficacy of the services or the specialized pods. 42 The County's trend analysis shows "marked improvements" in its Compliance with Paragraph 30 of the Settlement Agreement, although the charts (Figures 5.3 and 5.4) provided in the report are somewhat difficult to understand and appear to show nine non-compliant bookings in the First Quarter of 2019.
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CHS's Semi-Annual Report summarizes the subjects presented at the May 8, 2019 Bi-Annual Suicide Prevention meeting, which was attended by 60 representatives of various County departments.
The CHS Semi-Annual Report sets forth aggregate data for 13 suicides43 in the period 2014 through the First Quarter of 2019, broken down by prior attempts or other serious self-injurious behavior, facility, method, demographics (age,44 ethnicity, and gender), and proximity to court date.45 It also includes aggregate data summaries of 941 incidents of Self-Directed Violence ("SDV") by 588 inmates from January 2018 through March 2019, and the cases that "met criteria for CIRC" in 2018 and in the First Quarter of 2019. The serious self-injurious incidents that were reviewed at CIRC meetings are broken down, by prior suicide attempts, facility, method, lethality (risk rating scores), age, ethnicity, gender, and proximity to court date.46 For the most part, the County's analysis of the aggregate data does not go beyond these breakdowns to identify clinical issues "that place prisoners at significant risk of suicide or self-injurious behavior," propose corrective actions or systemic improvements to address these issues, or state whether any such issues were addressed by "corrective actions and systemic improvements" during the reporting period. Nor does the report propose any further analysis of the data to identify any such issues or find opportunities for systemic improvements.
The Mental Health Subject Matter Expert previously noted that "CHS is clearly developing a sound QM System. It is based on well-established principles and methods of QM."47 CHS's Report is a comprehensive description of the County's overall efforts to "implement a quality improvement program," and it reflects that the County continued to enhance its QM program in the Eighth Reporting Period. It is also analyzing aggregate data in almost all of the areas required by the subparts of Paragraph 61. The Monitor and Mental Health Subject Matter Expert agree with the County that the assessment of the County's compliance with Paragraph 60 "should be driven by the ability of the Department to demonstrate a sound quality improvement process and the ability to demonstrate that process through specific quality improvement projects directed by management."
Given the significant enhancements in the County's quality improvement program, the Monitor and the Mental Health Subject Matter have concluded that it has
43 Two of the suicides occurred in station jails; the rest were in TTCF or MCJ. 44 The range of the age groups are different from a high of nine years (26-34) to a low of five years (35-39), which makes it difficult to draw meaningful comparisons among the age groups even when analyzing rates per 100,000 inmates per year. 45 The proximity to court data is for the Third Quarter of 2018 through the First Quarter of 2019. See Amended Report, Fig. 7.19. 46 The introduction to Section E refers to the 11 cases reviewed at CIRC meetings between October 2018 and March 2019, but then summarizes data from 2018 CIRC meetings that was reviewed at the June 2019 JQIC meeting. See p. 70. The subparts of Section E break down the CIRCs for the period January 2018 through the First Quarter 2019, see Amended Report, pp. 71-80, although there is an inconsistency in the number of CIRC incidents reviewed (either 36 or 35). Compare, Amended Report, pp. 71, 73, and 75 with pp. 72, 76, 78, and 80. 47 See Monitor's Seventh Report, p. 69.
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achieved Substantial Compliance with Paragraph 60. To maintain Substantial Compliance with Paragraph 60, CHS's next two annual reports must reflect that it has used the analysis of aggregate data to identify clinical issues in the areas set forth in Paragraph 61; "recommend" and "implement" corrective actions and systemic improvements in these areas; and measure the effectiveness of the actions and improvements in the prior reporting period.48
48 To achieve Substantial Compliance with the companion provisions of Paragraphs 61 and 62, the County needs to use its analysis of aggregate data to "recommend," "implement," and "track" and measure the effectiveness of corrective actions and systemic improvements.
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61. The quality improvement program will review, collect, and aggregate data in the following areas and recommend corrective actions and systemic improvements:
(a) Suicides and serious suicide attempts:
(i) Prior suicide attempts or other serious self-injurious behavior (ii) Locations (iii) Method (iv) Lethality (v) Demographic information (vi) Proximity to court date;
(b) Use of clinical restraints;
(c) Psychotropic medications;
(d) Access to care, timeliness of service, and utilization of the Forensic Inpatient Unit; and
(e) Elements of documentation and use of medical records.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County’s semi-annual reports to (a) review, collect, and aggregate data in the areas set forth in Paragraph 61; (b) recommend corrective actions and systemic improvements in those areas; and (c) assess the effectiveness of actions and improvements in prior reporting periods.
As noted above, the CHS Semi-Annual Report sets forth aggregate data for suicides for the period 2015 through the First Quarter of 2019; Self-Directed Violence ("SDV") incidents from January 2018 through the end of March 2019; and serious selfinjurious incidents that were reviewed at CIRC meetings during the reporting period and also incidents from January 2018. Albeit somewhat limited, the CHS Report reflects that the County is starting to analyze and use aggregate data in its quality improvement program "to identify and address clinical issues that place prisoners at significant risk of suicide or self-injurious behavior."
With respect to the SDV incidents, the report indicates some corrective actions and systemic improvements have resulted from aggregate SDV data. For example, JQIC analyzed the SDV data and created "a list of the top ten inmates responsible for the highest number of SDVs." It then "checked with CIRC and CCC [the Complex Case Committee] to ensure inmates with high numbers of SDVs received the highest level of review and if indicated were placed on the CCC to ensure there was an individual treatment plan with collaborative input from nursing, mental health, and medical
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services."49 The Mental Health Subject Matter Expert notes that "[p]art of the review of the effectiveness of the corrective action plans would be both to determine whether treatment plans are improved (an interim outcome measure) and then whether SDV incidents were reduced in frequency or severity in the high utilizer group (the final outcome measure)."
The CHS report also describes the QI "interventions" that were developed to address issues related to patients returning to jail from LAC+USC on a 5150 hold.50 The report also notes that the HOH units "with the lowest number of SDVs were found in those areas designated for specialized programming, including FIP Step Down and The Living Module," which "suggests that more concentrated programming and services contribute to patient stabilization and a decrease in self-injurious behavior[.]" Although not framed as a "recommendation," it should lead to an expansion of the modules with such programming and services or "further analysis to determine whether there are any systematic differences between the populations in specialized and non-specialized HOH units that might bear on expanding these program." In addition, based upon a review of SDV data from Module 132 in TTCF and a walk through in the Sterile Pod 132F, the County identified two "structural" issues that will be addressed by the Custody Facility Services Bureau.
The CHS Report includes two sections that "review, collect, and aggregate data" in the areas required by Paragraph 61(b) and (d):
 aggregate data on the significant decrease in the use of clinical restraints in the Mental Health Unit of the CTC over the period from 2015 through the First Quarter of 2019 and an analysis of the cause and effect of the decrease; and
 aggregate data on the admission, discharge, and readmission of patients in the CTC-MHU for admissions, discharges, and readmissions from 2014-15 through the First and Second Quarters of 2019.
With respect to the use of clinical restraints, CHS attributes this, in part, to changes in Custody's use of force policies and "an increase in using discussion and negotiation techniques to gain compliance from inmates/patients" and, in part, to the early use of "long-acting injectable (LAI) psychotropic mediations in CTC-MHU." With respect to the CTC admission-related data, CHS reports that its "goal in collecting this data is to develop methods to evaluate whether or not patients were on the inpatient service long enough to receive appropriate treatment, whether or not the percentage of medication compliance was adequate for discharge, and whether the patient was stable upon
49 The Mental Health Subject Matter Expert and clinicians note, however, that they have not seen any "real treatment plans" outside of FIP that outline clear, measurable goals and objectives and specify intervention to meet those goals. 50 The Mental Health Subject Matter Expert and clinicians note that the County has done this "very well," with a "true PSDA model" and "on-going tracking."
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discharge[.]" There are, however, no conclusions or proposed corrective actions or systemic improvements based upon this data in the CHS Report.
The Department and CHS have enhanced the analysis of aggregate data, but have not always connected the analysis to corrective actions or systemic improvements in each of the areas required by the subparts of Paragraph 61. The Mental Health Subject Matter Expert previously noted some of these projects do not reflect a "sufficient breadth of analysis of aggregate data to develop CAPs, which would set benchmarks and look at trends and patterns of usage." For example, there is no "analysis of general prescribing patterns or medication monitoring, both critical aspects of quality management of psychotropic prescribing." He also notes that the "'QI Projects Relating to the Use of Psychotropic Medication' are not really about psychotropic medications" under Paragraph 61(c). Rather, they concern access to and timeliness of care under Paragraph 61(d) and "hoarding/diversion and medication adherence. All are important, but none are really about the proper use of psychotropic medications."
The Monitor and Mental Health Subject Matter Expert do not disagree with the County's assertion that QI "projects should be driven by management, by management's priorities, and with management's evaluation and understanding of available resources in mind." In order to achieve Substantial Compliance with Paragraph 61, however, the County must "review, collect and aggregate data" in each of the areas set forth in the subparts of the paragraph and "recommend corrective actions and systemic improvements" where appropriate. While the County has analyzed aggregate data in most of these areas. it still needs to show that the analysis is driving corrective actions and systemic improvements and that it is measuring the actions and improvements against established benchmarks. The County will need to analyze data in each of the areas, implement corrective actions and systemic improvements, and measure their impact to achieve Substantial Compliance with Paragraph 61.
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62. The County and the Sheriff’s Unit described in Paragraph 77 of this Agreement will develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the County's semi-annual Self-Assessments to set forth (a) the "development of corrective action plans to address the most recent recommendations of the quality improvement program;" and (b) the "implementation and tracking of corrective action plans to address recommendations of the program in prior quarters." CCSB's Semi-Annual Report describes all of the corrective action plans identified during the Executive Inmate Death Reviews of suicides that occurred in Fourth Quarter of 2018 and the First Quarter of 2019 and the status of those CAPs as of the end of the quarter. It reports that CCSB "tracks all suicide-related CAPs," and the Department attended all six of the JQIC meetings "to discuss CAP/Issues that were developed during the CIRC meetings." It does not, however, provide any discussion of these CAPs. It also provides summaries of the information that CHS and CCSB collected from incidents of self-directed violence, but without showing how this information was used to "develop, implement, and track corrective action plans addressing recommendations of the quality improvement plan." The Department needs to set forth more information regarding the tracking of CAPs and the progress towards completion in order for the Monitor and Mental Health Subject Matter Expert to be able to evaluate the County's compliance with the requirements of Paragraph 62. It also needs to discuss whether these CAPS/Issues raise systemic issues, recommend systemic improvements, or assess the effectiveness of such improvements from prior reporting periods.
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63. The County and the Sheriff will maintain adequate High Observation Housing and Moderate Observation Housing sufficient to meet the needs of the jail population with mental illness, as assessed by the County and the Sheriff on an ongoing basis. The County will continue its practice of placing prisoners with mental illness in the least restrictive setting consistent with their clinical needs.

STATUS: NON-COMPLIANCE

The Compliance Measures require that the County's Self-Assessment set forth (a) the average daily populations in HOH and MOH units in TTCF and CRDF during the reporting period; (b) the average number of beds in those units during the reporting period; (c) the number of days in which there was a waiting list for HOH or MOH housing; and (d) the average number of step-downs per week (i) from HOH to MOH and (ii) from MOH to the least restrictive setting consistent with the prisoners’ clinical needs. In addition, for two random weeks, the Department is required to review the count sheets documenting the number of occupied and available beds in the MOH and HOH units at TTCF and CRDF. Substantial Compliance requires "the immediate availability of HOH and MOH beds at TTCF and CRDF 95% of the time."

The County reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the Fourth Quarter of 2018 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 0% 92%

The County also reports the number of days in which the total number of HOH and MOH available beds was equal to or more than the number of HOH and MOH inmates for the two randomly selected weeks in the First Quarter of 2019 are as follows:

TTCF CRDF

MOH 100%
0%

HOH 0% 0%

The County's Eighth Self-Assessment reports that the Department "is considering alternative ways to accurately capture [detailed breakdowns relating to bed availability required by Compliance Measure 63-1,] but it is not able to do so currently due to limitations in the technologies involved in capturing and reporting that information."

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64. Within six months of the Effective Date, the County and the Sheriff will develop a short-term plan addressing the following 12-month period, and within 12 months of the Effective Date, the County and the Sheriff will develop a long-term plan addressing the following five-year period, to reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails. The County and the Sheriff will begin implementation of each plan within 90 days of plan completion. These plans will describe the projected capacity required, strategies that will be used to obtain additional capacity if it is needed, and identify the resources necessary for implementation. Thereafter, the County and the Sheriff will review, and if necessary revise, these plans every 12 months.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to (1) develop a short-term plan that will address the availability of licensed inpatient mental health care for prisoners in an initial 12-month period; (2) commence to implement the plan within 90 days after it is developed; (3) develop a long-term plan within 12 months after the short term plan that will address the availability of licensed inpatient mental health care for prisoners in the following five-year period; and (4) commence to implement the long-term plan within 90 days after it is developed.
On July 14, 2017, the County submitted to the Monitor a Plan Regarding Availability of Licensed Inpatient Mental Health Care (Long Term and Short Term Plans) to provide "an update regarding the County's current efforts to meet the needs of the acutely mentally ill."
The County's Eighth Self-Assessment reiterates that "the County continues to pursue a dual strategy to increase inpatient beds and the resources necessary to obviate the need for these beds. With increased services to address the underlying mental health needs (both through appropriate medication and clinical treatment), and the County's strong effort to divert people from the jails, the need for inpatient services should decline."51
The County's Eighth Self-Assessment also reiterates that "the County also operates 18 inpatient beds at Olive View-UCLA Medical Center. These beds house individuals who are diverted from the County Jail, either pre-trial or once they have been brought into the jail and are awaiting trial. The County's Office of Diversion [began] managing these beds in early July 2018, and is responsible for identifying appropriate individuals for them." In addition, the Eighth Self-Assessment reiterates that the "County also continues to operate its Mental Health Unit-Correctional Treatment Center Inpatient Step-Down Unit, which increased the capacity of FIP-related housing to 64 beds."
The County's Eighth Self-Assessment reports that the "FIP waitlist changes daily" and "consisted of approximately fourteen patients" as of June 10, 2019. "Four were considered high priority and were scheduled to be admitted within 24 hours." "The
51 The County should test this hypothesis and report the results to the Monitor.
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current average time from referral to admission for the that are less acute varies but averages about 30 days."
The County's plans are still not sufficient to "reasonably ensure the availability of licensed inpatient mental health care for prisoners in the Jails." As the Monitor has repeatedly noted, the County's long-term "plans must have a reasonable basis for projecting need in order to establish Substantial Compliance with Paragraph 64." Instead of using a reasonable methodology to project the number of prisoners who will need licensed inpatient mental health care in the future, the County again relies on the "most recent update submitted on or about July 14, 2017," and what it is currently doing to provide that health care.
Paragraph 64 requires the County and the Sheriff "to review, and if necessary revise, these plans every 12 months." Neither the 2017 Plan nor any of the County's SelfAssessments "'describe the projected capacity required' or project how many beds will be required over the long term (several years)." See Monitor's Fifth Report, p. 69. The County presumably has data regarding the number of FIP patients and the number and duration of patients on the FIP waiting list over the nearly four years since it entered into the Settlement Agreement with DOJ that could be used to assess the quantitative impacts of the steps that it has taken, project the capacity required in the future, and develop (or update) a plan to that will meet its future needs. It may be that, going forward, the capacity in the CTC, Olive View, and the Step-Down Unit is sufficient, but this cannot be determined without a reasonable basis for projecting the future needs.
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65. Consistent with existing Sheriff’s Department policies, the County and the Sheriff will ensure that psychotropic medications are administered in a clinically appropriate manner to prevent misuse, hoarding, and overdose.
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires that (1) the County's Self-Assessments set forth the (a) the results of weekly medication audits documenting the visual observation of the administration of medication during the quarter; (b) unauthorized medications found as a result of cell searches during the reporting period; and (c) incidents involving confirmed prescription drug overdoses; and that (2) "the Monitor concludes, after consulting with the Subject Matter Expert, that psychotropic medications have been administered in a clinically appropriate manner 85% of the time."
On April 6, 2018, the County provided a flow chart entitled "Provision 65 Pill Call – Ideal State Pod-Front Pill Call Procedures” (excluded HOH cell-to-cell procedure) that is the product of a work group convened to develop a "new method and practice of administering medications." The Monitor and Mental Health Subject Matter Expert concluded that the flow chart is a "reasonable approach," but that the "primary issue will be the nature of the interventions adopted by custody and healthcare staff in response to lack of cooperation" and "what happens if they are not able to verify that the inmate ingested the pills," which the flow chart partially addresses.
The County's Seventh Self-Assessment reported that a working group of representatives from Custody, Mental Health, and Nursing "initiated a pilot program in two modules at TTCF designed to test and improve pill call administration methods." The Eighth Self-Assessment reports that
[i]n February 2019, the pill call pilot program was expanded to all MOH areas at TTCF, and recently, to all of TTCF. Significantly, the pilot increased cooperation and communication among stakeholders through education, briefing, and hands on training with the goal of increasing medication compliance by inmates and more quickly and accurately identifying inmates who do not allow staff to verify medication ingestion and may be hoarding. Significant changes were also made to custody and nursing pill call audit forms and practices. Access To Care lieutenants significantly increased the number of custody audits being conducted on a regular basis. Nursing staff now routinely use the newly developed “medication given/ingestion unverified” alerts when an inmate takes medication, walks away and refuses to return it to nursing staff or allow verification. Separately, nursing staff also email a supervisor when an inmate engages in those practices to ensure that senior providers are quickly notified.
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With respect to the requirements of the Compliance Measures, the County reports that "[d]ue to inconsistencies found with past auditing practices, the County and Department have temporarily paused reporting [the results of weekly Administration Audits] for [Compliance Measure] 65-1(a)." As in the past, medication was found during a significant number of searches during the Fourth Quarter of 201852 and First Quarter of 2019,53 with wide variations in the number of medications found from one quarter to the next (e.g., TTCF went from 1,023 to 381 while PDC North went from eight to 184). There were also five confirmed drug overdoses during the Fourth Quarter of 2018 and four confirmed in the First Quarter of 2019.
52 During the Fourth Quarter of 2018, 122 medications "not appropriately possessed by inmates" were found during 147 unannounced searches at CRDF, 1,023 medications were found during 90 searches at TTCF, 693 medications during 226 searches at MCJ, and 90 medications during 572 searches at NCCF. There were eight medications found during searches at PDC North and none at PDC South and PDC East. The number of medications found at TTCF is obviously of concern. 53 During the First Quarter of 2019, 23 medications "not appropriately possessed by inmates" were found during 149 unannounced searches at CRDF, 381 medications were found during 112 searches at TTCF, 159 medications during 210 searches at MCJ, eight medications during 490 searches at NCCF, 184 mediations during 237 searches at PDC North, and nine medications during 305 searches at PDC South. There were no medications found at PDC East.
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66. Consistent with existing DMH policies, prisoners in High Observation Housing and Moderate Observation Housing, and those with a serious mental illness who reside in other housing areas of the Jails, will remain on an active mental health caseload and receive clinically appropriate mental health treatment, regardless of whether they refuse medications.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to review, on a random basis, the electronic medical records of prisoners in HOH and MOH or with a Serious Mental Illness ("SMI") to assess whether they have remained on an active mental health caseload and that 95% of HOH prisoners, 90% of MOH prisoners, and 85% of other prisoners with a serious mental illness been offered "clinically appropriate structured mental health treatment" and been seen by a QMHP at least monthly, regardless of whether they refuse medications.
For the Fourth Quarter of 2018, the County posted results show that 24% of prisoners in HOH, 4% in MOH, and 20% with serious mental illness who reside in other housing areas were "offered clinically appropriate structured mental health treatment and were seen by a QMHP at least once a month." For the First Quarter of 2019, the posted results for these categories are 30% of HOH prisoners, 6% of MOH prisoners, and 22% of others with serious mental illness.
The County's Eighth Self-Assessment reiterates that "[t]he County continues to work towards increasing its capacity to offer clinically appropriate treatment, including structured mental health treatment" and "improved standardization of the intake assessment process performed in the reception centers" to better identify "inmates at intake who have a serious mental illness." The County reports that during the reporting period, it "provided no fewer than nine trainings, relating to appropriate suicide assessment, clinical supervision, law and ethics, assessing and documenting for mental health, conservatorship and competency, incorporating community mental health history, assessing and treating personality disorders, mental health treatment in corrections and engaged leadership."
The Mental Health Subject Matter Expert and clinicians conducted a review of cases involving mentally ill inmates to assess the County's compliance with Paragraph 66. They found "limited evidence of treatment that qualifies as structured in HOH or MOH" and "occasional clinically appropriate treatment." They note that "[t]his is not unexpected. It is wise for the County to first develop the infrastructure and improve access to care before focusing on treatment content." Further, a "major challenge for the County will be consistency of clinical contacts. Because of rapid, sometimes unpredictable inmate turnover due to release, frequent patient movement within the jail, and changes in providers, it will be difficult to define and deliver a structured, clinically appropriate treatment based on individual patient needs."
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67. Within three months of the Effective Date, the County and the Sheriff will implement policies for prisoners housed in High Observation Housing and Moderate Observation Housing that require:
(a) documentation of a prisoner’s refusal of psychotropic medication in the prisoner’s electronic medical record;
(b) discussion of a prisoner’s refusal in treatment team meetings;
(c) the use of clinically appropriate interventions with such prisoners to encourage medication compliance;
(d) consideration of the need to transfer non-compliant prisoners to higher levels of mental health housing; and
(e) individualized consideration of the appropriateness of seeking court orders for involuntary medication pursuant to the provisions of California Welfare and Institutions Code sections 5332-5336 and/or California Penal Code section 2603(a).
STATUS: PARTIAL COMPLIANCE
Substantial Compliance requires the County to "review the electronic medical records of 25% of the prisoners in HOH and MOH who refused psychotropic medication during the quarter to verify that the records [of 85% of the prisoners] reflect the documentation and consideration of the matters required by the terms of Paragraph 67."
The County's Eighth Self-Assessment reiterates that the County "has historically experienced challenges implementing and assessing compliance with this Provision." It also reports that "[t]he County also continues to work towards better uses of technology to identify patients refusing medication 50% of the time for that week. Nursing staff then follow up with these inmates and consult with a psychiatrist assigned to the patient." Unfortunately, the "documentation of the information sought by some of the sub-sections of this Provision is not consistently included in the same place and [in the] same level of detail in the relevant records."
The Mental Health Subject Matter Expert and the clinicians evaluated 23 cases for compliance with Paragraph 67. They found that a QMHP considered whether a higher level of care was indicated in 35% of the cases, and 35% of the cases at CRDF and 22% of the cases at TTCF included "a reasonable determination of the reason for the recommendation for housing change." They also found "consideration of FIP and involuntary medication" in 67% of the cases "where there was evidence of possible dangerousness or grave disability. . . .[and the] assessments of this element were reasonable in all cases where an assessment was done." They believe that "the County is poised to achieve substantial compliance; when clinicians remember to address the issues, their work is generally adequate and they are already meeting with patients."
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Based upon the qualitative assessment by the Subject Matter Expert and the clinicians, the Monitor is of the view that the County has achieved Partial Compliance with Paragraph 67.
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68. Within six months of the Effective Date, the County and the Sheriff will develop and implement a procedure for contraband searches on a regular, but staggered basis in all housing units. High Observation Housing cells will be visually inspected prior to initial housing of inmates with mental health issues.

STATUS:

SUBSTANTIAL COMPLIANCE (as of January 1, 2016, through December 31, 2016 (verified) at MCJ, NCCF, PDC East, PDC South, and PDC North)

SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31, 2017 (verified) at TTCF)

PARTIAL COMPLIANCE (at CRDF)

Substantial Compliance requires that "85% of the housing units are searched for contraband at least once in the previous quarter; and 95% of the HOH units visually inspected prior to housing prisoners in these units." Self-Assessments are to include a summary of searches conducted and a review of 25 randomly selected Checklist forms for HOH units to confirm that the units were visually inspected prior to initial housing of prisoners in these units.

The County previously maintained Substantial Compliance for twelve consecutive months at TTCF, MCJ, NCCF, PDC East, PDC South, and PDC North, and these facilities were not subject to monitoring for compliance with Paragraph 68 during this reporting period.

The County’s posted results reflect that in the Fourth Quarter of 2018, all of the housing units at CRDF were searched at least once in the quarter, and 92% of the randomly selected HOH cells at CRDF were visually inspected before housing prisoners in these units, which is slightly below the 95% threshold for Substantial Compliance. During the First Quarter of 2019, all of the housing units at CRDF were searched at least once in the quarter, and 92% of the randomly selected HOH cells at CRDF were visually inspected before housing prisoners in these units.54

54 The Department has been "within three percent of Substantial Compliance with Compliance Measure 685(c) at CRDF" for four consecutive quarters. Because the Department has achieved Substantial Compliance with Compliance Measure 68-5(b) during these quarters, it requests "a finding that it has satisfied all of its monitoring obligations at CRDF for this Provision." As noted by DOJ, however, being "within 3% of substantial compliance for four consecutive periods is not tantamount to being in substantial compliance for the same time period."
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69. Consistent with existing DMH policies regarding use of clinical restraints, the County and the Sheriff will use clinical restraints only in the Correctional Treatment Center and only with the approval of a licensed psychiatrist who has performed an individualized assessment and an appropriate Forensic Inpatient order. Use of clinical restraints in CTC will be documented in the prisoner’s electronic medical record. The documentation will include the basis for and duration of the use of clinical restraints and the performance and results of the medical welfare checks on restrained prisoners. When applying clinical restraints, custody staff will ensure a QMHP is present to document and monitor the condition of the prisoner being placed in clinical restraints.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through March 31, 2019 (verified))
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the restraints were used, approved, and documented, and that the results of medical welfare checks on restrained prisoners were also documented.
The County’s Eighth Self-Assessment reports that for the Fourth Quarter of 2018, "100%. . . of electronic medical records reviewed. . .reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved and documented as required. Importantly, clinical restraints were only used on four patients in the Fourth Quarter of 2018."
The County’s Eighth Self-Assessment also reports that, for the First Quarter of 2018, 100% of the medical records reviewed "reflected that, for inmates placed in clinical restraints for psychiatric purposes, the restraints were used, approved, and documented as required by this Provision. . . .Importantly, clinical restraints were used on only two patients in the First Quarter of 2019." The County's results have been verified by the Monitor's auditors.
The Mental Health Subject Matter Expert and the clinicians conducted a qualitative assessment that evaluated "whether a psychiatrist timely approved the restraints and performed an assessment, whether a QMHP was present at the time of restraint, and whether the myriad monitoring requirements were met." Based upon "standard published by organizations such as the Centers for Medicare and Medicaid Services (CMS)," which "allow for telephonic orders for restraints by psychiatrists," they "scored as compliant cases where psychiatrists gave telephone orders and assess the patient within 24 hours." They "found that there were timely and sound psychiatric assessments and orders for restraints in almost all cases," "episodes of restraint continued to be very brief with most less than two hours," and "frequent contact and clinical assessment of those in restraint." In conclusion, it was their "impression that restraints are being well-managed and used only when necessary and for a short time."
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70. Within three months of the Effective Date, the County and the Sheriff will have policies and procedures regarding the use of Security Restraints in HOH and MOH. Such policies will provide that:
(a) Security Restraints in these areas will not be used as an alternative to mental health treatment and will be used only when necessary to insure safety;
(b) Security Restraints will not be used to punish prisoners, but will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape;
(c) Custody staff in HOH and MOH will consider a range of security restraint devices and utilize the least restrictive option, for the least amount of time, necessary to provide safety in these areas; and
(d) Whenever a prisoner is recalcitrant, as defined by Sheriff’s Department policy, and appears to be in a mental health crisis, Custody staff will request a sergeant and immediately refer the prisoner to a QMHP.
STATUS: PARTIAL COMPLIANCE
The Mental Health Subject Matter Expert and DOJ have expressed concern about the Department's Substantial Compliance with paragraph 70(c) if all inmates in HOH are routinely handcuffed when they are out of their cells "in a housing pod at the same time."55
In response to concerns expressed by the Mental Health Subject Matter Expert and DOJ, the County's Eighth Self-Assessment reports that:
The Department continues to use alternative types of mental health housing with the goal of housing inmates with mental health concerns in the least restrictive manner appropriate, these models include Step-Down modules, the HOPE Dorm and the Living Module. At CRDF, these programs operate using the FRESH program, which is a FIP step-down type model, and the LIFE program, which is a Living Module model. As previously reported, under the 'Living Module' concept, patients begin their mental health treatment in an HOH pod and transition into an MOH pod as their mental health improves. With each stage in the transition, the inmate-patient gains privileges and is less restricted in their movement. The Living Module now operates in six pods at TTCF and three pods at CRDF. Inmates in the Step-down modules and HOPE Dorm are not
55 The Mental Health Subject Matter Expert notes that paragraph 70(b) is also implicated because it required that restraint's "will be used only when there is a threat or potential threat of physical harm, destruction of property, or escape."
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restrained when out of cell. There are three FIP Step-Down pods at TTCF and CRDF.
Significantly, beginning in March 2019, the Department began a pilot program, aimed to provide P3/HOH inmates with significant unrestrained out of cell time. . .The pilot is currently available to inmates in five HOH pods at TTCF, and three HOH pods at CRDF.
The County continues to conduct weekly assessments of inmates in HOH housing. During those assessments, clinicians consider, among other things, whether an inmate is able to cohabitate with others. In addition, the County conducts daily huddle meetings to assess whether HOH inmates are suitable for a double man cell, or transfers to Enhanced Mental Health Housing or MOH. Separate from clinician assessments, inmates that are able to cohabitate are often trusted to be unrestrained when out of their cells together.
The Mental Health Subject Matter Expert notes, however, that while housing in a double-man cell is relevant, some inmates who need single-cell housing may still be able to come out of their cells unrestrained. After consulting with the Mental Health Subject Matter Expert, the Monitor is of the view that the County has not yet achieved Substantial Compliance with Paragraph 70(c) as many HOH settings do not have these programs. In order to achieve Substantial Compliance, the County has to demonstrate that it is continuing to conduct individual assessments in weekly and daily meetings, expanding the use of Living Modules and FIP step-down pods (or other less restrictive housing arrangements), and articulating policies for these programs. As expressed by one of the clinicians, the County "appear[s] to have made progress in the implementation of their various progressive housing units, which do contribute to less restrictive environments for some mental health inmates. . . .Whether the step-down initiatives are sufficiently established, and the reassessment of inmates identified as hostile is adequate, remain a concern related to the intent of this provision."
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71. The County and the Sheriff will ensure that any prisoner subjected to clinical restraints in response to a mental health crisis receives therapeutic services to remediate any effects from the episode(s) of restraint.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2016, through June 30, 2017 (verified))
Substantial Compliance requires the Department to review the electronic medical records of all prisoners placed in clinical restraints to verify that the prisoners received therapeutic services as required by Paragraph 71.
The County maintained Substantial Compliance with Paragraph 71 for twelve consecutive months during a prior reporting period and Paragraph 71 was not subject to monitoring in the Eighth Reporting Period.
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72. The County and the Sheriff will develop and implement policies and procedures that ensure that incidents involving suicide and serious self-injurious behavior are reported and reviewed to determine: (a) whether staff engaged in any violations of policies, rules, or laws; and (b) whether any improvements to policy, training, operations, treatment programs, or facilities are warranted. These policies and procedures will define terms clearly and consistently to ensure that incidents are reported and tracked accurately by DMH and the Sheriff’s Department.
STATUS: SUBSTANTIAL COMPLIANCE (as of January 1, 2017, through December 31, 2017)
Substantial Compliance requires the Self-Assessments to report on (a) suicide review meetings and (b) CIRC meetings that review incidents of serious self-injurious behavior in the reporting period.
The Monitor's Sixth Report found that the County had maintained Substantial Compliance with Paragraph 72 for the twelve month period ending on December 31, 2018, but expressed a concern that the information provided by the County was insufficient "for the Monitor 'to assess' whether the County is adequately reviewing potential non-custody staff misconduct.'"56 To address this concern, the County submitted a list of 2017 Performance Management cases reflecting the status and/or results of investigations Custody Health Services personnel in 2017. It includes whether the allegations were "substantiated" and, if so, the "Final Administrative and/or Disciplinary Action," but does not, as DOJ noted, "indicate to which suicides or suicide attempts the investigation and discipline listed correspond" or "how many of the investigations or disciplinary actions listed arose due to suicides or suicide attempts." The Monitor agreed that additional information was needed to assess whether the County maintained Substantial Compliance for twelve consecutive months during the Fifth and Sixth Reporting Periods.57
The County has provided a listing that identifies which of the cases involved suicides or deaths and additional information that describes what CHS personnel did in relation to a particular death or suicide, the results of the investigation, and the status of any disciplinary proceedings. Based upon this information, the Monitor is of the opinion that the Department was in Substantial Compliance with Paragraph 72 for twelve consecutive months in 2017 and was not subject to monitoring in the Eighth Reporting Period. 58
56 See Monitor's Sixth Report, p. 84, n. 44. 57 See Monitor's Seventh Report, p. 91. 58 The Mental Health Subject Matter Expert and the clinicians reviewed eight cases that were the subject of CIRC reviews during the First Quarter of 2018, and found that all of the cases "clearly addressed whether staff engaged in any violations of policies, rules or laws."
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73. Depending on the level of severity of an incident involving a prisoner who threatens or exhibits self-injurious behavior, a custody staff member will prepare a detailed report (Behavioral Observation and Mental Health Referral Form, Inmate Injury Report, and/or Incident Report) that includes information from individuals who were involved in or witnessed the incident as soon as practicable, but no later than the end of shift. The report will include a description of the events surrounding the incident and the steps taken in response to the incident. The report will also include the date and time that the report was completed and the names of any witnesses. The Sheriff’s Department will immediately notify the County Office of Inspector General of all apparent or suspected suicides occurring at the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified))
Substantial Compliance requires the Department to review quarterly a random sample of reports of any threats or exhibitions of self-injurious behavior to verify that the reports have the information required by Paragraph 73; and to provide the Monitor with the notifications to the Inspector General of all incidents involving an apparent or suspected suicide during the reporting period.
The County's Seventh Self-Assessment reported that it had maintained Substantial Compliance with Paragraph 73 for twelve consecutive months through September 30, 2018, and the Monitor’s auditors have verified the County’s results. Accordingly, the County was not subject to monitoring for compliance with Paragraph 73 during the Eighth Reporting Period.
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74. The Sheriff’s Department will ensure that there is a timely, thorough, and objective law enforcement investigation of any suicide that occurs in the Jails. Investigations shall include recorded interviews of persons involved in, or who witnessed, the incident, including other prisoners. Sheriff’s Department personnel who are investigating a prisoner suicide or suspected suicide at the Jails will ensure the preservation of all evidence, including physical evidence, relevant witness statements, reports, videos, and photographs.
STATUS: SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)
Substantial Compliance requires the Department to provide the Monitor with an Executive Suicide Death Review reflecting the results of the Department’s investigation of any suicide in the Jails within six months of the suicide. The review must reflect steps taken to preserve all of the evidence; and list the interviews of persons involved in, or who witnessed, the incident, and whether the interviews were recorded.
The County previously maintained Substantial Compliance with this provision for twelve consecutive months and it was not subject to monitoring during the Eighth Reporting Period. The County nevertheless continued to notify the Monitor of all inmate deaths, including suicides, and the subsequent death reviews. The Monitor continued to attend death reviews during the Eighth Reporting Period.
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75. Within three months of the Effective Date, the County and the Sheriff will review every suicide attempt that occurs in the Jails as follows:
(a) Within two working days, DMH staff will review the incident, the prisoner’s mental health status known at the time of the incident, the need for immediate corrective action if any, and determine the level of suicide attempt pursuant to the Centers for Disease Control and Prevention’s Risk Rating Scale;
(b) Within 30 working days, and only for those incidents determined to be a serious suicide attempt by DMH staff after the review described in subsection (a) above, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the incident, the prisoner’s incarceration, mental health, and health history, the status of any corrective actions taken, and the need for additional corrective action if necessary;
(c) The County and the Sheriff will document the findings that result from the review of serious suicide attempts described in subsection (b) above; and
(d) The County and the Sheriff will ensure that information for all suicide attempts is input into a database for tracking and statistical analysis.
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STATUS (75):

SUBSTANTIAL COMPLIANCE (as of October 1, 2017, through September 30, 2018 (verified))

Substantial Compliance requires (a) DMH to review documentation of randomly selected suicide attempts during the previous quarter to verify that the prisoner’s mental health status and need for immediate corrective action were considered timely by the DMH staff and that the staff determined whether the suicide attempt was serious; (b) that the Department and DMH reviewed the relevant information known at that time and the status of any corrective actions taken, and they considered the need for additional corrective action if necessary; and (c) that the information is reflected in the Department's database for tracking and statistical analysis.
The County's Seventh Self-Assessment reported that for the Second Quarter of 2018, "85% -- equal to the required 85% -- of documents reviewed showed CHS staff considered the inmate's mental health status and need for immediate corrective action;" "100% -- 5% more than the required 95% -- of suicide attempts are reflected in the Department's database;" and "90% rather than the required 95% -- of the suicide attempts" were reviewed by "management and command-level personnel" from Custody, mental health, and medical. The County did not meet the 95% threshold for management and command level reviews of suicide attempts as required by Compliance Measure 755(b) because "due to a miscalculation," one of the ten serious suicide attempts "was reviewed 31 days after its occurrence – failing to meet the compliance requirement by only 1 day." Because the delay was minimal and the "County is in Substantial Compliance with the other requirements of this Provision in the Second Quarter, the County requests a finding of Substantial Compliance." The Mental Health Subject Matter Expert concurs, and notes that the County is "doing a good job on these reviews, including some meaningful CAPs."

The County's Augmented Seventh Self-Assessment reported that for the Third Quarter of 2018 "that 91% -- 6% more than the required 85% -- of documents reviewed showed CHS staff considered the inmate's mental health status and need for immediate corrective action." The County also concluded that 100% -- 5% more than the required 95% -- of the suicide attempts were reviewed by "management and command-level personnel" from Custody, mental health, and medical; and 100% -- 5% more than the required 95% -- of suicide attempts are reflected in the Department's database for tracking and statistical analysis. The County's Seventh Self-Assessment reported that it had maintained Substantial Compliance with Paragraph 75 for twelve consecutive months through September 30, 2018, and the Monitor’s auditors have verified the County’s results. Accordingly, the County was not subject to monitoring for compliance with Paragraph 75 during the Eighth Reporting Period.

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76. The County and the Sheriff will review every apparent or suspected suicide that occurs in the Jails as follows:

(a) Within no more than two working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review and discuss the suicide, the prisoner’s mental health status known at the time of the suicide, and the need for immediate corrective or preventive action if any;

(b) Within seven working days, and again within 30 working days, management and command-level personnel from DMH and the Sheriff’s Department (including Custody Division and Medical Services Bureau) will meet to review relevant information known at that time, including the events preceding and following the suicide, the prisoner’s incarceration, mental health, and health history, the status of any corrective or preventive actions taken, and the need for additional corrective or preventive action if necessary; and

(c) Within six months of the suicide, the County and the Sheriff will prepare a final written report regarding the suicide. The report will include:

(i)
(ii) (iii)
(iv) (v) (vi)
(vii)
(viii) (ix) (x)

time and dated incident reports and any supplemental reports with the same Uniform Reference Number (URN) from custody staff who were directly involved in and/or witnessed the incident; a timeline regarding the discovery of the prisoner and any responsive actions or medical interventions; copies of a representative sample of material video recordings or photographs, to the extent that inclusion of such items does not interfere with any criminal investigation; a reference to, or reports if available, from the Sheriff’s Department Homicide Bureau; reference to the Internal Affairs Bureau or other personnel investigations, if any, and findings, if any; a Coroner’s report, if it is available at the time of the final report, and if it is not available, a summary of efforts made to obtain the report; a summary of relevant information discussed at the prior review meetings, or otherwise known at the time of the final report, including analysis of housing or classification issues if relevant; a clinical mortality review; a Psychological Autopsy utilizing the National Commission on Correctional Health Care’s standards; and a summary of corrective actions taken and recommendations regarding additional corrective actions if any are needed.

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STATUS (76):

SUBSTANTIAL COMPLIANCE (as of September 1, 2016, through December 31, 2017)

The County previously maintained Substantial Compliance with Paragraph 76 for twelve consecutive months and this provision was no longer subject to monitoring during the Eighth Reporting Period. Nonetheless, the County continued to conduct the reviews required by Paragraph 76 for the suicides that occurred during this period and invited the Monitor to attend these meetings.

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77. The County and the Sheriff will create a specialized unit to oversee, monitor, and audit the County’s jail suicide prevention program in coordination with the Department of Mental Health. The Unit will be headed by a Captain, or another Sheriff’s Department official of appropriate rank, who reports to the Assistant Sheriff for Custody Operations through the chain of command. The Unit will be responsible for:
(a) Ensuring the timely and thorough administrative review of suicides and serious suicide attempts in the Jails as described in this Agreement;
(b) Identifying patterns and trends of suicides and serious suicide attempts in the Jails, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary;
(c) Ensuring that corrective actions are taken to mitigate suicide risks at both the location of occurrence and throughout the concerned system by providing, or obtaining where appropriate, technical assistance to other administrative units within the Custody Division when such assistance is needed to address suicide-risk issues;
(d) Analyzing staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies and ensure implementation; and
(e) Participating in meetings with DMH to develop, implement, and track corrective action plans addressing recommendations of the quality improvement program.
STATUS: PARTIAL COMPLIANCE
CCSB's Semi-Annual Report for the Fourth Quarter of 2018 and the First Quarter of 2019 reports that "there were two (2) suicides within the jail facilities,59 eighteen (18) suicide attempts, and three hundred and fifty (350) Self-Directed Violence notifications in the jails. Each suicide was discussed in a Preliminary (24 hr), 7 and 30 Day Executive Review" as required by Paragraph 76. Of the 18 suicide attempts, only six were discussed during six (6) Critical Incident Review Committee (CIRC) monthly meetings.60
The Semi-Annual Report includes the following sections:
(a) "Administrative Review of Suicides." This summarizes the 24-hour, 7-
59 One was in MCJ and one was in a patrol station jail. 60 Section B of the Report, "Administrative Review of Serious Suicide Attempts" identifies 17 suicide attempts, of which six were deemed serious. One of the six appears to be the actual suicide that occurred at MCJ in the First Quarter of 2018.
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day, and 30-day suicide reviews that occurred during the Fourth Quarter of 2018 and First Quarter of 2019, which includes the corrective actions the Department took to mitigate suicide risks following these reviews. Based upon CCSB's Report and CHS's Semi-Annual Report, the Monitor remains satisfied that CCSB is continuing to ensure that CHS and the Department are timely and thoroughly conducting administrative review of suicides and serious suicide attempts in the jails as required by Paragraphs 76 and Compliance Measure 77-2(a).
(b) "Patterns and trends and statistical analysis of suicides and serious suicide attempts in the jails." This section breaks down the incidents of Self-Directed Violence in the Fourth Quarter of 2018 and First Quarter of 2019 by age group (by incident and unique inmates and per 100,000 inmates) and it concludes that inmates in the 26-34 age group, who made up 33% of the inmate population, had 43% of the acts of self-directed violence. Inmates in this age group also had a disproportionate number of the 11 serious self-directed violence incidents and the six serious suicide attempts reviewed at CIRCs. In this report, CCSB also compared the inmate population by security level and age, which shows that as "the age group increases, the proportion of inmates who have a high security level decreases," and the percentage of inmates in the 26-34 age group who have a high security level (8-9) is slightly higher than the percentage of the total population. The County analyzed the "distribution of self-directed violence incidents by security level" and found that a disproportionate number were committed by inmates with high security levels (8-9) and the rate per 100,000 inmates was much higher than the rates for inmates at lower security levels, although the rates of serious SDV incidents reviewed at CIRCs and serious suicide attempts are just slightly above average (and roughly the same as the rates for inmates with medium security levels (5-7)). The County does not, however, analyze the inmates who committed the 11 incidents reviewed by CIRC or the six suicide attempts61 to see if there is a correlation with the general conclusions that inmates in the 26-34 age group "are at a higher risk of self-directed violence" and "[i]nmates with a high-security level are at a much higher risk to engage in self-harm compared to inmates at low or medium security levels." Although this statistical analysis satisfies the requirements of Compliance Measure 77(b), it is limited to age groups and security level. The Mental Health Subject Matter notes that while these are "important variables to consider, especially the impact of security level, which is a known risk factor for SDV, further (and on-going) analysis is part of a sound quality improvement program."
(c) "Corrective actions taken by the department to mitigate suicide risks." This section summarizes matters the Department and CHS are "collaborating on." It describes (1) suicide prevention measures in IRC 231 (the "Detox Unit"); (2) expansion of the Living Modules in TTCF; (3) the status of "a total of twenty CAP/Issues related to 6 serious suicide attempts that were reviewed during the Critical Incident Review Meetings,"62 and eleven corrective actions related to the two suicides reviewed during the Reporting Period; (4) an Informational Bulletin informing patrol stations of a suicide
61 Inmates in the 26-34 age group committed six of the 11 incidents review by the CIRC, but the report does not indicate the security levels of these inmates. 62 See CCSB Report, p. 25.
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hazard that was identified in a station jail cell; and (5) the installation of mats in the IRC booking front and security chairs in IRC 231 to "reduce the risk of self-injurious behavior." CCSB's report of the CAPs discussed at the Executive Inmate Review Committee meetings under the "Administrative Review of Suicides" section above and the CHS's Summary of Recent CIRC Incidents and Data in its Semi-Annual Report reflect that corrective actions are being "taken to mitigate suicide risks." As in the past, the Mental Health Subject Matter Expert notes that "none of these CAPs were based on analysis of aggregate data or patterns and trends and statistical analysis of suicides and serious suicide attempts. While CAPs based upon reviews of individual cases are an important part of QI, it is essential to use aggregate data to drive CAPs and determine if CAPs derived from reviews of individual cases are effective."63
(d) "Technical assistance provided to, or obtained for other administrative units within the Custody Division to address suicide-risk issues." This section describes the briefings and training for the pill call pilot program that has been activated in MOH units; and briefings in May 2018 to a class of new Deputies assigned to TTCF and CRDF on requirements of some of the most challenging provisions of the DOJ Settlement Agreement.64
(e) "Analysis of staffing, personnel/disciplinary, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts." This section analyzes the issues in these categories for the two suicides that were reviewed during the Eighth Reporting Period, and concludes that staffing was an issue in both suicides, and safety checks was an issue in one of the cases. This led the Department to request additional station jail positions and preclude overtime personnel from conducting Title 15 checks. The section also sets forth conclusions, without much analysis, regarding these categories as they related to the six serious suicide attempts during the period.
(f) "Remedial measures, including policy revisions, re-training, or staff discipline, to address issues related to suicide and serious suicide attempts." This section consists of a table that summarizes the policy revisions, re-training, and staff discipline measures taken to address issues related to the two suicides reviewed during the Eighth Reporting Period. This section does not, however, discuss the serious suicide attempts during the period.
(g) "Summaries of meeting with DMH to develop, implement, and track corrective action plans." This section reports that in "January, CCSB and CHS began meeting once a month prior to the CIRC meeting to discuss every inmate" who was going to be reviewed at the meeting: It reiterates that "[a]t every [Joint Quality Improvement Committee] JQIC meeting, there is follow up to verify that
63 In response, the County notes that the "revamped" JQIC process provides the "forum at which both [CHS and the Department] present aggregate data for the development of corrective actions and resulting evaluations." 64 DOJ 36 (adverse triggering events), 52 (property), 57 (safety checks), 68 (searches), and 80 (out-of-cell time).
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the CAP(s) have been addressed and assigned, also the individual assigned to the CAP should verify their effectiveness. CCSB tracks all suicide-related CAPs, whether they are CHS or LASD CAPs, and does so continuously outside of the CIRC and JQIC context." There were a total of 6 JQIC meetings during the Eighth Reporting Period "to discuss CAP/Issues that were developed during the CIRC meetings." The section also sets forth one example of the "aggregated data" that CCSB presented at the JQIC meetings,65 "to identify patterns and trends related to suicides and self-directed violence." From the data, the group identified the module and pod in TTCF as the most common location of self-directed violence among high-risk inmates and focused "on this subpopulation as a way to identify discrete corrective action or quality improvement projects that can be put in place through JQIC." Based on the data, the report analyzes the severity and frequency of selfdirected violence incidents; compares incidents of self-directed violence in the sterile pod as opposed with other pods; and analyzes methods of self-harm. It does not, however, identify any systemic issues, corrective actions, or quality improvement projects that resulted from the analysis. As the Mental Health Subject Matter Expert has noted, the aggregate data must be "tracked and assessed by Custody and CHS" to "determine whether there are system-wide problems" and "what systemic improvements can be identified, implemented, and measured."66
As previously noted, "it is incumbent on CCSB to track the County's implementation of its Suicide Hazard Mitigation Plans [required by Paragraph 24] and the corrective actions to address suicide hazards identified in the annual inspections."67 CCSB's Report refers to DOJ Provision 24 "[f]or corrective actions taken by the Department to mitigate suicide risks."68 The most recent Facility Suicide Hazard Inspections posted by the Department for that provision were in July and August last year, and there is nothing in CCSB's Report indicating what steps the Department has taken to address the risks identified in those inspection reports.69
The Monitor and Subject Matter Expert note the Department has continued to enhance its participation in the quality management process as required by Paragraphs 60 and 77. We appreciate all of the work that CCSB has done to facilitate the implementation of the various provisions of the Settlement Agreement, and note that it continues to make progress in gathering, tracking, and assessing aggregate data related to suicides and self-directed violence, although the County is not consistently using the data
65 This involved inmates with multiple incidents involving self-directed violence in Module 132 at TTCF. The data showed that 50 out of 266 (19%) inmates accounted for nearly 50% of the incidents of selfdirected violence and 72% of the incidents in the one "sterile" pod. 66 See Monitor's Seventh Report, p. 101. 67 Id., p. 100. 68 See CCSB Report, p. 25. 69 The Monitor agrees with the Department that it is not subject to "re-monitoring" of Paragraph 24 through the "quality improvement provisions" of Paragraphs 60-62 and 77. The Department has established Substantial Compliance with Paragraph 24 by conducting annual inspections that identified suicide risks. It is, however, CCSB's responsibility under the Settlement Agreement to track and report on the implementation of the recommendations in the inspection reports. See Paragraph 77(c) (providing that CCSB is responsible for "ensuring that corrective actions are taken to mitigate suicide risk.").
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to identify systemic problems or solutions to those problems. The County's response to the Monitor's draft of this Report notes that it "continues to expand its data analysis and reporting capabilities and expects to demonstrate as much in future reports."
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78. The County and the Sheriff will maintain a county-level Suicide Prevention Advisory Committee that will be open to representatives from the Sheriff’s Department Custody Division, Court Services, Custody Support Services, and Medical Services Bureau; the Department of Mental Health; the Public Defender’s Office; County Counsel’s Office; the Office of the Inspector General; and the Department of Mental Health Patients’ Rights Office. The Suicide Prevention Advisory Committee will meet twice per year and will serve as an advisory body to address system issues and recommend coordinated approaches to suicide prevention in the Jails.
STATUS: SUBSTANTIAL COMPLIANCE (as of May 11, 2016, through May 18, 2017)
Substantial Compliance requires (1) the Committee to meet twice per year and (2) "recommend coordinated approaches to suicide prevention in the Jails."
The County maintained Substantial Compliance with Paragraph 78 for twelve consecutive months as of May 18, 2017, and this provision was not subject to monitoring in the Eighth Reporting Period. Nevertheless, the County has continued to hold BiAnnual Suicide Prevention meetings. The last meeting was held on May 8, 2019, and provided a comprehensive overview of the County's efforts to prevent suicides in the County's jails and treat to inmates suffering from mental illness.70 The Monitor attended this most recent meeting.
70 The overview noted an increase in the number of suicides in 2018 (five) over the prior three years (a total of seven), which trend continued during the first six months of 2019 (three).
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79. (a) Unless clinically contraindicated, the County and the Sheriff will offer prisoners in mental health housing:
(i) therapeutically appropriate individual visits with a QMHP; and
(ii) therapeutically appropriate group programming conducted by a QMHP or other appropriate provider that does not exceed 90 minutes per session;
(b) The County and the Sheriff will provide prisoners outside of mental health housing with medication support services when those prisoners are receiving psychotropic medications and therapeutically appropriate individual monthly visits with a QMHP when those prisoners are designated as Seriously Mentally Ill; and
(c) The date, location, topic, attendees, and provider of programming or therapy sessions will be documented. A clinical supervisor will review documentation of group sessions on a monthly basis.
STATUS: NON-COMPLIANCE
Substantial Compliance requires the Department to maintain records of therapeutically appropriate individual visits and group programming, and the names of the clinical supervisors who reviewed the documentation of group sessions; describe the medication support services available for prisoners not in mental health housing who are receiving psychotropic medications; and review electronic medical records of such to confirm that medication support services were provided to these prisoners.
The County’s Eighth Self-Assessment reports that in the Fourth Quarter of 2018, 41% of the prisoners who resided outside of mental health housing and were receiving psychotropic medications were "provided with medication support services," which is well-below the 85% threshold required by Compliance Measure 79.5(d) for Substantial Compliance. It also reports that "a shortage of medical doctors treating patients hindered its ability to better comply with this Provision."
The County’s Augmented Eighth Self-Assessment reports that in the First Quarter of 2019, 65% of the prisoners who resided outside of mental health housing and were receiving psychotropic medications were "provided with medication support services," which is still below the 85% threshold required by Compliance Measure 79.5(d) for Substantial Compliance.
The Department's posted results also reflect the names of the clinical supervisors who reviewed the documentation of group sessions as required by Compliance Measure 79.1(d), but the County did not provide records of therapeutically appropriate individual visits and group programming by QMHPs to prisoners in mental health housing.
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80. (a) The County and the Sheriff will continue to make best efforts to provide appropriate out-of-cell time to all prisoners with serious mental illness, absent exceptional circumstances, and unless individually clinically contraindicated and documented in the prisoner’s electronic medical record. To implement this requirement, the County and the Sheriff will follow the schedule below:
(i) By no later than six months after the Effective Date, will offer 25% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week;
(ii) By no later than 12 months after the Effective Date, will offer 50% of the prisoners in HOH ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week; and
(iii) By no later than 18 months after the Effective Date, will offer 100% of the prisoners in HOH ten hours of unstructured out-ofcell recreational time and ten hours of structured therapeutic or programmatic time per week.
(b) No later than six months after the Effective Date, the County and the Sheriff will record at the end of each day which prisoners in HOH, if any, refused to leave their cells that day. That data will be presented and discussed with DMH staff at the daily meeting on the following Normal business workday. The data will also be provided to the specialized unit described in Paragraph 77 and to DMH’s quality improvement program to analyze the data for any trends and to implement any corrective action(s) deemed necessary to maximize out-of-cell time opportunities and avoid unnecessary isolation.
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STATUS (80):

NON-COMPLIANCE

Paragraph 80 requires that, "no later than 18 months after the Effective Date [July 1, 2015]," 100% of the prisoners in HOH receive "ten hours of unstructured out-of-cell recreational time and ten hours of structured therapeutic or programmatic time per week." The parties have agreed that up to five hours of the structured time can consist of education or work programs, but at least five hours of the time must be therapeutic.

The County's Eighth Self-Assessment reports that in the Fourth Quarter of 2018, 48.2% of the prisoners at CRDF and 45.6% of the prisoners at TTCF were offered the required 10 or more hours of unstructured, out-of-cell recreational time, which is wellbelow the 100% threshold for unstructured recreational time. The results for the First Quarter of 2019 were 33% and 80% for CRDF and TTCF,71 respectively.

The County's Eighth Self-Assessment also reports that "[w]ith respect to the structured out-of-cell time, CHS is in the process of piloting an electronic system [at both TTCF and CRDF] to track structured out-of-cell time." There are, however, no reported results for structured therapeutic or programming time.

71 The County reports that it has undercounted unstructured out of cell time for Living Modules pods that "facilitate housing for inmates transitioning from High Observation Housing (HOH) to less restrictive forms of hosing as their mental health improves." By utilizing "iPod devices to document unstructured out of cell time for [these] pods," the County "expect[s] to see a compliance increase reflected in the data for upcoming quarters."
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81. Except as specifically set forth in Paragraphs 18-20 of this Agreement, and except as specifically identified below, the County and the Sheriff will implement the following paragraphs of the Implementation Plan in Rosas at all Jails facilities, including the Pitchess Detention Center and the Century Regional Detention Facility, by no later than the dates set forth in the Implementation Plan or as revised by the Rosas Monitoring Panel: Paragraphs 2.2-2.13 (use of force policies and practices); 3.1-3.6 (training and professional development); 4.1-4.10 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 6.1-6.20 (prisoner grievances and complaints); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.1-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.1-12.5 (force investigations, with the training requirement of paragraph 12.1 to be completed by December 31, 2016); 13.1-13.2 (use of force reviews and staff discipline); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.1-16.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 19.1-19.3 (early warning system); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
STATUS: PARTIAL COMPLIANCE
In the First Reporting Period, the Rosas Monitors approved polices adopted by the Department to implement the following provisions of the Rosas Implementation Plan: Paragraphs 2.2-2.13 (use of force policies and practices); 3.6 (training and professional development); 4.1-4.5 (use of force on mentally ill prisoners); 5.1-5.3 (data tracking and reporting of force); 7.1-7.3 (prisoner supervision); 8.1-8.3 (anti-retaliation provisions); 9.2-9.3 (security practices); 10.1-10.2 (management presence in housing units); 11.1 (management review of force); 12.2-12.5 (force investigations); 14.1-14.2 (criminal referrals and external review); 15.1-15.7 (documentation and recording of force); 16.116.3 (health care assessments); 17.1-17.10 (use of restraints); 18.1-18.2 (adequate staffing); 20.1-20.3 (planned uses of force); and 21.1 (organizational culture).
In the Second Reporting Period, the Rosas Monitors approved Department policies to implement the following provisions of the Rosas Plan: Paragraphs 6.1-6.20 (grievance system); Paragraph 8.2 (combining "Complaints of Retaliation"). They also approved revised policies to implement Paragraphs 13.1-13.2 (discipline for PREA violations, dishonesty, and failure to report force incidents). The Department has now implemented 104 of 106 provisions of the Rosas Plan; the other two provisions pertaining to the extension of Crisis Intervention training and safety checks are covered by Paragraphs 19-20 and 57-58 of the Settlement Agreement in the DOJ case.
Paragraphs 3.1-3.4, 4.6-4.9, and 12.1 of the Rosas Implementation Plan reflect training requirements in use of force, ethics, dealing with mentally ill inmates, and investigations of force incidents. The curriculum and lesson plans to implement these training requirements have been approved by the Rosas Monitors. The Department has achieved Substantial Compliance with the training required by Paragraphs 4.6 through 4.9 of the Rosas Plan at CRDF, NCCF, and the PDC facilities.72 Going forward,
72 See pp. 12-16, supra. Some of these results are subject to verification by the Monitor's auditors.
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personnel at these facilities must undergo the refresher training required under the Rosas Plan. The Department needs to provide Self-Assessments reflecting the training of personnel at these facilities in the use of force and ethics and professionalism required by Paragraphs 3.1 and 3.2 of the Rosas Plan to achieve Substantial Compliance with these provisions.
In the Eighth Reporting Period, the Monitor reviewed 37 randomly selected completed force packages for CRDF, NCCF, PDC North, and PDC South. Most of these packages were also reviewed by the Use of Force Subject Matter Expert. The Monitor concluded that the Department's use of force was reasonable in all but four of the cases. In one case, the force appeared to be excessive because an inmate was slammed to the ground and in another the inmate was punched in the face while on the ground. Fortunately, these cases were rare, and other problematic cases involved minimal force might have been avoided entirely with better communications, calling a supervisor, or taking advantage of time plus distance. With respect to specific provisions of the Rosas Action Plan pertaining to the use of force, the Monitor concluded that the Department was not in compliance with Paragraph 9.2, which requires uninvolved Custody personnel to escort inmates against whom force was used, and Paragraph 17.5, which requires Custody personnel to minimize the risk of medical distress.
The Monitor concluded that the Department's reporting and investigation of force incidents was reasonable in over 85% of the cases. Although there were no specific provisions of the Action Plan pertaining to the reporting or investigation of force incidents that were particularly problematic, the Department's Commanders should do a better job analyzing tactical issues and assessing how the force incident could possibly have been avoided or handled with less force, and conveying any lessons learned to line personnel and supervisors.
The Department needs to submit Self-Assessments that will be subject to verification by the Monitor's auditors to establish that it has maintained Substantial Compliance with other reporting and investigation provisions of the Rosas Plan at CRDF, NCCF, and the Pitchess Detention Center facilities.73
The Monitor previously reported that the Department had achieved Substantial Compliance with the grievance provisions of the Rosas Plan at NCCF, CRDF, PDC North, and PDC South.74 During the Eighth Reporting Period, the Monitor met with the Inmate Grievance Teams at CRDF and NCCF and with the Division Inmate Grievance Coordinator who has oversight responsibility for the implementation of the new grievance system. The Division Inmate Grievance Coordinator provided the Monitor
73 Paragraphs 5.1, 8.3, 11.1, 13.1, 13.2, 14.1, 14.2. As noted by DOJ, Paragraph 13.1 requires the Sheriff's Department to have a "firm policy of zero tolerance for acts of dishonesty or failure to report uses of force." The Monitor has expressed his concern to the Sheriff that recent actions by the Department to reinstate terminated deputies and deactivate internal investigations "sends the wrong message to members of the Department responsible for Custody Operations, many of whom have embraced the reforms that have been implemented" and "undermine [his] ability to hold Department personnel accountable for such misconduct in the future." 74 See Monitor's Seventh Report, p., 108.
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with his Executive Reports: Statistical Analysis and Trends for each month through May in the Eighth Reporting Period (with comparisons to the Fourth Quarter of 2018), broken down by facility and with response times in compliance with the 15-day response required by Paragraphs 6.9, 6.13, 6.14, and 6.15 of the Rosas Plan. In addition to providing these reports in the future, the Department needs to provide Self-Assessments of other provisions to demonstrate that it has maintained Substantial Compliance with the grievance provisions of the Rosas Plan for the periods required.75
On July 10, 2018, the Department presented to the Rosas Monitors its Custody Operations Employee Review System "to facilitate the identification, tracking, analysis, and review of specific employee-related incidents and issues." The Rosas Monitors concluded that this system addresses the requirements of Paragraphs 19.1, 19.2, and 19.3 of the Rosas plan for an Early Warning System. The Department implemented the Employee Review System as a pilot program at the Downtown Jail Facilities on July 27, 2018, and expanded it throughout Custody Operations on October 25, 2018.76
Paragraphs 4.10 and 9.1 of the Rosas Implementation Plan are moot since the Settlement Agreement requires the Crisis Intervention and Conflict Resolution training to be extended to the remaining deputies and Custody Assistants, and it specifies the required cell checks in the Jails. Accordingly, the Department has implemented all of the provisions of the Rosas Implementation Plan.
75 Paragraphs 6.4, 6.5, 6.7, 6.8, 6.10, 6.11, 6.12, 6.17-6.20, 7.2, 7.3 and 8.1. 76 The Department needs to submit Self-Assessments to demonstrate that it has maintained Substantial Compliance with Paragraphs 19.2 and 19.3 of the Rosas Plan.
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82. With respect to paragraph 6.16 of the Rosas Implementation Plan, the County and the Sheriff will ensure that Sheriff's Department personnel responsible for collecting prisoners’ grievances as set forth in that paragraph are also co-located in the Century Regional Detention Facility.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 15, 2016, through December 31, 2017)
The Rosas Monitors have approved a de-centralized inmate grievance system, which includes an Inmate Grievance Team co-located at Century Regional Detention Facility. The Department published its new grievance policies on July 15, 2016.
CRDF has had its own Inmate Grievance Team with the staffing required by CDM 8-01.020.00 since July 2016.
Pursuant to Paragraph 111 of the Settlement Agreement, the County was not subject to monitoring for Substantial Compliance with Paragraph 82 in the Eighth Reporting Period.
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83. The County and the Sheriff will install closed circuit security cameras throughout all Jails facilities’ common areas where prisoners engage in programming, treatment, recreation, visitation, and intra-facility movement ("Common Areas"), including in the Common Areas at the Pitchess Detention Center and the Century Regional Detention Facility. The County and the Sheriff will install a sufficient number of cameras in Jails facilities that do not currently have cameras to ensure that all Common Areas of these facilities have security-camera coverage. The installation of these cameras will be completed no later than June 30, 2018, with TTCF, MCJ, and IRC completed by the Effective Date; CRDF completed by March 1, 2016; and the remaining facilities completed by June 30, 2018. The County and the Sheriff will also ensure that all video recordings of force incidents are adequately stored and retained for a period of at least one year after the force incident occurs or until all investigations and proceedings related to the use of force are concluded.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2015, through June 30, 2016 at MCJ and IRC)
SUBSTANTIAL COMPLIANCE (as of October 1, 2015, through September 30, 2016 at TTCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 at CRDF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through March 31, 2019 at NCCF and PDC North)
SUBSTANTIAL COMPLIANCE (as of July 1, 2018, through March 31, 2019 at PDC South)
The Monitor visited NCCF and PDC North on April 4, 2018, and confirmed that the closed circuit security cameras were operational in Common Areas at those facilities. The Department subsequently ordered and installed an additional eight cameras to cover blind spots at PDC North. On July 12, 2018, the Department submitted a report showing all of the cameras requested were installed and operational at NCCF, PDC North, and PDC South.
Paragraph 83 also requires the Department to provide evidence that all video recordings of force incidents were adequately stored and retained for a period of at least one year after the force incident occurs.
The County's posted results for NCCF, PDC North, and PDC South reflect that the Department maintained Substantial Compliance at these facilities in that all of the video recordings of all force incidents at PDC North and South and randomly selected force incidents at NCCF in the Fourth Quarter of 2018 and the First Quarter of 2019 "were stored and retained by the Department." The Monitor reviewed the video recordings and confirmed that the Department's videos depict the force incidents on the
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Department's inventory. In order to maintain Substantial Compliance, however, the Department must show
that "90% of the force incidents on the quarterly lists. . . are on the inventory provided by the Department one year after the force incident." NCCF and PDC North are subject to this requirement of Paragraph 83 until March 31, 2020, and PDC South is subject to it until June 30, 2020.
The County previously maintained Substantial Compliance with Paragraph 83 at IRC, MCJ, TTCF, and CRDF for twelve consecutive months and was not subject to monitoring at these facilities during the Eighth Reporting Period.
On a recent visit to MCJ the Monitor noted the absence of cameras in the "sally ports"77 leading to the rows of cells in 3100 and 3300.78 This is where a Category 3 force incident with serious injuries to an inmate took place last year. The absence of a camera made it very difficult to determine what happened in the sally port. It is also possible that the force might not have happened if the inmate and/or the Deputy had been aware of a camera in the sally port. Although MCJ is no longer subject to monitoring for compliance with Paragraph 83, the Monitor strongly urges the County to put cameras in all of the sally ports in MCJ.
77The sally ports are cage areas with an inner door facing the row and an outer door on the opposite side facing a hallway. There are Deputy stations for monitoring the rows outside the ends of the sally port. Because of the age of MCJ, Deputies must enter into the sally ports to unlock the inner doors to the row in order to enable inmates to enter or exit the rows (escorted or unescorted). Since it appears that MCJ is not going to be replaced with a new facility at least for now, the County should consider automating the inner doors to the sally ports for the protection of Department personnel. 78 The Monitor was informed that there are other sally ports in MCJ that do not have cameras.
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84. The Sheriff will continue to maintain and implement policies for the timely and thorough investigation of alleged staff misconduct related to use of force and for timely disciplinary action arising from such investigations. Specifically:
(a) Sworn custody staff subject to the provisions of California Government Code section 3304 will be notified of the completion of the investigation and the proposed discipline arising from force incidents in accordance with the requirements of that Code section; and
(b) All non-sworn Sheriff’s Department staff will be notified of the proposed discipline arising from force incidents in time to allow for the imposition of that discipline.
STATUS: SUBSTANTIAL COMPLIANCE (as of July 1, 2017, through June 30, 2018 (verified))
Substantial Compliance under the Compliance Measures requires the Department to demonstrate that 95% of the investigations of force incidents in which sworn custody staff and non-sworn custody staff were found to have violated Department policy or engaged in misconduct were completed and administrative action, which could include discipline, was taken within the time frames provided for in Government Code Section 3304 and relevant Department policies.
The Department previously maintained Substantial Compliance with Paragraph 84 for twelve months and was not longer subject to monitoring for compliance with this provision in the Eighth Reporting Period.
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85. The County and the Sheriff will ensure that Internal Affairs Bureau management and staff receive adequate specialized training in conducting investigations of misconduct.
STATUS: PARTIAL COMPLIANCE Substantial Compliance requires the Department to provide the Monitor and Subject Matter Experts with (1) the curriculum/syllabus for the three specialized courses given to IAB management, and (2) a list of the sworn personnel assigned to IAB and proof that such personnel successfully completed the training. The County's Eighth SelfAssessment reports that 80% of the IAB investigators completed all three of the required courses as of the end of the Fourth Quarter of 2018 and 75% as of the end of the First Quarter of 2019.
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86. Within three months of the Effective Date, the County and the Sheriff will develop and implement policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical agents and other security equipment. The County and the Sheriff will develop and maintain an adequate inventory control system for all weapons, including OC spray.
STATUS: SUBSTANTIAL COMPLIANCE (as of April 1, 2016, through March 31, 2017 at MCJ and CRDF)
SUBSTANTIAL COMPLIANCE (as of October 1, 2016, through December 31, 2017 at PDC North)
SUBSTANTIAL COMPLIANCE (as of February 1, 2017, through March 31, 2018 at PDC South and PDC East)
SUBSTANTIAL COMPLIANCE (as of March 1, 2017, through March 31, 2018 at NCCF)
SUBSTANTIAL COMPLIANCE (as of April 1, 2017, through March 31, 2018 at IRC)
SUBSTANTIAL COMPLIANCE (as of April 1, 2018, through March 31, 2019 at TTCF)
CDM 7-08/080 ACCOUNTABILITY OF SPECIALWEAPONS, effective October 14, 2016, requires each facility to have unit orders that "establish procedures for the storage, issuance, reissuance, accountability, maintenance, and periodic inventory of all weapons. . . stored at, or issued from, the facility," which includes detailed requirements for the "Inventory, Control, and Accountability of Aerosol Chemical Agents."
In addition to providing written policies and procedures, Substantial Compliance requires the Department to provide up-to-date Unit Orders for each jail requiring the inventory and inspection of special weapons, and armory audit logs documenting the inventory and control of armory-level weapons.
The Monitor and Use of Force Subject Matter Expert inspected the armories at TTCF on March 15, 2019, and again noted the continued improvement and that the inventory logs were checked daily in the TTCF armories. The Department provided an armory log for the First Quarter of 2019. The Department has now maintained Substantial Compliance with Paragraph 86 for twelve consecutive months at TTTC, and it is no longer subject to monitoring at TTCF for compliance with that paragraph.
The Department previously maintained Substantial Compliance with Paragraph 86 for twelve consecutive months at MCJ, CRDF, PDC North, PDC South, PDC East, IRC, and NCCF, and were not subject to monitoring in the Eighth Reporting Period.
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NO. PROVISION

STATUS

SUBSTANTIAL COMPLIANCE DATES

18 Suicide Prevention Training Substantial Compliance (MCJ, (10/1/17 at MCJ &

NCCF, PDC South, PDC East, PDC South)1

TTCF, IRC, PDC North, &

(9/1/17 at NCCF)

CRDF)

(12/1/17 at PDC

East)

(4/1/18 at TTCF,

IRC, & PDC North)

(6/1/18 at CRDF)

19 Crisis Intervention &

Substantial Compliance (MCJ, (4/1/18 at MCJ,

Conflict Resolution Training NCCF, IRC, TTCF, CRDF, & NCCF, & IRC)

PDC North, South, and East)

(7/1/18 at TTCF)

(12/1/18 at CRDF,

PDC East, & PDC

North)

(3/1/19 at PDC

South)

20 Training at NCCF, PDC and Substantial Compliance (PDC

CRDF

East, PDC North, PDC South,

NCCF, & CRDF)

(8/1/17 at PDC East, PDC North, NCCF, & CRDF) (10/1/17 at PDC South)

21 CPR Certification

Substantial Compliance (NCCF, PDC East, PDC North, PDC South, TTCF, IRC, MCJ, & CRDF)

(10/1/15 – 9/30/16 at PDC East & PDC South) (1/1/16 – 12/31/16 at NCCF, PDC North, & IRC) (4/1/16 – 3/31/17 at TTCF) (10/1/17 – 9/30/18 at MCJ) (7/1/18 – 3/31/19 at CRDF)

1 Substantial Compliance Dates in bold reflect that the Department has achieved Substantial Compliance with the training requirements or maintained Substantial Compliance for twelve consecutive months with the other requirements; the results were verified by the Monitor's auditors when required; and the County or designated facilities are no longer subject to monitoring of this provision pursuant to Paragraph 111 of the Settlement Agreement.

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22 Use of Arresting and Booking Documents

Substantial Compliance

(7/1/16 – 6/30/17)

23 Suicide Hazard Mitigation Substantial Compliance Plans

(7/12/18)

24 Suicide Hazard Inspection Substantial Compliance

(10/1/17 – 9/30/18)

25 Transportation of Suicidal Inmates (station jails)

Partial Compliance

26 Identification and Evaluation Partial Compliance of Suicidal Inmates

27 Screening for Mental Health Substantial Compliance Care and Suicide Risk

(10/1/18 – 3/31/19)

28 Expedited Booking of Suicidal Inmates

Substantial Compliance (IRC & CRDF)

(4/1/17 – 3/31/18 at IRC) (1/1/19 – 3/31/19 at CRDF)

29 Mental Health Assessments Substantial Compliance (of non-emergent mental health needs)

(4/1/17 – 3/31/18)

30 Initial Mental Health Assessments & Treatment Plans

Substantial Compliance

(1/1/19 – 3/31/19)

31 Electronic Medical Records Substantial Compliance (NCCF) (1/1/19 – 3/31/19 at

Alerts

Partial Compliance (CRDF,

NCCF)

TTCF, MCJ, & PDC North)

32 Electronic Medical Records Substantial Compliance – Suicide Attempts

(1/1/16 – 12/31/16)

33 Supervisor Reviews of

Substantial Compliance

Electronic Medical Records

(7/1/16 – 6/30/17)

34 Discharge Planning

Stayed Pending Litigation

35 Referral for Mental Health Substantial Compliance

Care

36 Assessments After

Partial Compliance

Triggering Events

(11/1/17 – 12/31/18)

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37 Court Services Division Referrals

Partial Compliance

38 Weekly Rounds in Restricted Substantial Compliance Housing Modules

(1/1/16 – 12/31/16)

39 Confidential Self-Referral

Substantial Compliance (NCCF, PDC North, & PDC South) Partial Compliance (TTCF, MCJ, & CRDF) Not Rated (PDC East)

(7/1/17 – 6/30/18 at NCCF) (7/1/18 – 3/31/19 at PDC North) (10/1/18 – 3/31/19 at PDC South)

40 Availability of QMHPs

Partial Compliance

41 FIP Step-Down Protocols

Non-Compliance

42 HOH Step-Down Protocols Partial Compliance

43 Disciplinary Policies

Substantial Compliance (NCCF & PDC North) Partial Compliance (CRDF, MCJ, & TTCF)

(10/1/17 – 9/30/18 at NCCF & PDC North)

44 Protective Barriers

Substantial Compliance

(1/1/16 – 12/31/16)

45 Suicide Intervention and First Aid Kits

Substantial Compliance

(10/1/15 – 9/30/16 at CRDF, NCCF, TTCF, PDC East, & PDC South) (1/1/16 – 12/31/16 at MCJ & PDC North)

46 Interruption of Self-Injurious Partial Compliance Behavior

47 Staffing Requirements

Non-Compliance

48 Housekeeping and Sanitation Substantial Compliance

(1/1/16 – 12/31/16)

49 Maintenance Plans

Substantial Compliance

(3/1/16 – 2/28/17)

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50 Pest Control

Substantial Compliance

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC North, TTCF, & CRDF) (4/1/16 – 3/31/17 at PDC South & PDC East)

51 Personal Care & Supplies

Substantial Compliance

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC East, PDC North, PDC South, & TTCF) (7/1/16 – 6/30/17 at CRDF)

52 HOH Property Restrictions Partial Compliance

53 Eligibility for Education, Work and Programs

Partial Compliance

54 Privileges and Programs2

Partial Compliance

55 Staff Meetings

Substantial Compliance (CRDF, PDC North, & MCJ) Partial Compliance (TTCF)

(10/1/16 – 9/30/17 at CRDF) (4/1/17 – 3/31/18 at PDC North) (4/1/18 – 3/31/19 at MCJ)

56 Changes in Housing Assignments

Substantial Compliance

(1/1/16 – 12/31/16)

57 Inmate Safety Checks in Mental Housing

Substantial Compliance (MCJ) Partial Compliance (PDC North, TTCF, & CRDF)

(4/1/17 – 3/31/18 at MCJ)

2 Per agreement of the parties, the County must maintain Substantial Compliance for two additional quarters under the revised Compliance Measures.

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58 Inmate Safety Checks in Non-Mental Housing

Substantial Compliance (PDC South, PDC North, PDC East, CRDF, & IRC) Partial Compliance (TTCF, NCCF, & MCJ)

(1/1/16 – 12/31/16 at PDC South, PDC North, & PDC East) (7/1/17 – 6/30/18 at CRDF) (10/1/17 – 9/30/18 at IRC)

59 Supervisor Rounds

Substantial Compliance (at PDC North, PDC East, MCJ, CRDF, PDC South, NCCF, & TTCF)

(1/1/17 – 12/31/17 at PDC East & MCJ) (4/1/17 – 3/31/18 at NCCF) (10/1/17 – 9/30/18 at CRDF) (1/1/18 – 12/31/18 at PDC North & PDC South) (4/1/18 – 3/31/19 at TTCF)

60 Implementation of Quality Substantial Compliance Improvement Program

61 Requirements of Quality Improvement Program

Partial Compliance

62 Tracking of Corrective Action Plans

Partial Compliance

63 Sufficient HOH and MOH Non-Compliance Housing

64 Plans for Availability of Inpatient Health Care

Non-Compliance

65 Administration of Psychotropic Medication

Partial Compliance

66 Active Mental Health Caseloads

Non-Compliance

67 Prisoner Refusals of Medication

Partial Compliance

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68 Contraband Searches

Substantial Compliance (MCJ, NCCF, PDC East, PDC South PDC North, & TTCF) Partial Compliance (CRDF)

(1/1/16 – 12/31/16 at MCJ, NCCF, PDC East, PDC South, & PDC North) (1/1/17 – 12/31/17 at TTCF)

69 Clinical Restraints in CTC Substantial Compliance

(7/1/18 – 3/31/19)

70 Security Restraints in HOH Partial Compliance and MOH

71 Therapeutic Services for

Substantial Compliance

Inmates in Clinical Restraints

(7/1/16 – 6/30/17)

72 Administrative Reviews

Substantial Compliance

(1/1/17 – 12/31/17)

73 Reporting of Self-Injurious Substantial Compliance Behavior and Threats

(10/1/17 – 9/30/18)

74 Law Enforcement Investigations of Suicides

Substantial Compliance

(9/1/16 – 12/31/17)

75 Management Reviews of Suicide Attempts

Substantial Compliance

(10/1/17 – 9/30/18)

76 Management Reviews of Suicides

Substantial Compliance

(9/1/16 – 12/31/17)

77 Custody Compliance and Sustainability Bureau

Partial Compliance

78 Suicide Prevention Advisory Substantial Compliance Committee

(5/11/16 – 5/18/17)

79 Therapeutic Services in Mental Health Housing

Non-Compliance

80 Out-of-Cell Time in HOH Non-Compliance

81 Implementation of Rosas Recommendations

Partial Compliance

82 Grievances at CRDF

Substantial Compliance

(7/15/16 – 12/31/17)

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83 Closed Circuit Cameras

Substantial Compliance (MCJ, TTCF, IRC, CRDF, NCCF, PDC North, & PDC South)

(7/1/15 – 6/30/16 at MCJ & IRC) (10/1/15 – 9/30/16 at TTCF) (4/1/16 – 3/31/17 at CRDF) (4/1/18 – 3/31/19 at NCCF & PDC North) (7/1/18 –3/31/19 at PDC South)

84 Investigation of Staff Misconduct

Substantial Compliance

(7/1/17 – 6/30/18)

85 Internal Affairs Bureau Training

Partial Compliance

86 Maintenance and Inventory Substantial Compliance (MCJ, (4/1/16 – 3/31/17 at

of Security Equipment

CRDF, PDC North, PDC South, MCJ & CRDF)

PDC East, NCCF, IRC, & TTCF) (10/1/16 – 12/31/17 at

PDC North)

(2/1/17 – 3/31/18 at

PDC South & PDC

East)

(3/1/17 – 3/31/18 at

NCCF)

(4/1/17 – 3/31/18 at

IRC)

(4/1/18 – 3/31/19 at

TTCF)

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First4 Second Third Fourth Fifth Sixth Seventh Eighth

Substantial Partial

Non-

Substantial

Compliance Compliance1 Compliance Compliance

(Provisions)

(Facilities)2

5

16

10

14

30

13

24

22

27(1)

10

29

24

26(1)

10

29

23

24(2)

7

34

32

22

7

38

30

23

7

39

36

18

7

42

No Longer Subject To Monitoring3
4(2) 10(2) 15(5) 18(9) 21(10) 28(9)

1 The figure in parenthesis under Partial Compliance is the number of additional provisions where some facilities were in Partial Compliance and other facilities were in NonCompliance.
2 This represents the number of provisions where the Department is in Substantial Compliance at all or some of the facilities.
3 The figure in parenthesis under No Longer Subject to Monitoring is the number of additional provisions where some facilities are no longer subject to monitoring.
4 During the First Reporting Period, 43 provisions were not subject to monitoring.

 
 Agreement between US and LA County Jail

http://www.usdoj.gov/crt/split/documents/lacountyjail_mh.htm

Memorandum of Agreement Between the United States and Los Angeles County, California Regarding Mental Health Services at the Los Angeles County Jail
TABLE OF CONTENTS I. INTRODUCTION II. DEFINITIONS III. GENERAL PROVISIONS IV. SUBSTANTIVE PROVISIONS
A. Intake B. Evaluation C. Referrals D. Treatment E. Medication Administration F. Environmental Conditions G. Suicide Prevention H. Medical Records and Communication I. Staffing and Training J. Quality Assurance K. Abuse and Mistreatment V. CONSTRUCTION, IMPLEMENTATION, AND MONITORING OF COMPLIANCE
I. INTRODUCTION In August of 1996, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 et seq.,
the United States Department of Justice ("DOJ") toured the Los Angeles County Jail ("the Jail") with experts in the field of correctional mental health services. On September 5, 1997, DOJ issued a letter reporting its findings based on the tour of its experts, the County's response to the tour, and the additional information received. DOJ concluded that mental health care at the Jail violated the inmates' constitutional rights.
In its findings letter, DOJ detailed numerous alleged constitutional deficiencies with regard to mental health care, including inadequate (1) intake screening and evaluation, (2) diagnosis, (3) referral to mental health professionals, (4) treatment plans, (5) administration of medications, (6) suicide prevention, (7)

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tracking and medical record keeping, (8) staffing, (9) communication, and (10) quality assurance. The report also noted that the County had allegedly mistreated and abused mentally ill inmates, including using excessive force and improper restraint practices.
Since DOJ issued its findings letter, the parties have attempted to work cooperatively to resolve the concerns outlined in the letter. After its initial tour in June of 1996, DOJ has conducted several follow up investigatory inspections of the Jail and has continued to find inadequate mental health services.
The parties to this Memorandum of Agreement ("the Agreement") recognize the constitutional rights of inmates confined at the Jail. After discussions and negotiations, and in order to avoid potential litigation concerning the mental health services at the Jail, the parties have agreed to the provisions set forth in this Agreement. The parties have engaged in good-faith negotiations to reach this Agreement. The parties agree that the provisions of this Agreement will ensure that reasonable and adequate mental health care services are provided at the Jail.
Fulfillment of the terms of this Agreement, voluntarily negotiated and entered into by DOJ and Los Angeles County, is intended to resolve all remaining issues relating to mental health services at the Jail.
II. DEFINITIONS
1. "The Parties" shall refer to the County and the United States of America.
2. "The County" shall refer to Los Angeles County, the Los Angeles County Sheriff's Department; the Los Angeles County Department of Mental Health, and the agents and employees of the Sheriff's Department and Department of Mental Health.
3. The term inmate(s) shall refer to one or more individuals, male and/or female, sentenced to, incarcerated in, detained at, or otherwise confined at the Jail.
4. "Qualified professional" shall refer to an individual qualified to render the requisite and appropriate care, treatment, judgment(s), training and service, based on credentials recognized in the specific field.
5. "Competency-based training" means training deemed successfully completed by a staff member only when that staff member demonstrates to a trainer his or her ability or competency to perform a specified skill through an active hands-on demonstration of such skill.
III. GENERAL PROVISIONS
6. The facilities that are at issue in this case are "institutions" as that term is defined in 42 U.S.C. § 1997(1).
7. Los Angeles County owns and funds the operation of the Jail. In their official capacity, the Sheriff of Los Angeles County, and the Los Angeles County Department of Mental Health are responsible for overseeing and/or providing mental health services to the inmates at the Jail.
8. The County is responsible for assuring the fulfillment of the responsibilities and obligations imposed by this Agreement upon County employees, independent contractors, departments or other sub-units of the County government.
IV. SUBSTANTIVE PROVISIONS
A. Intake

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1. The County will maintain adequate twenty-four hour mental health screening of all inmates at the Inmate Reception Center ("IRC").
2. Each inmate entering IRC shall be individually and privately asked questions appropriate to determine whether the inmate has or had a mental illness, has attempted suicide, or has suicidal propensities.
3. Intake screening at IRC shall be completed by an appropriately trained individual, and shall be documented in the appropriate medical record for incoming inmates.
4. Incoming inmates screened at IRC who are in need of emergency mental health care shall receive such care immediately after intake at IRC.
5. The Jail's screening process for mental illness shall not rely solely on an inmate's report that he or she does not have a mental illness.
6. A reasonably quiet and private area shall be available for the mental health evaluation at IRC.
B. Evaluation
7. Within 24 hours of admittance to IRC (excluding weekends and legal holidays as long as an urgent evaluation is not indicated), the County shall provide an adequate mental health care evaluation of inmates who screen positive for possible mental illness at IRC. Within 72 hours of admittance to IRC, the County shall provide a mental health care evaluation to inmates admitted to IRC on the weekends or legal holidays (unless an urgent evaluation is indicated). If the evaluation identifies a serious mental illness, the evaluation shall result in a brief initial treatment plan.
8. A qualified and appropriately trained professional shall, within 14 days of admittance to IRC, complete and properly document an adequate mental health evaluation, including a medical evaluation if necessary, for each inmate screened positive for possible mental illness.
C. Referrals
9. The County shall refer general population inmates who may be mentally ill to a mental health professional.
10. Mental health staff shall make weekly rounds in locked down non-mental health housing modules (e.g. administrative segregation, disciplinary segregation) at the Jail to identify inmates who may have been missed during screening or who have decompensated while in the Jail.
11. The Jail will maintain a confidential self-referral system by which inmates can request mental health care without revealing the substance of their request to correctional officers.
D. Treatment
12. The County shall provide adequate mental health treatment to all inmates determined to be mentally ill.
13. The County shall ensure continuity of appropriate medicine to individuals identified as mentally ill who were receiving medicine prior to entering the Jail.
14. An individual, comprehensive, written, mental health treatment plan shall be prepared

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within 14 days by a qualified and appropriately trained mental health professional for every seriously mentally ill inmate. Changes to and compliance with the treatment plan shall be accurately documented in the inmate's medical/mental health record.
15. The County shall ensure adequate therapy and counseling for all mentally ill inmates who need such care. This includes adequate space for treatment, adequate staff to provide treatment, and adequate therapeutic programming.
16. The County shall provide adequate twenty-four hour crisis intervention for inmates, including transfer to special medical housing units, administration of psychotropic medications, provision of therapy treatment, and special observation, for inmates.
17. Inmates shall have access to appropriate licensed in-patient care when clinically appropriate.
18. Unless contraindicated, the County shall ensure that all inmates with serious mental illness and housed in the most intensive levels of outpatient mental health housing be offered at least 10 hours per week of structured out of cell therapeutic or programmatic activity and 15 hours of recreation per week. Unless clinically contraindicated or the inmate is in administrative segregation, no inmate in the Twin Towers Correctional Facility ("TTCF") with serious mental illness shall be locked down more than 19 hours per day. Inmates with mental illness or housed in mental health housing shall not be denied jail privileges or programs based solely on their status as mentally ill or on their placement in mental health housing.
19. The determination that, as a result of his or her mental illness, an inmate poses a clinical risk of dangerousness to self or others that precludes the provision of any right, service or privilege, shall be made by a qualified professional in consultation with correctional staff on an individual basis and shall be recorded in the inmate's records.
20. Inmate trusties shall never be placed in a supervisory position or used as escorts for mentally ill inmates or inmates in mental health housing. Inmate trusties shall be carefully selected and screened before being assigned trustie positions. Where trusties are allowed to work in mental health housing, they shall be closely monitored.
E. Medication Administration
21. The County shall ensure that a full range of appropriate psychotropic medications is available at the Jail and that psychotropic medications are properly prescribed, monitored and documented by appropriately trained mental health professionals.
22. The County shall ensure that all medications are appropriately administered and monitored by licensed health care professionals.
F. Environmental Conditions
23. The County shall ensure a sanitary and humane environment for all mentally ill inmates and all inmates housed in mental health housing. This includes, but is not limited to, seclusion and isolation units and cells which may house inmates with mental illness.
24. The County shall maintain a sufficient amount of adequate mental health housing at every appropriate level of care for every inmate in need of mental health housing. However, it is not necessary that every mentally ill inmate be segregated into mental health housing.
G. Suicide Prevention

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25. The County shall ensure that inmates observed to be potentially suicidal receive appropriate crisis intervention, (including placement in a safe setting and evaluations in a timely manner), by a qualified mental health professional to determine whether and what level of suicide observation is required.
26. An inmate under suicide observation shall be evaluated by a qualified mental health professional prior to being removed from mental health observation.
27. Suicide intervention procedures shall permit correctional staff to administer appropriate first-aid measures immediately. All correctional officers shall be trained in first aid and cardiac pulmonary resuscitation ("CPR") cutdown techniques and emergency notification procedures in the event of hanging. Officers shall have cut down tools available.
28. Suicide watch procedures shall provide for fifteen minute suicide watch and may be modified to provide for five minute suicide watch with the concurrence of custody administration and staff. Suicide watch must be documented.
29. Suicide observation cells and dormitories shall be maintained in a manner that is safe and will not exacerbate a suicidal inmate's mental condition. Inmates under suicide observation should be within sight of staff.
H. Medical Records and Communication
30. Documentation in an inmate's medical/mental health record shall provide complete, accurate, and legible information regarding an inmate's mental health, including but not limited to: assessments, treatment planning, administration and effect of medications, requests for and results of laboratory tests, and inmate progress or decompensation.
31. The County may create and implement a computer system that allows prompt, up-to-date, and reasonable access to every inmate's medical/mental health record who is housed at TTCF, twenty-four hours per day.
32. There may be an electronic integrated medical/mental health record for each inmate.
33. The County shall create and implement a Management Information System adequate to manage the inmates' mental health records.
I. Staffing and Training
34. The County shall provide sufficient mental health staffing to ensure timely access to adequate mental health treatment and meet the obligations and provide the services listed in this Agreement. Except for staffing for the women's case load population and the Forensic Inpatient Program, mental health staffing shall be no lower than one psychiatrist per 100 inmates who require medication. Staffing for the women's case load population shall be enhanced due to higher utilization rates of mental health services. Staffing for the Forensic Inpatient Program shall ensure timely access to adequate treatment and shall minimally meet licensure standards currently governing such program.
35. A psychiatrist shall be available, at least by telephone, twenty-four hours per day to evaluate and prescribe psychotropic medications in emergency situations.
36. Staffing shall include sufficient numbers of bilingual clinicians trained to provide mental health care, including evaluations and therapy, to all inmates who do not sufficiently speak or

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understand English.
37. The County shall provide adequate clerical, supervisory and administrative assistance to support mental health services and assist in maintaining adequate documentation, supervision, coordination and communication of mental health services at the Jail.
38. All staff shall be properly trained for every function/duty they are expected to perform.
39. The County shall implement mandatory orientation and continuing competency based in-service training for correctional staff in the identification and custodial care of mentally ill inmates, including, but not necessarily limited to: (a) interpreting and responding to aberrant or bizarre behaviors, (b) recognizing and responding to indications of suicidal thoughts, (c) proper suicide observation, (d) recognizing common side-effects of psychotropic medications, (e) professional and humane treatment of mentally ill inmates, and (f) response to mental health crises, including suicide intervention and cell extractions. The County shall require annual refresher training.
40. The County shall document all training.
J. Quality Assurance
41. The County shall implement and document a continuous quality improvement program for mental health services in the Jail. The continuous quality improvement program shall monitor the quality of mental health care.
42. The quality assurance program shall specify the procedures for medical and administrative review in the event of suicides, suicide attempts, mutilations, and other critical incidents.
K. Abuse and Mistreatment
43. Staff shall not be permitted to physically, verbally, or mentally abuse inmates with mental illness. Allegations of abuse of mentally ill inmates or inmates in mental health housing shall be promptly and thoroughly investigated and staff members found to have abused inmates shall be appropriately disciplined.
44. Physical restraints used for mental health therapeutic reasons must be consistent with community standards of care.
V. CONSTRUCTION, IMPLEMENTATION, AND MONITORING OF COMPLIANCE
45. This Agreement shall become effective on signature by the parties as a Memorandum of Agreement only and shall not be considered or constructed as a Consent Decree.
46. The County may hire an independent expert psychiatrist(s) or consultant(s) as a Monitor(s) to assess compliance with the Agreement. The Monitor(s) shall jointly be selected by the County and DOJ. The County shall provide such Monitor(s) with adequate assistance to make an assessment of compliance, including hiring additional independent expert consultants. Any additional expert consultants must be approved and be acceptable to both the County and DOJ. The County shall pay the Monitor(s) and any additional expert consultants for such monitoring services. The Monitor(s) shall submit a report to DOJ and the County assessing compliance with this Agreement within 45 days of any on-site compliance visit and shall make such on-site assessments and report at least twice annually. The Monitor(s) shall not be replaced without approval of the United States, and any Monitor(s) or additional consultants shall not be selected

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Agreement between US and LA County Jail

http://www.usdoj.gov/crt/split/documents/lacountyjail_mh.htm

without the written consent of the United States and the County. In the event the County chooses not to select a Monitor(s) or the County and the United States are unable to agree upon a Monitor(s), the United States shall continue its current investigation of the Jail pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, and the County shall continue providing the United States and its expert consultants with full and open access as described in Paragraphs 47-50 of this Agreement.
47. Every ninety (90) days following the signing of this Agreement and until the Agreement is fulfilled, the County shall submit to the Monitor(s) and the United States a status report stating whether the County is complying with each and every term of this Agreement. The report shall include, as appropriate, documentation, certifications, receipts and such other information as requested by the Monitor(s) and/or United States to assist in the evaluation of compliance with the terms of this Agreement.
48. The status reports, at a minimum, shall describe the actions that the County has taken up to and including the current reporting period to implement this Agreement, and shall specifically refer to the provisions of this Agreement upon which they report.
49. The County shall maintain sufficient records to document their compliance with all terms of this Agreement. The County shall also maintain any and all records required by or developed under this Agreement.
50. The Monitor(s) and/or DOJ shall have access to and, upon request, receive copies of any document and/or any databases directly related to the implementation of this Agreement, except confidential peace officer personnel files. The Monitor(s) and/or United States shall have access to Jail staff, including private interviews with consenting inmates, and staff, as necessary to assess compliance with this Agreement.
51. The County shall implement the terms of this Agreement. This Agreement shall become subject to termination at any time two years subsequent to its signing if the County has substantially complied with all requirements of this Agreement and substantial compliance has been maintained for at least one year.
52. Nothing in this Agreement shall preclude DOJ from initiating a civil action pursuant to 42 U.S.C. § 1997.
53. If the County expands the Jail or outsources any of the services covered under this Agreement, such expanded facility and/or outsourced services shall be covered under this Agreement.
Agreed to by:
For the County
LEROY D. BACA Sheriff Los Angeles County
MARVIN J. SOUTHARD Director Department of Mental Health Los Angeles County

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Agreement between US and LA County Jail
KEVIN C. BRAZILE Assistant County Counsel Los Angeles County
For the United States
RALPH F. BOYD, JR. Assistant Attorney General Civil Rights Division
DEBORAH W. YANG United States Attorney Central District of California
STEVEN H. ROSENBAUM Chief Special Litigation Section
MELLIE H. NELSON Deputy Chief Special Litigation Section
WILLIAM G. MADDOX JIM EICHNER Attorneys Special Litigation Section Civil Rights Division U.S. Department of Justice P.O. Box 66400 Washington, DC 20035

http://www.usdoj.gov/crt/split/documents/lacountyjail_mh.htm

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 U.S. Department of Justice
JMS:LES:CST:KKD:RMLM:JH:EJ:PZ DJ 168-12C-43
June 4, 2014
VIA ELECTRONIC AND FIRST-CLASS MAIL
Anthony Peck, Esq. Deputy County Counsel 4700 Ramona Blvd. Monterey Park, CA 91754
Stephanie Jo Reagan, Esq. Principal Deputy County Counsel Los Angeles County Department of Mental Health 550 South Vermont Avenue Los Angeles, CA 90020
RE: Mental Health Care and Suicide Prevention Practices at Los Angeles County Jails
Dear Mr. Peck and Ms. Regan:
We write to report our conclusions with regard to Los Angeles County’s compliance with the Memorandum of Agreement (“MOA”) that requires adequate mental health care and suicide prevention at the Los Angeles County Jail System (“Jails”). Since the entry of the MOA twelve years ago, there has been significant improvement in the delivery of mental health services. However, serious systemic deficiencies remain with regard to some aspects of the Jails’ mental health program. Based on our review, we conclude that the County violates the Eighth and Fourteenth Amendments of the United States Constitution by failing to provide adequate mental health services and protect prisoners from serious harm and risk of harm at the Jails due to inadequate suicide prevention practices. Consistent with the practice of our long-standing investigation of the Jails pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997, we write to update our conclusions of September 5, 1997 regarding mental health treatment and suicide prevention at the Jails and to discuss the minimum remedial steps necessary to address the identified deficiencies.
We notified the County of continuing weaknesses in the Jails’ mental health services during the 12-year tenure of the MOA, including through numerous reports from the Department of Justice’s long-standing experts, Joel Dvoskin, Ph.D., and Jeffrey L. Metzner, M.D. In the face of these ongoing problems and the ineffectiveness of the MOA to ensure that prisoners with mental illness are protected from suicide and other harms, we propose to enter into negotiations with the County regarding a court enforceable agreement to substitute for certain critical terms of

the MOA. The affected MOA provisions are: Suicide Prevention (§§ IV.G.25-29), Intake (§ IV.A.5), Referrals (§ IV.C.9), Treatment (§ IV.D.12 & 15-19), Medication Administration (§ IV.E.22), Environmental Conditions (§ IV.F.23-24), and Quality Assurance (§ IV.J.42). We are prepared for the following provisions related to mental health care and treatment to continue as part of the MOA: Evaluation (§ IV.B.7), Referrals (§§ IV.C.10-11), Treatment (§§ IV.D.13), Medication Administration (§ IV.E.21), Staffing and Training (§§ IV.I.34-35), and Quality Assurance (§ IV.J.41). As discussed below, the Department of Justice will cease monitoring those MOA provisions with which the County has achieved and maintained substantial compliance: §§ IV.A.1-4, A.6, B.8, D.14, D.20, H.30-33, and I.36-40. Despite our conclusions regarding constitutional violations at the Jails, we wish to commend the County on the considerable progress it has made in terms of mental health services at the Jails, especially with respect to increased mental health staffing, since our initial review in 1997.
The Department of Justice acknowledges that many of the prisoners confined to the Jails who have mental illness were failed by other systems. The delivery of mental health services in the corrections environment is difficult and presents unique challenges. Many of the prisoners may well be safely and more effectively served in community-based settings at a lower cost to the County. The remedies that we seek in order to ensure that the conditions in the Jails meet the minimum required by the Constitution – that ensure that prisoners are safe and that staff are not placed at an unreasonable risk of harm – can be implemented more effectively if the number of prisoners needing mental health services is reduced.
In considering solutions to this problem, we strongly encourage the Sheriff, the Mental Health Director, and the County to consider alternatives to incarceration for those prisoners with mental illness who can be supervised in the community without compromising public safety. We understand that the County Board of Supervisors recently voted unanimously to undertake an analysis of diversion programs for arrestees with mental illness in the County and the availability of beds in a non-jail setting to support the population.1 The United States applauds the County’s interest in increased community-based treatment and alternatives to incarceration for individuals with mental illness. While the United States cannot require measures to address the population pressures, we would consider any steps taken voluntarily as an important part of the solution to the issues we address in this letter. These measures would also be consistent with meaningful steps the County is taking to increase rehabilitative options for youth in the community as part of our amended MOA with the County involving its youth probation camps.
Our conclusions with regard to suicide prevention and mental health treatment at the Jails are summarized below, followed by our compliance assessment of the remaining MOA provisions.
I. SUMMARY OF CONCLUSIONS
We made the following factual determinations:

1

Abby Sewell, L.A. County Supervisors Vote to Move Forward on $2-billion Jail Plan, L.A. Times, May 6,

2014, available at http://www.latimes.com/local/lanow/la-me-ln-jail-plan-vote-20140506-story.html#.

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• There is inadequate mental health care to prevent prisoners from becoming suicidal, to identify suicidal prisoners, or to prevent prisoners from going into crisis.
• The County has failed to take necessary steps to address a dramatic increase in the number of suicides and suicide incidents in the Jails. In 2012, there were four completed suicides. In 2013, there were ten prisoner suicides and one more suicide in January 2014. Based on our review, many of the suicides that occurred in the last two years were preventable. In addition, the Jails reported a more than 20 percent increase in suicide “incidents” in 2013, when a total of 366 suicide “incidents” were recorded. While the Jails’ characterization of self-harm is undefined and inconsistent, it appears that “incidents” includes suicide attempts evidencing a discernible intent to commit suicide and those requiring a certain level of medical intervention after the suicidal behavior is discovered. Indeed, one of these critical incidents occurred at the Jails at least every seven days from January through September 2013. The number of suicides and selfharming behaviors, together with the numerous procedural and policy lapses surrounding many of these incidents, give us reasonable cause to believe that prisoners remain at significant risk of serious harm.
• The Jails do not provide appropriate custodial supervision for prisoners, including those on the mental health caseload and those who have been identified as having a heightened risk of suicide. Remarkably, about 44% of those who self-harmed were housed in mental health housing at the time of the incident, indicating a lack of adequate custodial supervision for even those prisoners who require higher levels of attention. We found repeated lapses in the Jails’ safety checks, which evidence a serious risk of harm to prisoners from suicidal behavior, as well as violence and other prohibited behavior.
• Prisoners with mental illness do not receive adequate supervision and are housed in conditions that present, rather than prevent, a risk of suicide. Deputies do not consistently perform timely, thorough safety checks. Living conditions in general are deficient (dimly lit, vermin-infested, noisy, unsanitary, cramped and crowded), most acutely at Men’s Central Jail but also at the Century Regional Detention Facility and in certain areas of the Twin Towers Correctional Facility, and create an environment that may contribute to prisoners’ mental distress. Often, suicide precautions are punitive in nature, even depriving some prisoners of a mattress to sleep on.
• Custody staff, the Medical Services Bureau, and the Department of Mental Health often operate in silos when addressing suicide incidents and risks, maintaining separate charts and even separate investigatory reports. The lines of communication between these entities are flawed, and at times non-existent. Our review of the Jails’ suicide incidents demonstrated that this lack of communication, or miscommunication, between medical, mental health, and custody staff resulted in critical breakdowns in the custody and care of prisoners at the Jails.
• In spite of the increase in suicides in the Jails, there remains a persistent failure on the part of the Jails’ command staff to critically review and appraise the contributions, intended or not, of its policies, staffing, and custody practices, to the suicides and suicide
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attempts that are occurring. Fifteen suicides in 25 months produced almost no discernible change in the Jails’ custodial practices. Critical incident reviews related to suicides are replete with inaccurate and incomplete information and do not identify or seek to remedy systemic problems. This failure to review, appraise, revise, and ultimately, to enforce the Jails’ own policies, is reflected in the overall escalation of suicide incidents and preventable prisoner deaths. This is a system failure that negates the Jails’ good custody policies and increases the risk of harm to prisoners.
These factual determinations provide us with reasonable cause to conclude that the Jails violate prisoners’ constitutional rights to be protected from harm, Farmer v. Brennan, 511 U.S. 825, 833 (1994), and serious risk of harm, Helling v. McKinney, 509 U.S. 25, 33-35 (1993).2
II. BACKGROUND
The County entered into the MOA with the United States following an investigation by the Civil Rights Division pursuant to CRIPA. CRIPA authorizes the Department of Justice to seek equitable relief where jail conditions violate the constitutional rights of prisoners in state and local detention facilities. Because a monitor was not selected to oversee the implementation of the MOA, the Department of Justice continued its investigation into conditions at the Jails with expert consultants to ensure compliance with the MOA. See MOA § V.46. The MOA does not preclude the Department of Justice from initiating a civil action under CRIPA to protect the constitutional rights of prisoners at the Jails. MOA § V.52.
As discussed below, during the 12-year tenure of the MOA, the County has achieved sustained, substantial compliance with certain provisions of the MOA. However, our compliance reviews have identified grave concerns with regard to the Jails’ suicide prevention practices and mental health treatment.3
On March 25-28 and June 25-28, 2013, we conducted on-site inspections at the Jails with our long-standing experts, Drs. Dvoskin and Metzner, to assess the County’s MOA compliance. We determined the need to conduct additional review with regard to suicide prevention at the Jails. On September 23-26, 2013 and January 7-10, 2014, we conducted on-site inspections with Margaret E. Severson, our expert consultant in suicide prevention. In conjunction with each visit, we reviewed an extensive number of documents, including policies and procedures, the Jails’ quality improvement documentation, investigative reports, incident reports, population data, staff training materials, and the Jails’ suicide review files. Consistent with our pledge of transparency and to provide technical assistance where appropriate, we conveyed our preliminary observations to County and Jail officials and legal counsel for the County and Sheriff’s Department at the close of the first three visits. At the conclusion of the January 2014 visit, we

2

Additional information and detail supporting our conclusions is included in the attached expert report of

expert Margaret E. Severson and monitoring report from Drs. Dvoskin and Metzner.

3

This letter does not address provisions in MOA § IV.K, Abuse and Mistreatment, as that subject will be

discussed in a separate letter related to our investigation of use of force and protection from harm at the Jails.

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informed County officials that we would provide detailed conclusions to the County in writing. This report details our assessment of the Jails’ MOA compliance, and non-compliance, as well as separately highlighting our conclusions on the Jails’ suicide prevention practices.
III. CONCLUSIONS OF INADEQUATE MENTAL HEALTH CARE AND SUICIDE PREVENTION PRACTICES
We conclude that Los Angeles County, including the Sheriff’s Department and the Department of Mental Health, violates prisoners’ constitutional right to adequate suicide prevention practices, which is required as a part of the Jails’ legal obligation to meet the serious mental health care needs of all prisoners. These deficiencies pose a substantial risk of serious harm to prisoners in violation of the Fourteenth Amendment’s due process protections for pretrial detainees, as well as the Eighth Amendment’s protections for those convicted of a criminal offense.4 Farmer, 511 U.S. at 832-834. In defining the scope of prisoners’ Eighth and Fourteenth Amendment rights, the Supreme Court has held that corrections officials must take reasonable steps to guarantee inmates’ safety and provide “humane conditions” of confinement. Id. at 832; Bell v. Wolfish, 441 U.S. 520 (1979) (holding pre-trial detainees protected by Fourteenth Amendment). Conditions must satisfy prisoners’ basic needs, including their needs for mental health care. Farmer, 511 U.S. at 832-834; Estelle v. Gamble, 429 U.S. 97, 103-05 (1976); Hoptowit v. Ray, 682 F.2d 1237, 1253 (9th Cir. 1982), abrogated on other grounds by Sandin v. Conner, 515 US 472 (1995); Gibson v. County of Washoe, Nev., 290 F.3d 1175, 11871188 (9th Cir. 2002). These obligations include the duty to protect prisoners against reasonable risk of self-harm. Helling, 509 U.S. at 32-34 (right to care extends to preventing “unreasonable risk of serious damage to [a prisoner’s] future health”); Conn v. City of Reno, 591 F.3d 1081, 1095–96 (9th Cir. 2010), vacated, 131 S. Ct. 1812 (2011), reinstated in relevant part, 658 F.3d 897 (9th Cir. 2011) (“A heightened suicide risk or an attempted suicide is a serious medical need.”); Cabrales v. County of Los Angeles, 864 F.2d 1454, 1461 & n. 2 (9th Cir. 1988) (applying the “deliberate indifference” standard to a § 1983 claim by the mother of a pretrial detainee who committed suicide in detention, and explaining that “the fourteenth amendment due process rights of pretrial detainees are analogized to those of prisoners under the eighth amendment”), vacated on other grounds, 490 U.S. 1087, 109 S.Ct. 2425, 104 L.Ed.2d 982 (1989), opinion reinstated, 886 F.2d 235 (9th Cir. 1989).
The most recent suicide demonstrates the Jails’ failure to take reasonable steps protect prisoners with mental illness from the risk of suicide and illustrates the systemic deficiencies in the Jails’ suicide prevention practices detailed in this letter. “Alan”5 was assessed as actively suicidal upon intake to the Jails in early 2014; he acknowledged a history of medical and mental health problems and a previous suicide attempt. The next morning, he underwent a mental health evaluation and was housed in the Twin Towers high observation unit with an order for no mattress, no sharps, and 15-minute checks. At 11:45 a.m., Alan met with a mental health supervisor and voiced thoughts of suicide, including: “I just feel like dying … I won’t care if I

4

For the sake of clarity, in this letter we refer to all individuals housed in the Jails, including pre-trial

detainees and individuals who have been convicted of a criminal offense, as “prisoners.”

5

We use pseudonyms to protect against disclosing personally-identifying information.

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die. If I had a rope I would just hang myself.” Corrections officials have an obligation to act when there is a strong likelihood that a prisoner will engage in self-injurious behavior, including suicide. Funtanilla v. Rubles, 5 Fed. Appx. 590, at **1 (9th Cir. 2001) (finding allegations that, while he was in suicide prevention cell, prison guard observed prisoner cutting his arm and left him there for two hours covered in his own blood, were sufficient to allege deliberate indifference on part of prison officials); Van Orden v. Caribou County, 546 Fed.Appx. 647, 649 (9th Cir. 2013) (“Because Bannister actively manifested her suicidality in the hours immediately preceding her suicide, we hold that the district court erred in concluding that no reasonable jury could find that Downs and Long were subjectively aware of a substantial risk of serious harm to Bannister.”). However, when Alan was apprised of potential interventions, including the punitive restrictions of suicide watch at the Jails, it was noted that he “changed his mind.”
Immediately following Alan’s interview, mental health staff noted in his electronic medical record that he should be housed with a cellmate in double-man housing and a psychiatric note reads “no longer having suicide thoughts.” Mental health staff relayed the order for doubleman housing verbally to custody staff, who then documented the order. Alan hanged himself later that day from the top bunk in his solely occupied double-man cell. When Alan was discovered, safety checks had not been completed for nearly three hours. Lemire v. California Dept. of Corrections and Rehabilitation, 726 F.3d 1062, 1076-77 (9th Cir. 2013) (holding that fact issues precluded summary judgment on Eighth Amendment failure to protect and substantive due process claims against warden and captain who knowingly withdrew all floor staff from prison building which housed mentally ill inmates, leaving inmates unsupervised for over three hours, during which time an inmate committed suicide). The Assistant Sheriff over the Jails recently indicated that several Jail practices were not followed with regard to Alan’s suicide.6 However, as discussed below, our investigation concluded that the circumstances of Alan’s death, including inadequate mental health care, deficient suicide precautions, and lax custody supervision, are far too common in the Jails.
The Jails are in the midst of a trend of ongoing systemic problems, which include: (1) supervision lapses and violations of security check policies and procedures; (2) incomplete information collection and communication in intake assessments and evaluations; (3) poor documentation in the medical records, in the deputies’ incident reports, and in the Jails’ critical incident reviews; (4) inadequate mental health treatment; (5) inattention to custody-related contributors to the suicides; and (6) an overall failure to adequately investigate and respond to the suicides that have occurred and the system failures that repeatedly come to light after a suicide.
A. Inadequate Intake Screening and Identification of Individuals with Mental Illness and at Risk for Suicide.
Constitutionally minimum standards require jails to have a program to “identify, treat, and supervise” prisoners at risk of suicide. Coleman v. Wilson, 912 F. Supp. 1282, 1298 n.10 (E.D. Cal. 1995) (noting that identifying prisoners at risk of suicide is one of the six basic

6

Rina Palta, Suicidal LA Jail Inmate, Later Found Dead, Was Left Alone for Hours, Southern California

Public Radio, May 5, 2014, available at http://www.scpr.org/news/2014/05/05/43961/la-jail-inmate-who-committed-

suicide-was-not-check/.

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components of a minimally adequate prison mental health care delivery system). Identification of persons at risk for suicide and self-injury can and does occur at any point during their incarceration. However, formal mechanisms to identify suicidal prisoners must be in place and a regular part of the custodial process that begins at the pre-booking phase of a person’s detention and extends through the initial screening, classification, the history and physical examination, and the prisoner and staff sick call request process. Madrid v. Gomez, 889 F. Supp. 1146, 125657 (N.D. Cal. 1995) (“While a functioning sick call system can be effective for physical illnesses, there must be a ‘systemic program for screening and evaluating prisoners in order to identify those who require mental health treatment.’”) (internal quotations omitted).
After years of consultation with and technical assistance from Drs. Dvoskin and Metzner, the Jails’ mental health and suicide prevention policies and procedures are largely adequate as written, including intake forms for screening for mental health needs and prisoners’ suicide risk. However, implementation and practice diverge from the written policies in a manner that poses a risk to prisoners.
1. The Jails’ Screening Process Inappropriately Excludes Some Prisoners.
The Department of Justice did identify at least one particularly critical deficiency with regard to the Jails’ intake screening policies. It appears some prisoners are excluded or delayed from the Jails’ screening process by policy when they are held in one of the Jail system’s lockup facilities. In 2012, two days after his arrest, “Brian” hanged himself in the Century Regional Detention Facility (“CRDF”) lockup. As a matter of policy, Brian did not receive a mental health screening upon his arrest or admission to a pre-arraignment housing unit in CRDF. The official arrest report indicates that Brian was detained on domestic violence charges for reportedly choking his victim and stating “you don’t think I won’t kill you right now, right here? I have nothing to live for!” However, it is unclear if any of this information was actually passed on to the Jails’ staff when he was admitted, as the arresting/transporting officer’s space for comments on the Jails’ Arrestee Medical Screening Form is blank and the questions about mental health and suicide conditions are marked “no.” Brian had the word “Suicidal” as part of two tattoos, the significance of which is unknown because there is nothing in the death review documents that refers to or attempts to explain these tattoos. The Jails’ electronic medical record includes information from a previous intake screening two months prior to Brian’s death, which states that he reported a history of medical, mental health, and substance abuse problems, including diagnoses of schizophrenia and depression, and auditory hallucinations. The Jails’ policy omitting Brian from the screening is constitutionally deficient. Coleman, 912 F. Supp. at 1298. In this case, given Brian’s significant mental health history and the suicidal statements he made upon his arrest, an adequate screening may have prevented his death.
2. The Jails Do Not Obtain or Disseminate Complete Information Upon Intake.
There are a series of screenings upon intake to the Jails, which are designed to identify prisoners who are in need of medical or mental health care or who may be at risk for suicide or self-harm. Unfortunately, often they are not filled out completely or adequately incorporated into the prisoners’ electronic medical record. As a result, intake screening is insufficient to identify and protect individuals at risk for suicide.
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When a prisoner is brought into the Jails, the arresting or transporting officer is asked to complete the “Outside Agency Medical Declaration” on the Arrestee Medical Screening Form by answering three questions, including: “Is any person in your agency aware of any medical or mental condition, prescribed medication taken by or in possession of this arrestee, or any medical problem or injury regarding this arrestee?” In reality, an answer to this question is rarely found on the form. Out of a sample of 26 suicide incidents reviewed by the Department of Justice, 16 of these Agency Declarations are entirely blank, and an additional seven only list the prisoner’s name. While the instructions for completing this portion of the form have changed slightly over time, the rate of completion does not appear to have changed. It appears there is no enforcement of the requirement that arresting or transporting officers fill out this form.
The Arrestee Medical Screening Form also asks the arresting officer to describe the prisoner’s behavior, whether medical treatment was sought, and whether the prisoner has a history of mental illness or suicidal behavior. It is unclear exactly who is expected to give all of the information and who actually completes the form. Importantly, this form is not made part of the Jails’ electronic medical record; instead, it is placed into a “hard chart” that becomes part of the Medical Services Bureau’s property. The Jails’ mental health staff are not automatically informed of the contents of the hard chart and the breakdown of communications can contribute to the trajectory of prisoner self-injury. Our review of completed suicides from 2012 and 2013 indicates that arresting officers often have information that could prove valuable to the Jails’ custody and mental health staff in their suicide prevention efforts. Moreover, when the arresting officers do have information that indicates a prisoner is at a heightened risk of suicide, the officers have a legal obligation to report such information. Conn, 591 F.3d at 1097 (finding that officers’ failure to report to jail that prisoner wrapped a seatbelt around her neck and made suicidal statements en route to the jail constituted a factual issue as to whether the officers’ omissions caused the eventual suicide).
For example, “Christopher” committed suicide at the Jails in 2013. Christopher was admitted to the Jails, six days before his death, after being arrested at his home while reportedly drunk, combative, and actively suicidal. Christopher hanged a noose in his garage but was stopped from hanging himself by a family member and, before finally being subdued by officers after a series of forceful attempts to control him, reportedly said he was going to “commit suicide by cop.” The police report states that he was placed on a suicide watch at a local police lockup, where he was taken immediately after his arrest. Christopher’s Arrestee Medical Screening Form reads “no” throughout the first page, but the second page references his suicidal thoughts. This form was not placed into or referenced in the electronic medical record; instead, it was filed in the hard chart. It appears that the Jails’ mental health staff also did not receive the Behavioral Observation and Mental Health Referral form filled out by lockup staff. Like the arresting agency screening, that form was placed in the hard chart. Therefore, the Jails’ mental health staff were apparently not aware of the critical circumstances of Christopher’s arrest at the time of his mental health intake evaluation. Later that day, a nurse made an entry into the electronic medical record that Christopher “made statements that he wanted to kill himself,” referencing the arrest report, but mental health staff never received the full arrest documentation relating Christopher’s recent suicidal actions and statements. Christopher denied suicidal ideation, past and present, on intake. He was initially assigned to high observation mental health housing, but
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was transferred to a medical isolation cell three days later due to a tuberculosis scare. Shortly thereafter, he was found hanging from a light fixture during a security check.7
In addition, our review of the Jails’ suicide incidents revealed that when these forms are filled out, there are often inconsistencies between information on the Arrestee Medical Screening Form and the 15 Questions Screening Form that is used upon intake at the Inmate Reception Center. This may be a testament to the importance of multiple screenings, but it may also be evidence of the arresting agency’s rush to leave the prisoner at the Jails, poor training, a lack of accountability in making sure the forms are complete when the prisoner is formally accepted into the Jails, and communication lapses. In the case of “Dean,” the Arrestee Medical Screening Form was marked “yes” for risk of suicide, but the 15 Questions Screening Form was marked “no” for currently suicidal. In response to 15 Questions Screening, Dean answered “yes” to having a history of mental health problems, to the use of psychotropic medications, and to having a history of suicidal behavior. Dean also had a history of at least seven psychiatric hospital admissions, including a hospitalization for anxiety and depression just two months before his intake screening. Dean had also been previously incarcerated in the Jails about two months prior to his intake screening and he was housed in mental health housing at that time. But at intake, mental health staff found that Dean did “not meet the criteria for mental health services” or suicide precautions. Eleven days after his admission to the Jails, Dean hanged himself in his single cell in non-mental health housing.
This breakdown may be a further reflection of the “silo approach” that divides the Sheriff’s Department from the County Department of Mental Health’s Jail Mental Health Services. The two entities have separate policies and procedures and such policies do not consistently reference each other or the Jails’ “unit orders.” The Department of Mental Health’s policy on suicide prevention reads, in part, “Inmates booked into the [ ] Reception Centers are initially screened … through observation, interview, administration of a screening tool, 15 Questions (15Q), review of pertinent medical records from prior incarcerations, and reports from arresting or transporting officers regarding potential suicide risk.” Policy 70.7, Suicide Prevention §4.1.1 (emphasis added). Based on our review, this policy is not enforced with regard to arresting or transporting officers. Further, it is unclear who has the authority to enforce this mental health policy, given that the arresting or transporting officers do not report to the mental health staff. A better approach would be to integrate medical and mental health related policies and procedures into the relevant Sheriff’s Department unit orders, by merging or explicitly cross-referencing them.
B. Insufficient Supervision of Prisoners with Mental Illness and Suicide Risk.
Prisoners with mental illness and those who are identified as being at risk for suicide do not receive adequate supervision and are housed in conditions that present, rather than prevent, a risk of suicide. Correctional facilities have a duty to ensure that the conditions of confinement

7

In contrast to most critical incident reviews, which do not indicate any remedial measures, the review for

Christopher’s death includes both a recommendation for a review of the policies and procedures regarding safety

checks “to ensure that procedures were followed” and a recommendation for refresher training regarding completing

a Behavioral Observation and Mental Health Referral form. The Sheriff’s Department also issued Information

Bulletin #2013-09, entitled “Handling of Suicidal Inmates,” to all custody staff.

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do not pose a substantial risk of serious harm to prisoners by heightening the risk of suicide. Van Orden, 546 Fed.Appx. at 648.
Due to changes in State law, the prisoner population of the Jails has increased dramatically in recent years: from 14,500 prisoners in October 2011 to approximately 19,000 in September 2013. While population levels of this number are not historically unusual for the Jails, the result has been an increase in both the number of prisoners on the mental health case load and the acuity of the prisoners’ mental illness. The Jails’ mental health staff reported significant increased severity of mental illness among prisoners generally, which has affected all areas of service. While it is commendable that the Jails have seen a significant increase in the number of mental health staff during this time, it is clear that the custody deputy staffing level is not sufficient to provide adequate supervision for prisoners, including those at heightened risk for suicide. “Inadequate staffing can create an objective risk of substantial harm in a [correctional] setting that is sufficient to satisfy the objective prong of the deliberate indifference test.” Lemire, 726 F.3d at 1076 (citing Hoptowit, 682 F.2d at 1251).
1. Deficient Prisoner Supervision Policies and Practices.
Perhaps as a result of understaffing, poor supervision is apparent throughout the Jails, which increases the risk of harm to prisoners from suicidal behavior, as well as violence, sexual assault, and the inability to access medical care in a timely manner. This runs afoul of the Jails’ obligation to provide a reasonable level of safety to prisoners. Farmer, 511 U.S. at 832. The lack of supervision is evident even in the “safer” housing units of the Jails, such as the open units at CRDF, that are more amenable to good supervision and prisoner management. Some areas of the Jails reported frequent lockdowns as a result of staffing shortages. In various areas of the Jails, which house general population as well as prisoners on the mental health case load, general security checks are conducted only every 60 minutes, as opposed to every 30 minutes. This is contrary to generally accepted correctional standards and allows ample time for prisoners to engage in suicidal behavior, as well as violence and other prohibited activities. In general, prisoners should not be left unsupervised for 60 minutes at a time, regardless of their classification level. See Lemire, 726 F.3d at 1077 (citing Hoptowit, 682 F.2d at 1249) (noting that prisoners should not be left unsupervised for more than 30 minutes and that those with mental illness are at heightened risk to suffer harm when left unsupervised for extended periods).
Custody supervisory staff and deputies repeatedly mentioned the inconsistent operation of the Title 15 scanner system, which is supposed to verify that regular security checks are made as required. In the suicides we reviewed, we observed a repeated failure over the last two years to complete the mandated Title 15 safety checks. For example, the Jails’ critical incident review revealed that the Jails’ electronic scanners were not working on the day that “Frieda” committed suicide by hanging in 2012, thus there is no confirmation of when custody safety checks were completed in Frieda’s unit. No documents contain a clear statement about the probable time of Frieda’s death and, due to the lack of clarity about the security checks that may have been completed on the day of her death, it cannot be determined how long Frieda was hanging before being discovered. When the electronic system is not operational, written documentation of safety checks indicates that the checks are not consistently made. When checks are documented, the name of the deputy making the check and the time of the check completion are frequently
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missing. We also noted some instances of handwritten checks documented at exact time intervals throughout a housing unit, which calls into question the veracity of the documentation and violates generally accepted correctional standards requiring staggered checks.
In many of the recent suicides, the security checks are not even documented on an hourly basis. For example, the documentation surrounding “Gary’s” 2013 suicide show that he was last seen at 6:21 p.m. and then discovered hanging at 8:30 p.m. There are also units of the Jails where deputies do not actually walk through the unit to complete their security checks, such as the dormitories in Men’s Central Jail, and other units where supervision is accomplished by walking along the enclosed guard walk rather than along the halls of the cellblocks. In many areas of the Jails, when the security checks, including suicide checks, are conducted, they are not staggered, which facilitates the possibility of a planned suicide occurring during the known period without observation between checks.
The “K6G” housing units house gay, bisexual, transgender, and intersex (“GBTI”) prisoners. Jail officials indicated that there were more suicide attempts among this population when housed in single cells and that since designating these dormitories for GBTI prisoners, suicide behaviors have decreased. Despite this explanation and an apparent acknowledgment that GBTI prisoners may be at a heightened risk for suicide, deputies not only register security checks only at 60 minute intervals in the K6G dormitories, but checks are “completed” from the vantage point of the control room, rather than actually walking through the housing areas. As there are 140 persons housed in each of the two dormitories, it is virtually impossible to see very deep into the bunk areas, which take up the majority of the space within the dormitories. Consequently, without direct supervision or actual walkthrough security rounds, the deputies must rely on the prisoners to report problems within the units. In another 2013 death, “Henry” committed suicide in K6G module 4400, which is an administrative segregation cell rather than a dorm, by hanging himself with a noose fashioned from a county issued shirt. Prisoners on the B row of module 4400 informed deputies of a “man down,” in D row. Ten minutes later, deputies requested assistance for a “possible suicide attempt.” The Jails conducted a “safety check audit” that found only 43% compliance with safety check requirements in this module on the day of Henry’s death.
2. Inadequate Supervision for Individuals on Suicide Precautions.
The problems of inadequate supervision extend even to those prisoners with most demonstrated risk of self harm. In 2012, “Elliot” committed suicide at the Jails. During his intake screening five weeks before his death, Elliot reported suicide attempts a few months prior and treatment with anti-psychotic, anti-anxiety, and anti-depressant medication. A Jail psychologist referred him to the forensic in-patient program. After a deputy reported that Elliot was “covered with feces and urine” and had “unpredictable behavior,” a Jail psychiatrist determined Elliot to be incoherent, and he was sent out to the hospital for treatment and observation. Elliot returned from the hospital six days later, was placed in medical housing in Twin Towers, and received a sheet, two blankets, and a shirt and pants, even though he was identified as being at risk for suicide. Approximately three weeks later, he was found with a sheet tied around his neck.
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The timing and frequency of safety checks is not clear from any documentation provided for Elliot’s suicide. The Medical Services Bureau incident review suggests that at the time of Elliot’s suicide, he was housed in a room monitored by cameras, but the responsibility for watching monitors had not been established nor assigned to any specific employee. According to medical staff, the current practice is that “everyone” looks at the monitor. It is important to note that there are cell areas not captured on the video monitor, even though “close observations” are ordered on all patients housed in a monitored room. Accordingly, even if a specific employee is assigned to monitor the camera constantly, video monitoring may not be enough to prevent the recurrence of a similar suicide event. Video monitoring is never an adequate substitute for live staff supervision, especially when a prisoner requires direct supervision due to a medical, mental health, or suicide risk.
The command staff in some instances looks to solve custody problems by using mental health staff to perform security functions like watching monitors and assisting with safety checks. Following the 2014 suicide of Alan, the suggestion was made to have mental health staff present on the high observation housing units 24 hours a day to provide supervision of prisoners. This is inappropriate. While we commend the Jails’ commitment to increased mental health coverage, mental health staff are not a substitute for corrections staff. Custody deputies have primary responsibility for the safety and security of the prisoners and the institution; mental health staff is responsible for the identification of mental health needs and the provision of services and treatment to address those needs. Custody and mental health staff must work collaboratively in the effort to operate a safe and secure Jail system, and do so with a healthy dose of respect for their respective expertise and responsibilities.
C. Custodial Disregard for Clinical Recommendations on Suicide Precautions.
Clinical staff also expressed some frustration that their clinical opinions are ignored or overruled, for example, when they have completed suicide risk assessments and recommended no change in housing. Housing decisions must always be a collaborative effort based on information provided by custody, medical, and mental health staff. When clinical staff determines an inmate is suicidal, the first line of intervention is generally to increase restrictions, including moving the prisoner to “suicide housing,” instituting full suicide precautions, and providing medication. However, if there were opportunities for mental health staff to suggest and consider other and ancillary treatment alternatives, it may be that less physical movement in the system could be realized. At present, threats of suicide and actions of self-harm result in a prisoner’s movement to suicide precautions in designated areas of the Jails, and subsequently to a brief stay in moderate or high observation housing. Finding a space for a highly suicidal prisoner can be challenging in part because of all this movement.
A lack of appropriate housing for suicidal prisoners and a disregard of housing recommendations by mental health staff may have contributed to Elliot’s suicide, discussed above. The Jails’ electronic medical record reveals inconsistencies about the use of suicide precautions with Elliot. Upon his return from the hospital, a note in the record indicates that a suicide blanket was ordered, and then cancelled. A week later, a nurse noted that he is on suicide watch. Six days before his death, a psychiatrist, who diagnosed him with Schizoaffective Disorder, wrote that Elliot would be transferred to high observation psychiatric housing, and
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noted many warnings had been given about his psychiatric condition and risks for violence. The transfer did not occur and there is no explanation for this failure in the documents we reviewed. On the day prior to his suicide, Elliot was seen at his cell by mental health staff, who noted that Elliot was naked and his clothes were not in his cell. There is no documentation or follow up, but at some point he was given a sheet, which he used to carry out his suicide the following day.
It is especially significant that even though mental health staff should be able to insist that safety checks be completed at intervals not longer than five minutes for prisoners in need, there seems to be little commitment by custody staff to seeing that these enhanced checks are accomplished. As discussed above, housing and supervision decisions must take into account information from mental health staff. When a mental health clinician finds that a prisoner is suicidal and recommends enhanced monitoring, disregard for such a recommendation can be evidence of deliberate indifference to a prisoner’s safety. Clouthier v. County of Contra Costa, 591 F.3d 1232, 1244-45 (9th Cir. 2010). In a jail system with an increasing number of suicides and suicide incidents, the need for more intensive levels of prisoner supervision is critical. Madrid, 889 F. Supp. at 1259 (emphasizing the need for “adequate monitoring . . . on far more than just isolated occasions, particularly in the [isolation units]”). Inadequate custody staffing is not an excuse for refusing to provide more intense levels of prisoner surveillance.
D. Unsafe Housing of Prisoners at the Jails.
The general lack of adequate supervision is especially troubling given the hazardous conditions that exist in nearly every housing unit in the Jails, including bars, open bunks, wide mesh vent covers, hidden corners, small cell windows, and other known suicide risks. Living conditions in general are deficient (dimly lighted, vermin-infested, noisy, unsanitary, cramped and crowded) and create an environment that may contribute to prisoners’ mental distress. The County has a constitutional duty to ensure that conditions in the Jails constitute adequate shelter and to maintain sufficient sanitation for prisoners. Johnson v. Lewis, 217 F.3d 726, 731-32 (9th Cir. 2000). While these rights are guaranteed for all prisoners, hazardous environmental conditions can pose a particularly significant threat for prisoners who are vulnerable to mental health decompensation or suicide risk. Redman v. County of San Diego, 942 F.2d 1435, 1443 (9th Cir. 1991) (citing Colburn v. Upper Darby Township, 838 F.2d 663, 669 (3d Cir.1988) (holding that corrections officials may be constitutionally liable when they “know or should know of a particular vulnerability,” such as a prisoner in severe emotional distress, and fail to protect the prisoner from that vulnerability).
Mental health line staff complained that many of the cells are very dirty and that steam cleaners were not routinely being used to clean feces-smeared cells. Contraband that can be used for self-harm (plastic bags, broken plastic spoons) is readily visible throughout the housing areas. These conditions provide ample opportunity for suicidal actions. For example, the Supplemental Assessment Team Area in the Twin Towers Correctional Facility houses prisoners who require additional evaluation for mental health challenges within 24-72 hours of their admission or identification. Although these areas are designated as high observation housing, with single and two-man cells intended to house prisoners who are in crisis, the cells are not suicide resistant.
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E. Suicide Precautions at the Jails are Unnecessarily Punitive and Clinically Inappropriate.
Prisoners on suicide precautions often face arguably punitive restrictions, regardless of whether they are clinically indicated. When on a suicide watch, prisoners are not allowed to have pencils, combs, and other potentially harmful instruments, including paper, which some inmates have reportedly used to choke themselves. Prisoners placed on suicide watch are generally issued suicide resistant gowns, one or two suicide resistant blankets, and a mattress, absent explicit instructions to withhold one or more of these items. However, prisoners and line mental health staff reported that in practice, it was very common for prisoners to be denied access to mattresses, ostensibly because they were too easily torn. It was also reported by mental health staff that prisoners in high observation housing were not consistently permitted eyeglasses, hairbrushes, or thermal underwear, though custody staff disputed some of these allegations. The Jails should allow prisoners to retain their eyeglasses unless there is a documented and adequate clinical reason for removal, such as if the prisoner recently used eyeglasses to injure himself. In general, property restrictions should be individualized, documented, and necessary.
Suicidal gestures and comments are commonly countered with the threat of housing changes, the use of restraints, and limitations on privileges until the prisoner denies suicidal ideation, at which time the mental health staff lower the prisoner’s risk level precipitously and virtually ignore the prisoner’s risk history. The danger of moving quickly from high observation housing to merely bi-weekly contact with mental health staff is demonstrated by numerous recent suicides at the Jails. When Jail staff discontinue suicide precautions despite a reasonable inference that the prisoner is still at risk for self-harm, the staff demonstrate deliberate indifference to the prisoner’s suicide risk. Clouthier, 591 F.3d at 1244-45. Even in some of the Jails’ designated “step-down units,” it was reported that prisoners are allowed out of their cells only one to two hours per day and are required to eat in their rooms. This is grossly inappropriate. In the absence of an individualized and documented clinical reason, inmates in the step-down unit should spend the majority of the day out of their cells, including therapeutic programming, organized activities, meals, and unstructured time in the day room. When suicide precautions are unnecessarily harsh, it raises the risk that some prisoners who are actually suicidal will be hesitant to admit their suicidality. These prisoners report that they would prefer to “take their chances” rather than experience what they regard as the punitive conditions of suicide watch. This was true in the previously cited example of Alan’s death.
F. Therapeutically Inappropriate Environment for Prisoners with Mental Illnesss.
Severe restrictions are not confined to prisoners on suicide watch (or disciplinary sanctions). In some of the high observation housing units for female prisoners, women moved into the day room for treatment groups or other functions have one arm restrained with handcuffs extended from a chain secured to the floor while seated individually at tables. This approach to prisoner management may be a reflection of the low level of security staffing throughout the women’s housing units rather than a necessary safety-structural requirement for delivering appropriate assessment and treatment services. Well-regarded and evidence-supported womencentered treatment approaches would support the delivery of services in an environment that
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allows for group interaction, the building of connections, and the minimizing of the kinds of physical and emotional restraints that prove counterproductive to women’s health. See, e.g., Covington, S.S. & Bloom, B.E., Gender-Responsive Treatment and Services in Correctional Settings, Women and Therapy, 29(3/4), 9-33 (2006); Epperson, M., Wolff, N., Morgan, R., Fisher, W., Frueh, B.C., and Huening, J., The Next Generation of Behavioral Health and Criminal Justice Interventions: Improving Outcomes by Improving Interventions, New Jersey: Rutgers (2011). Similar restrictive handcuffing policies are followed at Twin Towers. While specific prisoners may at certain times require a higher degree of restraint in order to participate in therapy, such determinations must be made and documented on an individualized basis in accordance with the prisoners’ specific mental health and safety needs.
Additionally, prisoners have inadequate access to recreation on many high observation housing units. Prisoners who exhibit mental illness are frequently housed in their own single cells, which increases their isolation and opportunity for self-harm. Despite the fact that they are not in any high-custody or segregation status, many prisoners with serious mental illness in Men’s Central Jail spend as many hours per day in their small, four-man cells as segregation prisoners spend in single-man cells. Isolation or extended 22-hour cell confinement of prisoners with serious mental illness is not appropriate.8
Finally, the unacceptable, unsanitary, and unsafe conditions at the Jails, including the punitive nature of suicide precautions, are exacerbated by inappropriate and unprofessional behavior by deputies. The Eighth Amendment’s prohibition on the unnecessary and wanton infliction of pain includes the intentional infliction of psychological pain. Jordan v. Gardner, 986 F.2d 1521, 1525 (9th Cir. 1993). We received reports, from both prisoners and staff, of deputies using obscene and derogatory language towards prisoners with mental illness. Verbal abuse of prisoners is unacceptable and can contribute to increased mental distress and suicidal ideation, especially for prisoners with mental illness. It is impossible to establish a therapeutic milieu if prisoners with mental illness are harassed and disrespected consistently by the deputies assigned to supervise them.
G. Deficient Tracking, Reporting, Investigations, and Suicide Reviews Contribute to Sustained Deficiencies in Suicide Prevention Practices.
The suicide prevention sub-committee review process is broken and ineffective. At present, nowhere in the review process are custody personnel or practices effectively scrutinized. In most of the cases reviewed, that scrutiny should have been focused on: (1) the repeated

8

As one court noted, long periods of isolation for those with serious mental illness can be “the mental

equivalent of putting an asthmatic in a place with little air to breathe.” Madrid, 889 F. Supp. at 1265-66; see also

Brown v. Plata, 131 S. Ct. 1910, 1933 (2011) (acknowledging the concern that prolonged isolation may result in

inappropriate delays of mental health care); Wilson v. Seiter, 501 U.S. 294, 304 (1991) (holding that when

conditions of confinement combine to “have a mutually enforcing effect that produces the deprivation of a single,

identifiable human need” they violate the Eighth Amendment); Hoptowit v. Ray, 682 F.2d 1237, 1247 (9th Cir.

1981) (“[T]he court must consider the effect of each condition in the context of the prison environment, especially

when the ill effects of particular conditions are exacerbated by other related conditions.”); Coleman, 912 F. Supp. at

1320-21; Casey v. Lewis, 834 F. Supp. 1477, 1547-49 (D. Ariz. 1993) (describing the inappropriate use of isolation

for prisoners with serious mental illness because “[d]uring lockdown, inmates are provided improper mental health

care or no mental health care”).

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violation of suicide and safety check procedures; (2) the adequacy of the custody staffing in the units where the suicides occurred; (3) the placement of suicidal inmates into single cells, which can be done by custody staff without consulting prisoner classification or mental health staff; (4) the persistent submission of incomplete and poorly documented incident reports; and (5) the continued accessibility of instruments (plastic bags, plastic spoons, razor blades) that can be used to complete a suicide or effect a suicide attempt. The obfuscation inherent in not seeking and critically examining all the documentation around a death, the absence of corrective measures taken to add custody staff to housing units, the unwillingness to monitor and enforce policy adherence, and the lack of insistence on precise and accurate reports of critical incidents all signal a system destined to experience more of these incidents. The escalation in suicides and suicide attempts between 2012 and 2013 are evidence of this trajectory. An increased rate of suicides without meaningful change or remedial measures to address significant and known inadequacies in suicide prevention practices is evidence of on-going constitutional violations. Coleman v. Brown, 938 F. Supp.2d 955, 974 (E.D. Cal. 2013) (finding an “ongoing violation of the Eighth Amendment” where the suicide rate has not declined and majority of prison suicides involve longstanding, known deficiencies).
1. Inadequate Tracking and Documentation of Suicides and Suicide Attempts.
First, the labeling and recording procedures used to document suicide incidents are not consistent, which creates uncertainty about the nature of the suicide incidents that occurred system-wide. When asked for clarification as to who characterizes the type of self-harm behavior (as threats, gestures, attempts, and completions) when they occur, the Jails’ mental health authorities acknowledged that they do not have clear working definitions for attempts, gestures, and threats. At present, the categorization appears to be done on the basis of discernible intent to commit suicide and on the level of medical intervention required after the suicide behavior is discovered. Thus, a prisoner caught in the process of creating a noose may not be classified as having made a suicide attempt or gesture. The fact that a suicide attempt or gesture did not result in actual, physical harm does not negate the Jails’ obligation to take precautions against the heightened risk evidenced by suicidal behavior. Conn, 591 F.3d at 1095 (citing Doty, 37 F.3d at 546). All suicidal or self-injurious events must be taken seriously and included in the Jails’ data collection, review, and response to critical incidents. Tracking and analysis of attempts and gestures enables correctional facilities to identify and correct system weaknesses. It is unclear if the Jails have any data or analysis of suicidal gestures that occur in the Jails system.
Moreover, there is a sustained failure to adequately report the details of suicide incidents, including attempts, that occur in the Jails. Even with completed suicides, deputies’ reports lack substantive detail and are rarely signed with the time of completion noted. For example, “Jack” committed suicide by hanging in 2013. A prisoner worker found Jack hanging from an air vent in his cell at 10:15 p.m. After the worker reported the suicide, the events thereafter were apparently recorded on a video, but the video has been lost. There are no relevant times listed on the reports detailing this critical incident, beginning with the notification of the hanging until Jack was pronounced dead. The suicide critical incident review contains a note that the Title 15 scanner was “not available” to log security checks. The autopsy report states that Jack was last checked at 9:00 p.m. It appears some time was wasted during the intervention period when the
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responding officer had to open the housing door for other officers to enter, but none of the documentation is clear with regard to any times. None of the reports written by the many responding deputies are time stamped or dated, nor are the times of report completion noted. All of the deputies’ reports look very similar in detail and in language. There are no photographs of the suicide scene in the critical incident review or in the other materials reviewed, although our review revealed that such photographs are routinely taken by the Sheriff’s Department and Coroner’s investigators.

Even without any guidelines for categorization of incidents, mental health staff determined that 75 out of 281 suicide incidents from January 1, 2013 through September 21, 2013 qualified as “critical incidents.” All but three of these incidents involved people who had been seen by the mental health staff sometime prior to the incident. Importantly, no more than seven days passed between critical incidents. This demonstrates a system replete with on-going problems related to suicide prevention, but also a system in which serious problems are not being effectively addressed. In short, there is a need to more accurately and systematically define and record information relative to the suicide attempts that occur in the Jails. Further, the opportunity for self harm and the influence of traumatic exposure (and the possibility of contagion effects) should be investigated as suicide risk reduction efforts proceed. Accurate information on the number, type, and facts surrounding “suicide incidents” must be available to the suicide review sub-committee so the members can recommend comprehensive and effective remedial measures in response to a prisoner suicide.

2. Ineffective, Inaccurate, and Incomplete Suicide Mortality Reviews.

Although the Jails have a system in place to review prisoner suicides, the process is incomplete and inaccurate. The review process is not managed by supervisory staff with sufficient authority to hold staff accountable and mandate change to remediate problems. Members of the review committee do not work collaboratively to ensure complete and accurate dissemination and analysis of information. The final reviews are missing critical information that could enable the review team to better formulate conclusions about the actions leading up to the prisoner’s death.

Currently, the review process begins within 24 hours of a suicide and continues with meetings 7 days after the suicide and again at one month after the death.9 For a suicide review process to yield life-saving benefits, a ranking official must lead the inquiries, some of which are (or should be) directed at other ranking officials. In contrast, the Jails’ suicide review process, including the drafting of a written critical incident review, is largely led by a team of deputies and one sergeant, who have neither the rank nor the power to fully investigate and document their findings. These officers, good-intentioned as they may be, have neither the authority nor experience to question the supervision and security practices of employees of equal or higher rank. The sub-committee works as a trifurcated body, such that Sheriff’s Department custody officials work separately from the Medical Services Board officials, who work separately from the Jails’ mental health staff in compiling and reviewing the materials. Unfortunately, the three entities do not always share their materials with each other. A custody deputy compiles and

9

Prior to approximately September 2013, a single suicide review was conducted approximately 30 days after

a suicide.

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writes the final critical incident review document, and mental health staff on the sub-committee do not see the file prior to the final review meeting at which it is discussed. Mental health staff have no input or involvement in the draft document. The sub-committee does not include interviews of, or direct input from, the clinical staff that actually saw or provided on-going services to the prisoner involved. This results in missing, incomplete, and potentially inaccurate information in the review process, and a sense of disenfranchisement among the clinical staff. There is a major gap in the communication between the custody and mental health divisions of the Jails, which should both play a critical role in mortality and morbidity reviews.
The written reviews are not completed in a timely manner, often taking eight months or more to complete. Indeed, two years after many of the prisoner suicides detailed in this letter, none of the critical incident reviews are complete because they still do not contain final signatures denoting approval. The Sheriff’s Department attributes these delays to the wait for an autopsy report from the Coroner’s Office. However, the Assistant Chief Coroner for the Los Angeles Coroner’s Office confirmed that most autopsies are completed within a maximum of six weeks after the death. The autopsy report often contains critical information for the Jails’ custody staff and mental health providers. Many of the autopsy reports are missing completely from the Jails’ critical incident reviews. The Jails’ inexplicable failure to obtain such reports in a timely manner impedes the ability to complete timely investigations of custodial suicides, which in turn delays the implementation of changes that might emerge from such investigations.
In addition to the missing autopsy reports, the critical incident reviews are missing other significant information. The specific interventions used when a suicide attempt was discovered and the timing of each phase of the intervention (i.e., when CPR started, when medical and custody staff were notified, when they responded, when mental health staff were notified, when the paramedics were called, etc.) is obscure or absent from the review documentation. The fact that this information can often be found in separate records not available to the deputies completing the critical incident reviews further emphasizes the breakdown in communication during this process. In the end, assessing an accurate timeline of discovery-interventionresolution is nearly impossible through the Jails’ official review process due to missing, incomplete, or in some cases inaccurate documentation. In general, the County’s documentation practices are inadequate.
The many errors in the critical incident reviews, errors of both omission and inaccurate recording, create suspicion with regard to their veracity. For example, the final critical incident review for the suicide of Dean is marked by errors in facts and appears to be the product of cutting and pasting from another suicide that occurred prior to Dean’s death. Inconsistencies and errors in his age, his record of incarceration in the Jails, and in the dates of the critical incident review meetings make the entire review document questionable. Apparently none of these errors were noted by members of the review committee, as they remained in the critical incident review three months after Dean’s death.
3. Lack of Remedial Response to Suicide Reviews.
Importantly, the Jails’ suicide reviews fail to identify lapses in practice or policy and therefore do not result in comprehensive or effective remedial measures to correct identified
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deficiencies. The critical incident reviews of suicides consistently end with the same or similar conclusions: a finding that no medical, mental health, or custody systems or practice issues contributed to the prisoner’s suicide. Remedial measures, when advised, suggest custody briefings and written reminders to custody staff or revisions in policy - but the substance of these recommendations is not detailed. These conclusions and recommendations are rote, noncommittal, and cursory. Even where there is a clear contributory problem, such as when nursing staffing dropped to 20 personnel below the staffing level on the day of “Kyle’s” 2013 suicide, the critical incident review did not include a recommendation to address the deficiency. Rarely are custody staffing deficiencies detailed in the files, even though there is a form (the Watch Commander’s Incident Form) that requires this detail. Finally, the Jails’ summary of the suicide reviews, compiled in an incomplete document called the 2012-2013 LASD Inmate Suicides Summary and Synopses, is little more than a cursory view of the incidents and as such, is not a useful document to form the basis for action. The omission of critical reviews of custody responses to suicide incidents is suspect. The absence of recommendations geared toward enforcing existing policies and unit orders by (1) enhancing staffing levels, (2) providing effective training in report writing and documentation, and (3) taking definitive action when safety checks procedures are repeatedly violated, suggest that the critical incident review process, while perhaps well intended, amounts to little more than a bureaucratic exercise. The evidence of this is in plain sight: these same problems have happened repeatedly and more frequently over the 25-month period encompassing 15 suicides.
For example, in the case of Brian, discussed above, the documents we reviewed demonstrated numerous lapses. For instance, Brian was admitted into the Jails without undergoing the screening designed to prevent and identify acute health problems; the transporting officers failed to report his thoughts of having “nothing to live for;” and Jails staff failed to enforce its admission policy related to information from the arresting/transporting officer. There are gaps in the deputies’ documentation of the suicide itself, including the response times of the three deputies who arrived on the scene, which make it difficult to evaluate the effectiveness of the response. A deputy’s report notes that, on the shift prior to this suicide, Brian was “yelling, banging and kicking his cell door throughout the night,” but it is not known if mental health staff were notified of Brian’s level of agitation. In addition, even a cursory look at the electronic medical record would have revealed Brian’s significant psychiatric history. Despite these deficiencies, the Jails’ critical incident review of the suicide did not identify any remedial action regarding medical, mental health, training, and policy and procedures. The conclusions and recommendations in the critical incident reviews for Elliot, Dean, Henry, Kyle, and Michael are similarly lacking: no critical findings and no remedial action or training is suggested.
Even in the rare cases where the critical incident review actually includes or implies a critical finding, insufficient remedial measures are recommended. This is clear in the case of “Lily,” who committed suicide in the Jails in 2013, on the anniversary of a family member’s death, a year after she was charged with murdering family members. Lily had a significant history of mental illness and suicidal ideation. As the anniversary of the deaths drew near, her psychotic depression intensified, her auditory and visual hallucinations were more prominent, and her psychologist noted that Lily talked of her alleged victims’ visits, of hearing their voices, and reminded the psychologist of the anniversaries of their deaths, but there is no apparent
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increase in her level of supervision. At 11:00 a.m. the deputy completing cell checks in her unit noticed that Lily had not changed sleeping positions since the prior safety check, which is recorded as having occurred 38 minutes earlier, at 10:22 a.m. Lily, lying face down with blankets over her head, did not respond when called and, when the deputy entered the cell, Lily did not respond to the flashlight used to “nudge her left thigh.” The deputy left the cell and requested that medical staff respond. Lily was found with a plastic bag over her head at 11:04 and pronounced dead at 11:20 a.m. The critical incident review reveals that the deputy, when observing that Lily had not moved, had a discussion with another deputy and with a prisoner prior to taking further action, and that when she nudged Lily with the flashlight, she realized she was “stiff.” There are no times listed in the deputies’ incident reports until Lily’s death is pronounced. The unit activity log shows a Title 15 check completed at 9:20 and then not again until 10:22. The 15 minute safety check log sheets that relate to prisoners in certain cells are preprinted in quarter hours (e.g., 11:00; 11:15; 11:30; 11:45) so that the deputy does not fill in the exact time of the safety check. Obviously, the deputy cannot observe all prisoners subject to these frequent safety checks at the same time, so the logs are necessarily inaccurate. A memorandum from a training officer indicated his findings that the deputy “failed to perform a thorough and complete assessment of the inmate as taught by the custody headquarters’ training staff.” However, in the end, no remedial actions were recommended for custody services, medical services, mental health, or for training. The critical incident review does recommend a policy and procedures review, related to: (1) the barcodes that accurately scan the time and location of a Title 15 check to ensure veracity and to create a record, and (2) plastic bags not being permitted in cells of those classified as high security or mental health risks. In fact, plastic bags have been removed from some housing areas, but there is no indication of a change with regard to tracking of required safety checks or any recommendations regarding Lily’s insufficient level of supervision and the inadequate response by mental health staff to her worsening condition. Lily’s death was preventable. As with the other suicides that have occurred in this system, there were specific points where therapeutic and security responses and interventions that could have saved her life should have happened and did not.
The suicide and critical incident reviews consistently evidence a complete neglect of critical analysis with regard to custody practices. Concerns about the timing, frequency, and adequacy of safety checks, while sometimes mentioned, at most result in referrals to the Internal Affairs Bureau for investigations. Unfortunately, investigations of suicides at the Jails are inadequate and untimely. The Sheriff’s Department investigates its own jail suicides, using Sheriff’s detectives to do so, and the resulting investigations are often incomplete and superficial. Assigning the investigation to an outside law enforcement or justice-system agency would not only avoid the appearance of bias in the investigation, but would open the door to a more critical and meaningful review of the circumstances of the death. Moreover, many Internal Affairs Bureau inquiries remain active even one year after a death, which negates the possibility for a timely impact that might prevent further suicides.
The lack of a comprehensive, self-critical, and remedial mortality and morbidity review process allows obvious and on-going deficiencies to continue unabated in violation of the Constitution. Coleman, 938 F. Supp.2d at 974. For example, on most days, the Sheriff’s Department transports many prisoners to criminal (and presumably some civil) courts located throughout the complex Los Angeles County land mass. Sheriff’s deputies indicated that suicide
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incidents occur with some regularity in the court holding cells. In 2013, “Michael” hanged himself in the court holding area. While there is scant information about Michael, because he was held in a local lockup prior to his court appearance and had not been screened by the Jails, apparently he asked to see someone from mental health. Significantly, the Jails’ mental health staff are not responsible for prisoners as they are transported to and from courts and held in court holding cells. Further, mental health staff indicated that they are not informed of self-harm incidents when they occur during court movement. Consequently, there is a large segment of the Jails’ population that on any given day may be influenced or affected by self-harming behaviors and mental health staff, and perhaps custody housing staff as well, are unaware of it. This is a critical deficiency. Not only is intervention and follow-up warranted after any suicidal behavior, the behavior itself constitutes a risk for further suicide behavior. Moreover, the Jails’ documentation of suicide attempts in 2013, not including any incidents in the court holding cells, revealed that 48 percent (174) of those incidents occurred within one week of a court date. These facts indicate that the Jails need to do an in-depth look at their court transport and holding procedures and communication practices regarding prisoners’ behavior during such periods, as well as facilitating an appropriate alert or response to suicidal behavior that may be triggered by court proceedings. However, the Jails’ dysfunctional critical incident review process has neither identified nor addressed these issues.
H. Deficiencies in Mental Health Services Contribute to Inadequate Suicide Prevention.
Despite 12 years of monitoring by the Department of Justice, detailed reports by the Department’s experts, and consultation with those experts on policies, practices, and plans of correction, the deficiencies and examples noted above demonstrate that significant weaknesses remain with regard to mental health services at the Jails. The Eighth and Fourteenth Amendments both guarantee prisoners’ right to receive constitutionally adequate mental health care. Doty v. County of Lassen, 37 F.3d 540, 546 (9th Cir.1994). In addition to failing to comply with the Jails’ constitutional obligation to provide for the serious mental health needs of its prisoners, these systemic problems contribute to and allow for the Jails’ dangerous conditions for suicidal prisoners.
In addition, our meetings with the Jails’ psychiatrists and direct service providers (clinical social workers and counterparts), suggest that mental health services, within the Jails, are offered within a fairly traditional medical model, focusing on diagnostic assessments, treatment with medications if indicated, and limited follow up, rather than on a public health model that includes a broader preventive agenda focusing on larger population issues in addition to individual pathology.10 As we emphasized previously, we strongly encourage the County to embrace both alternatives to incarceration for individuals with mental illness and augment its efforts to provide a robust community care network to provide mental health services to the

10

The 2012 Surgeon General’s report National Strategy for Suicide Prevention: Goals and Objectives for

Action, available at http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/index.html,

speaks to the public health approach in suicide prevention. Also see, the 2001 publication: Mental Health: Culture,

Race, and Ethnicity A Supplement to Mental Health: A Report of the Surgeon General available at:

http://www.ncbi.nlm.nih.gov/books/NBK44243/.

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public, which may decrease the number of individuals who are arrested as a result of behavior stemming from untreated mental illness.
Following their most recent review of the Jails, Drs. Dvoskin and Metzner expressed considerable concern with the Jails’ inability to progress in some areas, particularly those related to providing adequate mental health treatment and programming to prisoners on the Jails’ mental health caseload, especially for prisoners who are not in mental health housing. Breakdowns in mental health services are evident in the suicides we reviewed. For example:
• Elliot committed suicide after 61 days in custody. During his intake screening, he reported suicide attempts a few months prior and treatment with anti-psychotic, antianxiety, and anti-depressant medication. The coroner’s report included significant mental health history, including diagnoses of schizophrenia and bipolar disorder, auditory hallucinations, panic and anxiety disorders, substance abuse, and the initiation of numerous 72-hour holds. However, even months after the suicide, the Jails’ psychiatrists were not aware of the coroner’s report or of this significant history for a prisoner who was their patient for two months.
• In the 2012 death of Frieda, the Jails’ 15 Questions Screening Form reflects a history of suicidal behavior and mental health problems. Although Frieda was referred for psychiatric evaluation on intake, she was not seen until four days later, and then only by a social work intern. The intern evaluated Frieda, noted her history of having a Posttraumatic Stress Disorder, but indicated that her “symptoms do not appear outstanding enough to warrant [moderate observation housing].” The medical notes do not indicate any supervisory review of the intern’s evaluation. Frieda hanged herself, while housed alone, two weeks after admission to the Jails. The autopsy report reveals that Frieda had a significant history of depression and three or four suicide attempts over several years, yet there is no indication of any substantive contact with the Jails’ mental health staff following her intake.
• In late 2012, Nicole committed suicide at the Jails with a lethal overdose of prescription psychotropic medications. Nicole was admitted to the Jails directly from a hospital emergency room after a serious suicide attempt on charges of murdering a family member. All of her screening interviews and documentation noted suicidal intent, with the 15 Questions Form indicating “extremely suicidal.” After telling the mental health staff at intake that she would be better off dead than alive, she was referred to the forensic in-patient unit. Shortly thereafter, Nicole was placed in four-point leather restraints and she remarked to the nurse on duty that she was “deeply sad.” There is no indication in the medical record about why Nicole was placed in four point restraints, nor is there documentation of what, if any, other less restrictive alternatives were considered or tried prior to applying the four-point restraints. Ninety minutes after being placed in full-body restraints, Nicole insisted that she was not going to hurt herself, was released from the restraints, placed on a 30 minute close observation, and given a safety gown and blanket. This abrupt change in supervision and attention, without any sort of step-down or transition, is contrary to generally accepted professional standards. Nicole was diagnosed with Mood Disorder NOS, Depressive Disorder NOS, rule/out Major
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Depressive Disorder, and rule/out Bipolar Disorder, and placed in a single cell. Over the next three months, there are only three instances of mental health staff notes found in the medical records and several group activity notations. These records note that Nicole is consistently depressed. On one occasion, Nicole was sent to a local hospital for complaints of “dizziness.” While there, she was prescribed a psychotropic medication. The dosage of this medication was increased when she returned to the Jails. Nicole was noted to be “med compliant.” Nicole saw a psychologist again a week before her death, who observed her to be depressed and evidencing “…a psychotic process.” Despite this observation, Nicole was not scheduled to be seen again until two weeks later. However, she ingested a fatal overdose of her prescribed medication a week before her next appointment.11
These examples, and those discussed in the previous sections, demonstrate that, despite some significant improvement during the tenure of the MOA, the Jails are not providing adequate mental health treatment in a consistent manner. In addition to the areas detailed in the discussion above, such as deficient screening and crisis intervention, the Jails are failing to comply with their obligations to provide: adequate treatment and referrals for prisoners in general population; sufficient in-patient care for those in need; adequate treatment to prisoners refusing medication; sufficient discharge planning; appropriate therapy and clinical contacts; and appropriate medication administration practices.
1. Insufficient Treatment for Prisoners in General Population.
Due to the increase in the Jails’ population overall, and the accompanying increase in prisoners with mental illness, there are now nearly 1000 male prisoners who are seriously mentally ill or otherwise in need of psychotropic medication who are currently housed in nonmental health housing in different areas of the Jails. In response, the Jails have increased mental health staffing and the hours of mental health coverage in these areas of the Jails. Unfortunately, each of the six full-time psychiatrists serving these areas requires an escort deputy to bring prisoners to and from their offices, or to escort psychiatrists to housing units, and to provide security supervision. Prior to July 2013, the deputies assigned to the Jail Mental Health Evaluation Teams were serving this function, which left six of the teams without a deputy for the majority of the day shift. As a result, we strongly recommended that the Jails consistently assign one full-time deputy or equivalent to each psychiatrist, in addition to the deputies assigned to the mental health teams, in order to maximize their productivity while adhering to the team model that has been so successful.
In addition, the threshold for custody referrals for prisoners in need of mental health care in the non-mental health housing units, particularly those in the Men’s Central Jail, is too high, basically waiting until the prisoner is in psychiatric crisis. Custody staff should be alerted (e.g., through shift briefing trainings) to look for less obvious signs of increasing emotional distress, so that mental health referrals can occur earlier.

11

Despite the autopsy report finding of an overdose of prescription psychotropic medications, the Jails’

critical incident review lists Nicole’s cause of death as suicide from an overdose of “Tylenol/aspirin.”

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2. Insufficient Access to In-Patient Care When Clinically Appropriate.
The Jails do not have enough in-patient beds to provide appropriate licensed in-patient care to the current population of prisoners with mental illness. While it is commendable that the Jails’ mental health staff is attempting to address the problem by mandating daily psychiatric contact for prisoners awaiting transfer to in-patient care, this is not an acceptable alternative to additional in-patient beds. The Jails’ mental health staff estimate that the current population requires approximately 200 additional in-patient beds. The Jails do not have sufficient in-patient care capacity to provide an adequate level of care to prisoners with serious mental illness. As such, the County should explore alternative options for treating and housing these prisoners in a setting that can meet their needs.
3. Inadequate Mental Health Treatment for Prisoners Refusing Medication.
In some areas of the Jails, psychiatrists decline to order psychotropic medications or continue to meet with a prisoner if a prisoner discloses an intention to refuse medication, even if the prisoner appears to suffer from an obvious or previously diagnosed mental illness. Unfortunately, this can result in prisoners with serious mental illness failing to be entered onto the mental health caseload. It is important to note that prisoners might initially refuse psychiatric medication, but later agree to take it at the urging of the treatment team. Thus, it may be useful to consider either ordering medications that will be refused, or ordering a follow-up psychiatric evaluation. Regardless, all prisoners with serious mental illness should be routinely followed by mental health staff, even if they are refusing medication and other treatment.
As demonstrated by several of the suicide incidents, some prisoners in mental health crisis do not receive adequate intervention. Moreover, the County must examine the policies and practices with regard to involuntary medication when clinically indicated, including related guardianship issues. The increase in population has made it difficult to transfer all prisoners in need to appropriate housing.
4. Insufficient Discharge Planning.
In order to facilitate the provision of adequate mental health treatment, the County committed to Corrective Action Plan 4.7, which requires the Jails to improve discharge planning and linkage to Service Area mental health providers and aftercare services. While discharge planning for prisoners in male mental health housing appears reasonably adequate, discharge planning for prisoners with a serious mental illness in non-mental health housing is very scarce. We also received reports of inadequate discharge planning at CRDF. The Jails need to remedy this issue and ensure adequate discharge planning for all prisoners in need of mental health care in the community, regardless of their housing location, as part of the Jails’ obligation to provide adequate mental health treatment.
5. Inappropriate and Insufficient Therapy and Clinical Contacts.
The MOA requires that prisoners with serious mental illness who are housed in the most intensive levels of outpatient mental health housing be offered at least 10 hours per week of structured out of cell therapeutic or programmatic activity and 15 hours of recreation per week. Meeting the 10 hours per week of structured therapeutic activity threshold remains a challenge,
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related in part to medication noncompliance issues for a subset of high observation housing prisoners who are refusing to attend therapies. As discussed above, the Jails should explore potential avenues related to involuntary medication practices, including guardianship issues, and assessing the quality/relevance of certain offered group activities. Having the ability to involuntarily medicate prisoners on a nonemergency basis, where clinically indicated, could be clinically very beneficial to many prisoners who are significantly impaired due to their mental illness. The Jails must also improve efforts to provide the required weekly recreation time, particularly at CRDF, where women in the high observation housing unit reported that they were not offered any outdoor recreation time. Additionally, prisoners with mental illness should be allowed to participate in the Jails’ educational and work programs, where appropriate.
Group treatments in some housing units are three hours in duration, which is too long for both the prisoners and for the therapists. This results in prisoners refusing to participate and also diminishes the effectiveness of group treatment. We recommend that structured out-of-cell group activities should generally be about 90 minutes in duration and not longer than two hours.
In some high observation housing units, most clinical contacts occur at cell front, and much less often in the dayroom. While frequent cell front contacts can assist in providing emotional support and creating a therapeutic alliance, they are no substitute for private and confidential mental health treatment. This is not adequate treatment and indicates both a lack of adequate treatment space and, potentially, a reflection of custody staffing deficiencies that limit the ability to safety transport prisoners for clinical contacts. These staffing deficiencies obstruct the prisoners’ opportunities for unstructured out of cell time and outdoor recreation, which can negatively impact their mental health status.
6. Inappropriate Medication Administration Practices.
Lack of adequate supervision is not only a problem with custody staff. During the Department of Justice’s September 2013 on-site review of the Jails, we observed a nurse during medication rounds in a high observation housing unit, where medical staff are aware of the prisoners’ heightened risk level. The nurse would bring a paper cup to the prisoner in her cell and tell the prisoner to fill the cup with water and bring it back to the cell window or trap door, after which the nurse gave the prisoner her medication(s). The prisoners could turn their backs and walk away without conversation, which makes “cheeking” or otherwise saving one’s medications possible. In the case of Nicole, who likely stored up her medications to effect her overdose, the critical incident review contains no recommendations for, or even discussion of, potential remedial measures about the practices and protocols used for medication administration in the housing units. This practice is of concern not only because of the risk of suicide by medication overdose, but because Jails’ staff report that in shakedowns, stockpiled medications are frequently found, and that medications are used as a commodity for “sale” or trade between prisoners at the Jails.
IV. MINIMUM REMEDIAL MEASURES FOR DEFICIENT MENTAL HEALTH SERVICES AND SUICIDE PREVENTION ISSUES
Suicides can be prevented and suicide incidents reduced when medical, mental health, and custody services act together and in accord with their policy directives. Insisting on complete arresting officer information before accepting an inmate into the Jails; sharing
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information about prisoners’ risk conditions across disciplines; resisting the inclination to house persons with mental illnesses and those who have suicide ideation in single cells; ensuring that security and safety checks are performed and increasing the frequency of such checks in those units where persons at elevated risk for suicide are likely to be found; having an accurate, participatory death review process; and scrutinizing the practices of all the Jails’ divisions, including custody, will likely go a long way to reduce the rising number of suicide incidents in the Jails.
The above conclusions demonstrate how the Jails’ non-compliance with the existing MOA provisions related to suicide prevention (§§ IV.G.25-29), including certain mental health provisions related to Intake (§ IV.A.5), Referrals (§ IV.C.9), Treatment (§ IV.D.12 & 15-19), Medication Administration (§ IV.E.22), Environmental Conditions (§ IV.F.23-24), and Quality Assurance (§ IV.J.42), poses a serious risk of harm to prisoners. These current MOA provisions roughly encompass the Jails’ duties to provide adequate screening and suicide risk assessment upon intake, properly evaluate prisoners identified as suicidal, ensure appropriate crisis intervention and emergency response for prisoners who attempt suicide, properly monitor and observe prisoners who are at risk for suicide, provide safe housing for suicidal prisoners, administer medications in a manner that does not pose an unreasonable risk of suicide attempts, and ensure an adequate morbidity and mortality review to identify problems and potential remedial measures. In order to address the deficiencies outlined above, the existing MOA provisions must be replaced with a court-enforceable remedy that addresses these subject areas but provides greater detail and structure in order to ensure adequate suicide prevention practices at the Jails.
The reduction of the number of prisoners with mental illness confined to the Jails may be essential to the effective implementation of remedies. The United States welcomes the efforts that the County has begun to create diversion programs to keep people safely supervised in the community rather than confined to the Jail. We encourage the County to expand these programs.
In order to rectify the deficiencies identified in this letter, a court-enforceable agreement should require the Jails to implement, at a minimum, the following remedial measures:
A. Custody Practices and Staffing Related to Suicide Prevention and Safety of Prisoners with Mental Illness.
1. The Sheriff’s Department must develop, implement, and enforce an effective policy and procedure for obtaining relevant and available information on prisoners’ mental health status and suicide risk from the arresting or transporting officer upon intake to the Jails.
2. The Sheriff’s Department must conduct an appropriate and objective assessment of custodial staffing needs throughout the Jails, with particular consideration of staffing in housing areas for prisoners with mental illness and high observation housing units, including suicide observation.
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3. The Sheriff’s Department must ensure that custodial safety checks are completed and documented in accordance with policy and legal requirements, at least every 30 minutes in general population and appropriately staggered, and more frequently as necessary due to the prisoner needs (including for prisoners on suicide watch), environmental challenges posed by the facilities, or requests by medical or mental health care staff.
4. Custodial safety checks must be completed in a manner that allows deputies to view each prisoner in a housing unit in order to assure prisoner well-being and security within the unit.
5. The Sheriff’s Department must develop, implement, and enforce an effective policy and procedure for unit contraband searches on a regular but staggered basis.
6. The Sheriff’s Department, in consultation with the Department of Mental Health, must develop advanced training curricula for special management housing, including moderate observation housing, high observation housing, and suicide watch, and ensure that deputies assigned to these areas receive adequate training in identifying mental health symptoms, assessing suicide risk, using appropriate communication strategies when dealing with prisoners in mental health crises, and in effective crisis intervention techniques.
7. The Sheriff’s Department, in consultation with the Department of Mental Health, must revise the deputy suicide prevention training to include adequate training on response to suicide incidents, including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance.
8. The Sheriff’s Department must notify the Jails’ medical and mental health staff of any crisis or suicide incident that occurs during court transport or in a court holding cell, including providing relevant incident reports.
9. Cameras cannot substitute for deputy staffing. However, if a cell is designated for constant monitoring by camera, then designated custody staff must be assigned to view the monitors in those areas where cameras have been placed in the cells.
10. Any prisoner brought directly to CRDF and held pre-arraignment must be screened by the Jails’ medical and, if indicated, mental health staff prior to being placed in the pre-arraignment unit.
11. The Sheriff’s Department must consider housing recommendations from medical and mental health staff, including recommendations for “no change in housing,” when considering a change to a prisoner’s housing unit or classification level following potential suicidal ideation, gesture, or incident, or other indication of mental health issues.
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12. The Sheriff’s Department must ensure that any relevant information regarding a prisoner’s medical or mental health status or history (for example, from the arrest report) is communicated to medical and mental health staff for inclusion in the prisoner’s electronic medical record.
B. Mental Health and Medical Care Treatment and Suicide Prevention.
1. The Department of Mental Health shall include deputies on the relevant housing units as members of the treatment team and shall advise such deputies of any prisoner’s special handling needs.
2. Mental health staff and custody staff, working collaboratively, must ensure adequate crisis intervention for prisoners exhibiting signs of mental health crisis.
3. Mental health staff must consider, and revise as necessary and consistent with legal requirements, Jail policies and procedures related to involuntary medication of prisoners in acute stages of a mental health crisis.
4. Every prisoner seen for ongoing services by mental health staff must have a treatment and an individualized discharge plan in the electronic medical record. When services are discontinued, a brief discharge summary should also be made in the electronic medical record to allow for an expedient review of the prisoner’s history should he or she be readmitted to the Jails at another time.
5. Excluding restraints used for transport (handcuffs), prisoners should only be subjected to mechanical restraint in response to a mental health crisis when necessary based on an individualized assessment: if the prisoner poses an immediate and serious risk of harm to him/herself or others; after a graduated range of less restrictive measures has been exhausted or considered in a clinically justifiable manner; for reasons other than as punishment, for convenience of staff, or in the absence of or as an alternative to treatment; and in accordance with applicable written policies, procedures, and plans governing restraint use.
6. If the Department of Mental Health subjects a prisoner to restraint in response to a mental health crisis, mental health staff must ensure the prisoner receives therapeutic services to remediate any effects from the episode(s) of restraint.
7. The Department of Mental Health must provide adequate mental health treatment to all prisoners with mental health needs, including those who refuse medication.
8. The Department of Mental Health must develop and implement an adequate policy and procedure for seeking involuntary medication of prisoners when clinically appropriate.
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9. The Sheriff’s Department must refer prisoners from general population who are demonstrating a potential need for mental health care to the Department of Mental Health for evaluation.
10. The Department of Mental Health must ensure adequate therapy and counseling for all prisoners with mental illness, including those housed in general population.
11. The Department of Mental Health must provide adequate 24 hour crisis intervention for prisoners, including transfer to special housing units, administration of psychotropic medications, provision of therapy treatment, and special observation.
12. Unless contraindicated, all prisoners with serious mental illness and housed in the most intensive levels of outpatient mental health housing must be offered at least 10 hours per week of structured out of cell therapeutic or programmatic activity and 10 hours of unstructured out of cell time, including recreation, per week.
13. Unless clinically contraindicated or the prisoner is in administrative segregation, no prisoner with serious mental illness shall be locked down more than 19 hours per day. Prisoners with serious mental illness in segregated placements shall be offered adequate therapeutic and recreational out-of-cell treatment, consistent with their security levels and treatment needs.
14. Prisoners with mental illness or housed in mental health housing shall not be denied jail privileges or programs based solely on their status as mentally ill or on their placement in mental health housing.
15. The Sheriff’s Department must provide adequate space for treatment and individual and group therapy and programming.
16. The Department of Mental Health must ensure adequate access to appropriate licensed in-patient care when clinically appropriate, either in the Jails or in another appropriate facility.
17. The Department of Mental Health must provide adequate discharge planning and linkage to community mental health providers and aftercare services for prisoners on the mental health case load.
18. Mental health staff and custody staff, working collaboratively, must ensure that conditions of suicide watch are not unnecessarily punitive. Property restrictions must be individualized, documented, and necessary to accommodate the prisoner’s mental state and behavior. Prisoners on suicide watch shall be provided mattresses, including suicide-resistant mattresses when warranted, unless providing a mattress is clinically contraindicated. Orders to remove a prisoner’s mattress must be documented in the electronic medical record.
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19. Intermediate steps between highly restrictive suicide precautions (e.g., mechanical restraints, suicide protective gowns and blankets, and constantly monitored cells) and the discontinuation of suicide precautions shall be developed, knowing that “recovery” from depression and suicide ideation is a process that extends beyond the moment when an inmate no longer admits to suicide ideation.
20. The Medical Services Bureau and the Department of Mental Health must consolidate and manage prisoner medical and mental health records to ensure that all relevant information is available to all health service providers.
21. All intake forms, including the 15 Question screening form and the Arrestee Medical Screening Form, must be included in the electronic medical record.
22. Supervisors shall periodically review clinician notes and entries in the electronic medical records to independently assess and ensure accuracy and veracity of the notes.
23. Medication administration procedures must be adequate to prevent prisoners from hoarding medications or from deviating from the prescribed medication regimen without the knowledge of medical and mental health staff.
24. Relevant custody, medical, and mental health staff shall meet on a regular basis to ensure coordination and communication regarding the needs of prisoners in mental health housing.
25. Jails staff must ensure that prisoners in mental health housing have equal access to educational and work programs, and that adequate translation services are readily available for prisoners requiring mental health services.
C. Suicide Tracking, Investigation, and Review Process.
1. The Sheriff’s Department, working collaboratively with the Department of Mental Health, shall develop and implement a consistent method for categorizing, documenting, and tracking suicide gestures and attempts. Information on all such incidents must be included in the prisoners’ electronic medical records.
2. The Sheriff’s Department, the Medical Services Bureau, and the Department of Mental Health must work collaboratively to review each prisoner death. Written mortality reviews shall be prepared by a Sheriff’s Department official of appropriate rank.
3. Prisoner death reviews must include accurate and complete information surrounding the prisoner death, including time-stamped and signed reports from deputies and medical and mental health staff relevant to the incident.
4. Prisoner death reviews must be completed in a timely manner.
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5. Autopsy reports shall be sought from the coroner’s office within six weeks of a prisoner death, and Jails staff must conduct prompt and regular follow up to receive any reports still outstanding after six weeks. Findings from autopsy reports must be incorporated into the final written suicide review, including another subcommittee meeting to assess the autopsy report, if necessary.
6. Suicide review reports should include an approximate time of death and an accurate timeline regarding the discovery of the prisoner and any responsive actions or medical interventions.
7. If available, suicide review reports shall include and maintain any relevant video recordings of the incident or response, and photographs of the scene. The County shall document the chain of custody for all evidence related to a prisoner death, including relevant videos and photos.
8. The Sheriff’s Department must ensure an accurate, complete, and unbiased investigation of suicides that occur in the Jails. This may involve an arrangement with a neighboring jurisdiction, district attorney’s office, or private organization to conduct or facilitate the investigation.
9. Each suicide review shall identify any deficiencies in custodial, medical, or mental health practices or policies that may have contributed to the suicide and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies. The subcommittee shall designate a member to follow up on each recommendation to ensure implementation.
10. The suicide review process shall result in data-driven efforts to identify and address systemic issues. The subcommittee shall collect data on suicide attempts and incidents, including location, method, and deficiencies (lack of staffing, missed security checks, inadequate mental health contacts, etc.) in order to target problems for remediation.
D. Environmental Conditions.
1. The Sheriff’s Department shall conduct a systematic review of all housing, with particular emphasis on moderate observation housing, high observation housing, and areas in which suicide watch is conducted, and identify and address suicide hazards.
2. The Sheriff’s Department shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. Such policies should include oversight and supervision, including meaningful inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.
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3. The Sheriff’s Department shall implement a preventive maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, and sink units are adequately maintained and installed.
4. The Sheriff’s Department shall ensure adequate lighting in all prisoner housing, programming, and work areas.
5. The Sheriff’s Department shall ensure adequate pest control throughout the housing units, medical units, kitchen, and food storage areas.
6. The Sheriff’s Department shall ensure that all prisoners have access to needed hygiene supplies.
V. COMPLIANCE ASSESSMENT OF REMAINING MOA PROVISIONS
With regard to the remaining provisions of the MOA related to mental health care, and the associated Corrective Action Plans developed by the Jails in conjunction with Drs. Dvoskin and Metzner, the Jails have made considerable progress. The Jails have achieved and sustained substantial progress, meaning the Jails have achieved compliance with most, or all, components of those requirements, with the following MOA provisions: §§ IV.A.1-4, A.6, B.8, D.14, D.20, H.30-33, and I.36-40. As such, we will no longer conduct compliance assessments on those provisions and the Jails are not required to report on those areas. While our conclusions confirm continued problematic practices in certain areas connected to some of these MOA provisions, those concerns are discussed in our conclusions regarding mental health treatment and suicide prevention and shall be addressed with the remedial measures set out above.
The remaining MOA provisions related to mental health care, excluding those implicated by the suicide prevention conclusions, are in partial compliance and will require further monitoring and consultation. A brief review of the Jails’ compliance status with regard to the remaining MOA provisions, §§ IV. B.7, C.10-11, D.13, E.21, I.34-35, and J.41, follows. The monitoring report from Drs. Dvoskin and Metzner contains a more detailed review of the Jails’ MOA and Corrective Action Plan compliance, as well as additional recommendations for achieving compliance.
§ IV.B. Evaluation
7. Within 24 hours of admittance to IRC (excluding weekends and legal holidays as long as an urgent evaluation is not indicated), the County shall provide an adequate mental health care evaluation of inmates who screen positive for possible mental illness at IRC. Within 72 hours of admittance to IRC, the County shall provide a mental health care evaluation to inmates admitted to IRC on the weekends or legal holidays (unless an urgent evaluation is indicated). If the evaluation identifies a serious mental illness, the evaluation shall result in a brief initial treatment plan.
Partial Compliance.
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Subject to the discussion above regarding screening issues identified in relation to our suicide prevention conclusions, much of the reception and screening process at the Jails continues to function well. There is some evidence, in an effort to avoid false-negative screening results, that mental health staff are now over-identifying too many prisoners for follow-up assessment. Any attempt to remedy this problem should be addressed carefully. Overcorrection could result in an increase in false negative conclusions, which have far more dangerous consequences.
§ IV.C. Referrals
10. Mental health staff shall make weekly rounds in locked down non-mental health housing modules (e.g. administrative segregation, disciplinary segregation) at the Jail to identify inmates who may have been missed during screening or who have decompensated while in the Jail.
Partial Compliance.
Currently, the mental health teams conduct rounds throughout the male non-mental health housing areas and respond to crises and referrals. Given the dramatic increase in the number of prisoners with mental illness living in non-mental health housing throughout the system, it is a challenge to provide adequate treatment to everyone in need. We identified many prisoners in non-mental health housing who were currently experiencing symptoms of serious mental illness, particularly in the Men’s Central Jail. Every prisoner with mental illness housed in the Men’s Central Jail non-mental health housing should be seen at least once every month by a psychiatrist to ensure that the prisoner’s mental health status is not deteriorating in the difficult environment at Men’s Central Jail. We also recommend consideration of creating a mental health housing unit for prisoners believed to be vulnerable due to the nature of their charge or other reasons, who are currently segregated in Men’s Central Jail.
In addition, it is important that the Jails take into account any impact that a prisoner’s mental health status may have on his or her actions that contributed on the behavior leading to an assignment to administrative or disciplinary segregation. To the extent that mental health staff identify individuals in locked down non-mental health housing who ought to be moved, either because segregation is having a negative impact on the prisoner’s mental state or because the prisoner’s disciplinary infraction was due to his or her mental health diagnosis, the Sheriff’s Department must consider such mental health recommendations with regard to a prisoner’s housing assignment. Custody staff must also consult with mental health staff when an inmate with mental health issues is subject to discipline.
11. The Jail will maintain a confidential self-referral system by which inmates can request mental health care without revealing the substance of their request to correctional officers.
Partial Compliance.
To address this MOA provision, the County committed to Corrective Action Plan 4.17, which requires the Jails to provide reasonable access to clinicians and psychiatrists through a self-referral process. The Jails’ own data indicate compliance with regard to prisoners in most male mental health housing, but there is inconsistent information regarding compliance for
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prisoners in CRDF and a need for a quality assurance initiative to track access for prisoners who are not in mental health housing.
§ IV.D. Treatment
13. The County shall ensure continuity of appropriate medicine to individuals identified as mentally ill who were receiving medicine prior to entering the Jail.
Partial Compliance.
While we found greater consistency with regard to medication continuity, a minority of prisoners continued to experience two- to three-day delays in receiving their medications following the initial orders by the psychiatrist.
20. Inmate trusties shall never be placed in a supervisory position or used as escorts for mentally ill inmates or inmates in mental health housing. Inmate trusties shall be carefully selected and screened before being assigned trustie positions. Where trusties are allowed to work in mental health housing, they shall be closely monitored.
Sustained Compliance.
While this provision is in sustained compliance, we note that in some areas of the Jails, such as the K6G dormitory units and CRDF, prisoners must use trustees to submit their medical and mental health request slips to designated deputies for collection. An alternative method of collection must be implemented so that other prisoners are not assigned the responsibility to collect and deliver these sensitive medical documents.
§ IV.E. Medication Administration
21. The County shall ensure that a full range of appropriate psychotropic medications is available at the Jail and that psychotropic medications are properly prescribed, monitored and documented by appropriately trained mental health professionals.
Partial Compliance.
The Jails’ quality improvement initiatives demonstrate that policies and procedures have been successfully implemented with regard to bridging medication orders and timely renewal of psychotropic medications. Issues remain with regard to obtaining relevant laboratory studies, but the Jails are appropriately addressing the problem. The Jails’ quality improvement studies were generally consistent with prisoner reports relevant to medication management issues. However, a minority of prisoners continued to experience two- to three-day delays in receiving their medications following the initial orders by the psychiatrist.
§ IV.I. Staffing and Training
34. The County shall provide sufficient mental health staffing to ensure timely access to adequate mental health treatment and meet the obligations and provide the services listed in this Agreement. Except for staffing for the women's case load population and the Forensic Inpatient Program, mental health staffing shall be no lower than one psychiatrist per 100 inmates who require medication. Staffing for the women's case load population shall be enhanced due to
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higher utilization rates of mental health services. Staffing for the Forensic Inpatient Program shall ensure timely access to adequate treatment and shall minimally meet licensure standards currently governing such program.
Partial Compliance.
As mentioned above, in response to the increased population of the Jails due to changes in State law, the number of mental health services staff at the Jails has increased. The current mental health staffing is sufficient and the number of vacancies has remained low. In most areas, the Jails have attained full compliance with the staffing requirements for psychiatry, including an acceptable level of psychiatric staffing enhancement for the women’s population. The psychiatrist-to-patient ratio in non-mental health housing is approximately 1:73, as compared to earlier finding of 1:350. However, we reiterate our concerns with regard to staffing in CRDF, especially the lack of a dedicated Jail Mental Evaluation Team.
35. A psychiatrist shall be available, at least by telephone, twenty-four hours per day to evaluate and prescribe psychotropic medications in emergency situations.
Partial Compliance.
Psychiatric coverage and the number of vacancies remain low. However, the low level of custody staffing is negatively impacting the psychiatrists’ ability to evaluate and treat prisoners in a timely manner. Until this issue is resolved, psychiatrists will be hampered from providing adequate treatment.
§ IV.J. Quality Assurance
41. The County shall implement and document a continuous quality improvement program for mental health services in the Jail. The continuous quality improvement program shall monitor the quality of mental health care.
Partial Compliance.
The quality improvement process continues to improve. The Jails have implemented many quality improvement initiatives, some of which have yielded timely and effective results. For example, one quality improvement study regarding continuity of psychiatric medications on a particular unit revealed that a significant problem was being caused because of the need for an additional high-volume printer, and the problem was easily remedied. This is a wonderful example of how quality improvement projects are supposed to work; the team analyzed and identified the source of the problem and an inexpensive solution that had previously been missed, to the detriment of psychiatric care. As a result, medication continuity and psychiatric care was dramatically improved. However, the Jails need to broaden efforts not only to identify problem areas for additional quality improvement initiatives, but to ensure remedial actions are taken as a result of these studies. In addition, the discrepant information obtained relevant to the involvement by mental health line staff in the quality improvement process is very concerning.
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VI. CONCLUSION
We applaud the cooperative and productive partnership the CoUnty has formed and continued with the Department of Justice with regard to reforms at the Los Angeles County Jail System. We also commend the strides made in most areas ofMOA compliance. As discussed, this commitment and demonstrated improvement allows us to recommend removing the provisions in sustained compliance from further MOA monitoring by the Department of Justice. However, given the gravity of the conclusions with regard to the Jails' deficient suicide prevention program and the serious harm posed as a result, we recommend that the County negotiate with the Department of Justice regarding the terms of a court:,enforceable settlement governing remedial suicide prevention measures at the Jails. We hope to continue working with County officials in an amicable and cooperative fashion to resolve our outstanding concerns regarding the Jails.
Please note that this assessment is a public document. It will be posted on the Civil Rights Division's website. We are obligated to advise you that, in the event that we are unable to reach a resolution regarding our concerns with regard suicide prevention, the Attorney General may initiate a lawsuit pursuant to CRIPA to correct deficiencies of the kind identified in this letier anytime following the date that is 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working cooperatively with you. The lawyers assigned to this investigation will be contacting the County to discuss this matter in further detail. Please contact us if you have any questions. You may reach Jonathan Smith at (202) 514-5393, Luis Saucedo at (202) 598-0482, or Robby Monteleone at (213) 894-2458.

Sincerely,

~ J'r~.---­ Birotte,
United States Attorney Central District of California

cc: Beong-Soo Kim, Esq. Jones Day
Attachments

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Friday , June 6, 2014

Justice Departm ent Concludes T hat Los Angeles County Jails Sy stem Has Made Progress, but Serious Deficiencies Continue
The Justice Department today released its latest compliance assessment of mental health serv ices at the Los Angeles County Jails based on a memorandum of agreement (MOA) designed to protect the constitutional rights of prisoners with serious mental illness at the jails. The department concluded that, despite progress in some areas of the MOA, the county of Los Angeles fails to prov ide sufficient suicide prev ention practices to protect prisoners from

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self-harm. The department also found that other serious deficiencies in the mental health care deliv ery sy stem remain and combine with inadequate superv ision and deplorable env ironmental conditions to depriv e prisoners of constitutionally -required mental health care.
The Los Angeles County Jails sy stem is the largest jail sy stem in the country , housing approx imately 1 9,000 pre-sentenced and sentenced prisoners in sev en facilities throughout the county . The Los Angeles Sheriff’s Department operates the jails sy stem and supports the deliv ery of mental health serv ices within the jails by the county ’s Department of Mental Health. In 2002, the department entered into the MOA with the county to resolv e a longstanding civ il inv estigation into conditions of confinement at the jails under the Civ il Rights of Institutionalized Persons Act (CRIPA). The MOA giv es the department access to personnel, documents and prisoners to ev aluate the county ’s compliance with the MOA. The department is assisted by expert consultants in correctional mental health care and suicide prev ention, and prov ides ongoing technical assistance as part of its monitoring activ ities. The county has cooperated fully and openly with the department.
The comprehensiv e assessment released today confirms that certain conditions and practices hav e not been remedied under the MOA and continue to v iolate the constitutional rights of prisoners with mental illness. There hav e been 1 5 completed suicides at the jails in less than 30 months and the department concluded that some of the deaths may hav e been prev entable with proper suicide prev ention practices. The department’s assessment also rev eals widespread lapses with regard to basic superv ision of prisoners at risk; deficient mental health care for prisoners with clearly demonstrated needs; deplorable env ironmental conditions, most acutely at Men’s Central Jail; and a suicide rev iew process that often includes inaccurate information and fails to remedy ev ident and repeated problems in order to prev ent similar incidents in the future.
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At the same time, the department’s assessment rev eals that the county has achiev ed substantial compliance with certain aspects of the MOA. For ex ample, the county has implemented nearly all prov isions related to mental health screening at intake, dev eloped a robust electronic medical records sy stem, increased the number of clinical and support staff and ensured that custodial staff receiv e initial and ongoing training in the identification and custodial care of prisoners with mental illness. The county has demonstrated a sustained lev el of acceptable performance and improv ement in these areas, which will no longer be subject to ev aluation under the MOA.

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“The Los Angeles County Jails hav e an obligation to prov ide conditions of confinement that do not offend the Constitution and to take reasonable measures to protect inmates from harm,” said Acting Assistant Attorney General Jocely n Samuels for the Civ il Rights Div ision. “Although the county has consulted with the Justice Department for y ears, our latest assessment rev eals serious deficiencies that require further correctiv e action. We are hopeful that county officials will continue their long-standing cooperation to ensure that sustainable reforms are implemented fully .”

The department intends to enter into discussions with county officials from the Los Angeles County Sheriff’s Department and the county ’s Department of Mental Health to address the results of the ev aluation. The department ex pects that those MOA requirements that are in substantial compliance will terminate and no longer be subject to monitoring. The department will propose additional correctiv e action in the form of a court-enforceable agreement to address the remaining areas with serious deficiencies that v iolate prisoners’ constitutional rights. The department’s compliance letter includes a comprehensiv e list of recommended remedial measures that are designed to ensure adequate mental health treatment, superv ision, suicide prev ention and conditions of confinement for prisoners throughout the jails.
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The challenges that the county faces in prov iding constitutionally adequate mental health serv ices at the jail are driv en in part by a rapid increase in the number of prisoners who are seriously mentally ill. The county has begun to take steps to ex pand div ersion programs that will prov ide community superv ision and treatment in a manner consistent with public safety . The department applauds these efforts.

CRIPA was enacted in 1 980 to eradicate egregious and harmful conditions that result in a pattern or practice of civ il rights v iolations in jails, prisons, juv enile justice facilities and other public institutions. CRIPA authorizes the department to inv estigate and, if necessary , initiate a civ il action to guarantee the federal and constitutional rights of institutionalized persons.

The MOA is enforced by the Special Litigation Section of the Civ il Rights Div ision and the U.S. Attorney ’s Office for the Central District of California, Civ il Div ision. A copy of the MOA can be obtained on the department's website and additional information about the Civ il Rights Div ision’s enforcement activ ities under CRIPA can be found at the div ision website .

1 4-61 0

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 U.S. Departmen t o f Justic e Civil Right s Divisio n

Office o f th e Assistan t Attorne y Genera l

Wishington, D.C. 20035
June 6, 1996

Ms. Joann e Sturge s Los Angeles County Executiv e 500 W. Temple Street, Room"383 Los Angeles, CA 9001 2
Re: Lo s Angeles County Jai l
Dear Ms. Sturges:
I am writing to inform you that the United State s Departmen t of Justice intend s to investigate condition s i n the Los Angeles County Jail system pursuant t o the Civil Rights of Institutionalized Person s Act, 42 U.S.C. § 1997 et seq.
The purpose of the investigation i s to determine whethe r conditions i n the jail system violate th e constitutional right s of its inmates. Th e investigatio n will focu s on allegations of inadequate mental health services , including but not limite d to: inadequat e facilitie s an d staffing, imprope r use of physical restraints, inadequat e suicid e prevention, and the abuse of mentally il l inmates by sheriff's deputies working i n the jail . Initiating thi s investigation does not evidence any prejudgment that the facility violates detainees' or inmates' constitutional rights. I f we do find any violations, we will confer with you and your staff about appropriat e correctiv e actions.
We will endeavor to coordinate with relevant officials of your Department an d will be i n touch with your staff t o work out the specifics of this investigation. Pleas e fee l fre e to contact us if you have any desire t o communicate on this matter. Th e

CRIPA Investigatio n

™ ••

• • ••

« •

•• •

JC-CA-002-001

- 2 attorney assigned t o this case i s Christy Lopez, a t (202 ] 616-3197.
Deva Assistant Attorney Genera l
Civil Rights Divisio n cc: Sherif f Sherman Block
Los Angeles Sheriff's Departmen t DeWitt Clinton, III, Esquire Los Angeles County Counsel Captain Herb Pettu s Men's Central Jai l Nora M. Manella, Esquire United States Attorney Central District of Californi a

 
 Memorandum

LK:SHR:MHN:MM:CEL:cmw DJ 168-12C-4 3
Subject
Findings Letter re: Los Angeles CountyJail

August 14 , 1997

To
Isabelle Katz Pinzler Acting Assistant Attorney General Civil Rights Division

From
Steven H. Rosenbaum Chief Special Litigatio n Section

RECOMMENDATION
We recommend tha t you sign the attached finding s lette r regarding our investigation, pursuant t o the Civil Rights of Institutionalized Person s Act ("CRIPA" ) , 42 U.S.C. § 1997 e_k seq. . into mental health care provided t o inmates housed in the Los Angeles County Jail.
BACKGROUND
We initiated thi s investigation i n June 1996, and toured several of the jail's facilities i n August 1996. W e provided ou r expert consultants' report t o the County in February 1997, to which they responded i n March. (Ordinarily , we do not provide our expert reports before we issue a findings letter. W e made an exception to that policy here as a result of negotiations over our access to the jail, which the County was initially incline d to deny.) I n June 1997, we finally received documentation fro m the jail that we had requested severa l time s over a period of months. Th e attached findings letter includes informatio n received during our tours of the jail and from documentation provided by the County subsequent t o our tours.
The Los Angeles County Jail system consists of eight primary facilities that house a population fluctuatin g between eighteen and twenty thousand inmates , making it the largest jail system in the nation. B y the jail's own estimate there are currently over 1700 inmates in need of mental health services. B y some estimates the jail houses more mentally il l persons than any mental health hospital or facility i n the country. Th e jail is failing to provide care that meets minimum constitutional standard s to its seriousl y mentally il l inmates. A s discussed i n the attached letter, mentally ill inmates are over-medicated, mis-medicated, and abused by deputies and other inmates. The y are housed i n the most unsanitary

CRIPA Investigatio n

•• • • • • • •• •
JC-CA-002-002

- 2 -
areas of the jail under conditions tha t exacerbate their mental illnesses. Th e inadequate provision of mental health care has resulted in the death and serious injur y of numerous inmates with mental illnesses, several of these deaths are discussed i n the attached letter.
Although the County routinely pays settlements and judgments of hundreds of thousands of dollars to the victims of its deficient mental health care system, i t continues to violate the constitutional right s of mentally il l inmates on a broad scale. The County has been relatively cooperative and has acknowledge d throughout ou r investigation tha t it s mental health care system is deficient, stating that most of the problems are due to inadequate staffing, overcrowding, an d aging facilities and systems. Th e County refused t o provide any documents initially , but then agreed to provide som e documents, although it severely restricted access to some types of documents, such as inmates' medical/mental health records, incident reports , and custod y division policies. W e were, however, able to obtain much of this information while on site at the jail or from non-County sources. The County has made some steps towards improvement i n light of our consultants' conclusions. However , the County has not addressed other serious deficiencies i n its system and progress in the areas it has begun to address appears to be exceedingly slow. Onc e the County has been notified of our findings, we anticipate beginning negotiations aime d at reaching an agreement that will ensure that the mental health care provided t o inmates of the County system is brought up to constitutional minimu m standards.
CONCLUSION
We recommend tha t you approve and sign the attached finding s letter.
Attachment
Approved _
Disapproved
Comments:

 
 U.S. Department of Justice Civil Rights Division

Office of the Assistant Attorney General

fftehington, D.C 20035

Ms. Joanne Sturges Los Angeles County Executive 500 W. Temple Street, Room 383 Los Angeles, CA 90012

September 5, 1997

Re: CRIPA Investigation of Mental Health Services in the Los Angeles County Jail

Dear Ms. Sturges:

On June 6, 1996, we notified you of our intent to investigate conditions in the Los Angeles County Jail system (Jail) to determine whether those conditions violate inmates' constitutional rights. The investigation was conducted pursuant to the Civil Rights "of Institutionalized Persons Act (CRIPA), 42 U.S.C. §§ 1997 at sejj^., and focused on allegations of inadequate mental health care, including but not limited to: inadequate facilities and staffing, improper use of physical restraints, inadequate suicide prevention, and the abuse of mentally ill inmates by sheriff's deputies working in the Jail. Having concluded our investigation, we are writing to advise you of our findings, supporting facts, and recommended remedial measures, as required by CRIPA.

The Los Angeles Sheriff's Department (LASD) operates eight primary detention facilities. At the time of our tour, the total inmate population was approximately 18,500 inmates. The average length of stay at the Jail is 36 days. For inmates held under California's three-strikes law, the average length of stay is 187 days for second-strike inmates and 127 days for third-strike inmates. At the time of our tour, the Jail system was nominally providing mental health services to approximately 1700 of these inmates. Our experts found the number of inmates in need of mental health care was significantly higher than 1700, and because the inmate population has risen significantly since the time of our tour, it is likely that the current number of inmates needing mental health services is also higher. Mentally ill inmates are housed primarily at Men's Central Jail (MCJ), the Sybil Brand Institute for Women (SBI), and North County Correctional Facility (NCCF).

We thank Frederick Bennett, Assistant County Counsel, Barry King, Chief of the Sheriff's Department's Custody Division, Areta Crowell, Director of the Los Angeles County Department of Mental Health (DMH), which provides mental health services to inmates in

CRIPA Investigation

i • •• •• •• • •
JC-CA-002-003

- 2-
the Jail, and the Sheriff's and Department of Mental Health's staff at the Jail for their cooperation and assistance during our investigation. We appreciate that this is an especially challenging time for the Jail, and that even under ideal conditions, operating a system such as the Los Angeles County Jail is difficult. The County has so far shown a professionalism and willingness to confront the serious problems at the Jail that make us optimistic that we will be able to resolve the issues raised in this letter in an amicable and efficient manner.
We would also like to thank the County for its March 15, 1997, response to our expert consultants' report. We found the County's response informative and constructive, and are encouraged that the County acknowledges many of the problems with the Jail's provision of mental health services and is already taking positive steps in response to several of the problems raised by our expert consultants. We have taken the County's response into consideration in completing our findings. When we do not agree with the County's assessment of what the conditions in the Jail are or should be, we have attempted to explain the reasoning behind our disagreement.
I. LEGAL FRAMEWORK
It is well settled that, with respect to inmates who have been convicted of criminal offenses, "the treatment a prisoner receives in prison and the conditions under which he is confined are subject to scrutiny under the Eighth Amendment." Helling v. McKinney. 509 U.S. 25, 31 (1993). Under the Due Process Clause of the Fourteenth Amendment, pretrial detainees "retain at least those constitutional rights . . . enjoyed by convicted prisoners." Bell v. Wolfish. 441 U.S. 520, 545 (1979). Further, with respect to pretrial detainees, the Fourteenth Amendment prohibits punishment of these persons and restrictive conditions or practices that are not reasonably related to the legitimate governmental objectives of safety, order and security. Id- at 535-37.
The Jail has a duty to ensure that inmates receive adequate medical care, including mental health care. See Farmer v. Brennan. 511 U.S. 825, 832 (1994). Deliberate indifference to inmates' serious medical needs violates the Eighth Amendment because it constitutes the unnecessary and wanton infliction of pain contrary to contemporary standards of decency. Helling v. McKinnpy. 509 U.S. 25, 32 (1993); Esf.pTLp v. Gamble. 429 U.S. 97, 104 (1976). It is firmly established in the Ninth Circuit that "medical needs" include mental health needs as well as physical health needs. ££&, e.g.. Hoptowit v. Ray. 682 F.2d 1237, 1253 (9th Cir. 1982); Madrid v. Qomsz., 889 F. Supp. 1146, 1255 (N.D. Cal. 1995); Balla v. Idaho State Board of Corrections. 595 F. Supp. 1558, 1576-77 (D. Idaho 1984).

- 3-
The Eighth Amendment protects prisoners not only from present and continuing harm, but from future harm as well. Helling at 33. Thus, deliberate indifference to inmates' serious mental health needs violates the Constitution even if that indifference has not yet resulted in injury.
II. FINDINGS AND SUPPORTING PACTS REGARDING MENTAL HEALTH CARE
Based upon our investigation, we have concluded that unconstitutional conditions exist at the Los Angeles County Jail, including a deliberate indifference to inmates' serious mental health needs. This conclusion and our recommendations for remedial measures described in Section III, are based in significant part on the opinions of our four expert consultants whom we retained to advise us in this matter. We already have provided your counsel with the joint report of our consultants and you have had the opportunity to respond.
A.
We believe that the Jail's provision of mental health care is constitutionally inadequate in numerous aspects. The Jail fails to identify adequately inmates with serious mental illnesses and does not adequately treat those inmates it has identified as mentally ill. Some inmates with mental illnesses enter the Jail without their illness being discovered; others report their mental illness, but are then "lost" in the Jail system, misclassified and placed in unsafe housing, or transferred repeatedly between facilities. For many mentally ill inmates who are properly identified, the treatment they receive is below constitutional minimum standards. They too often wait dangerously long periods before being evaluated or prescribed medication, have their illnesses misdiagnosed and their medications improperly administered. Mentally ill inmates are housed in conditions that often exacerbate their condition and they are not permitted to participate in the same programs as other inmates, even where their mental illness would allow such participation. They are the victims of predatory behavior at the hands of other inmates and have been abused by correctional staff. Clinical response to suicidal inmates is delayed, on occasion with tragic results, and suicidal inmates are placed in housing that permits them to act on their suicidal ideation.
The reasons for the poor state of mental health care in the Jail are manifold. The number of inmates in need of mental health care overwhelms available staff resources. The Jail's systems of medical record keeping and inmate tracking and classification are deficient to the point that custody and mental health staff cannot adequately access information necessary to provide appropriate care. The Jail does not adequately prevent abuse of mentally ill inmates and does not adequately investigate allegations of such abuse when it occurs. Many current custody

_4 -

:

policies are obstacles to the provision of adequate mental health care. A lack of adequate training of custody staff in dealing with inmates with mental illnesses negatively impacts the provision of mental health care. The chronic overpopulation in the Jail results in insufficient housing and treatment space, further exacerbating the Jail's inadequate system of mental health care.

Our findings are based upon several sources, including: (a) the February 10, 1997, Report by Department of Justice Expert Consultants Mr. Ray Coleman, Dr. Joel Dvoskin, Dr. Dennis Koson, and Dr. Jeffrey Metzner, (Expert Report) previously provided to your counsel; (b) interviews with Sheriff's Department and Department of Mental Health staff; (c) interviews with inmates conducted by personnel from the Department of Justice and their consultants; (d) documents provided by the Jail; (e) written communications sent directly to us by inmates, former inmates, families of former inmates, and advocates; and, (f) the County's March 15, 1997, response (Response) to our expert consultants' report.

Whether at the Inmate Reception Center (IRC) at MCJ or Twin Towers, inmates entering the Jail system are not adequately screened for mental illness. Based on interviews with staff, information provided by the Jail, and our observations during our tour of MCJ's IRC and SBI's intake area, we believe that the Jail fails to question each inmate privately and individually regarding the inmate's medical or mental health, but instead relies on a group videotape orientation that instructs each incoming inmate to inform medical personnel if he or she has medical or mental health problems.1/ Only if an inmate tells medical personnel during intake that he or she has medical or mental health problems will medical services ask an individual inmate appropriate screening questions about his or her medical and mental health, recording this information on the Jail's
1/ The County states in its March 15 response that the Jail's "screening methodology meets the California legal requirements as set forth in Title 15." Response at 33. However, whether the Jail's policies are deemed to comport with California law is not dispositive of whether the actual conditions at the Jail comply with minimum standards required by the Constitution. Moreover, the Jail's stated and observed practice of completing a medical screening form only for inmates who self-identify as having medical or mental problems does not appear to comply with Title 15's requirement that the Jail's health authority maintain "individual, complete, and dated health records which shall include . . . receiving screening form/history." Cal. Code Regs. Tit. 15, § 1205 (1996).

- 5-
"medical services data base form."2/ When this form is created by nursing staff for patients who self-identify as mentally ill at intake, there is no medical examination. The database is thus not an adequate medical screening instrument because it is not completed for every inmate, and it is not an adequate medical assessment because it does not include a medical examination.
The system relies on inmates self-reporting mental health problems, a method which is likely to result in a significant number of inmates entering the Jail with undetected mental illnesses. Many mentally ill inmates will fail to self-report their illness to the Jail unless they are independently and privately questioned by trained personnel. Our consultants found that there are strong disincentives for mentally ill inmates to self-report. Those who have been in the system before will have learned that identifying oneself as mentally ill may lead to being put in lock-down housing, and an increased likelihood of abuse. In addition, according to the September 1996 report of Merrick Bobb, the Special Counsel retained by the County to advise the Board of Supervisors regarding progress by the LASD, deputies report that because inmates in holding cells are sometimes not fed, "savvy" inmates will wait to report medical problems until they are in permanent housing. Los Angeles Sheriff's Department 6th Semiannual Report by Special Counsel Merrick J. Bobb & Staff at 12 (September 1996).
As discussed below, the Sheriff's deputies' lack of training in identification of mentally ill inmates, and the Jail Mental Health Services policy of targeting only "high impact" seriously mentally ill inmates, also results in an under-identification of inmates who may be just as mentally ill as the "high impact" inmates, only more quiet. The Jail also appears to fail to make use of "special handling" cards. We were told by an IRC Lieutenant that special handling cards are the method by which IRC staff are informed that an incoming inmate has been previously identified as having a mental health problem. However, it appears that these cards are not consistently filled out or passed on. We understand that the Jail is now reviewing the special handling card procedures in its custody facilities. Response at 12.
Intake mental health referrals are assigned to a clinician, who evaluates the inmate "as soon as possible." Response at 11. Due to delays in this process, many inmates who are screened positive for mental illness do not receive an evaluation for days. This delay is unacceptable and dangerous. In one case
2.1 We found that the question on the Spanish-language version of the medical announcement regarding suicide was not as comprehensive as the question on the English-language version. We are told this problem has been corrected. Response at 12-13.

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noted by our consultants, an inmate was screened positive for mental illness and a mental health assessment was ordered at that time. By the time a mental health worker was able to get to that inmate's evaluation two days later, it was too late—the inmate had killed himself earlier that day. Further, it appears that the mental health worker was not even aware that the inmate killed himself, as the notation in the inmate's chart states "discharged." We agree with the County that it would be appropriate to have mental health staff immediately evaluate inmates who are identified as requiring mental health services, Response at 28; however, as the County acknowledges, unless an inmate is having a mental health crisis, an inmate is not immediately evaluated. Response at 11.
The intake mental health evaluation is inadequately documented. The documentation consists only of a check on the inmate's screening form with no mention of diagnosis or level of impairment. Another troublesome aspect of intake is that when inmates enter the Jail with properly prescribed psychotropic medications, these medications are taken from them upon arrival. They receive no mediation until assessed. Such inmates are thus placed in danger of decompensating to crisis level immediately upon entering the Jail system. We are encouraged by the County's statement that physicians at the Jail can prescribe certain psychotropic medications to such inmates for a limited period of time, Response at 28, and encourage the County to ensure that this practice is implemented to avoid unnecessary and dangerous decompensation. The Jail has had similar problems with inmates returning to the Jail from outside facilities, such as Patton or Metropolitan State Hospitals. These inmates are sometimes placed in general population where they may wait weeks to see a psychiatrist or receive the medications they were previously prescribed, needlessly and dangerously decompensating as they wait to be reevaluated.
An additional deficiency in the Jail's screening process is its policy of "screening" male inmates (i.e. asking inmates to self-report) upon intake into the IRC and re-"screening" them each time they are transferred to or from any of the Jail's facilities. While this practice may have the effect of serving as a "back-up system to the initial screening at IRC," Response at 29, this practice increases the inefficiency and inconsistency of the screening process and would not be necessary if the Jail's initial screening process and referral system were adequate. Many inmates are transferred numerous times during their incarceration. By not adequately screening each inmate at the IRC and then providing this information with the inmate upon transfer, the Jail causes unnecessary duplication of work, delay in providing mental health services, and an increased likelihood that an inmate will be inconsistently classified. Although the development of the County's Jail Hospital Information System is still in its nascent stages, Response at 3, such a system has the

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potential to solve the Jail's problems with maintaining consistent, accessible medical records for every inmate. However, the Jail is unable to provide even a "ballpark" estimate for when this system might be implemented, and there are indications that it may take years. Thus, we encourage the County to take interim steps to improve medical records and screening, as it stated in its response it is currently considering. Response at 29.
C. Jnadetjuate Referral Sy3t*.lH
Because the Jail's screening and evaluation process misses many mentally ill inmates at intake, it is especially important that the Jail maintain an effective system for referring general population inmates who may be mentally ill to a mental health professional. The Jail's referral process fails to adequately identify and obtain services for mentally ill inmates. The referral system is deficient in several respects. The primary problem with the referral process is that the Jail has set too high a threshold for what is referable. Jail Mental Health Services has an explicit, written policy of limiting mental health-services to "high impact" seriously mentally ill inmates. An inmate must be actively and observably suicidal or psychotic, or in the words of one deputy "bouncing off the walls," before he or she has a chance of being referred to mental health for treatment. This policy not only excludes the entire subset of seriously mentally ill inmates whose mental illness may not manifest itself through outward aggression or bizarre behavior, but increases the likelihood that no inmate's mental illness will be treated until the inmate decompensates to an acute crisis. Treating inmates' serious mental illness only when they reach crisis level is not only inadequate from a mental health care perspective, but also wastes the Jail's scarce mental health resources, as providing crisis care requires far greater resources per inmate than providing non-crisis mental health care.
Another deficiency in the Jail's referral process is that the mental health staff tours the Jail's housing units too infrequently. When they do tour they do not ask the deputies on duty if there is anyone in need of mental health services, but rather rely on deputies to refer such cases to mental health staff unprompted. Finally, the Jail's use of different colored jumpsuits for mentally ill inmates decreases the efficacy of the referral system because it indicates to deputies that all mentally ill inmates already have been identified, encouraging them to attribute aberrant behavior of general population inmates (.!_._£_, ' those not in special clothing) to other causes (e.g. . manipulation or defiance) rather than possible mental illness.

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D. Inadequate Treatment
1. Summary
Treatment available to mentally ill inmates is inadequate at all of the Jail's facilities. Other than psychotropic medications, treatment of the Jail's mentally ill inmates consists of: a day treatment program at MCJ for approximately fifty inmates; inpatient mental health care at MCJ's Forensic Inpatient Unit (FIP) for thirty-five male and female inmates,- and an attempt at therapy for some of the women with mental illnesses at SBI. The rest of the approximately 1700 identified mentally ill inmates in the Jail receive no mental health treatment other than perhaps psychotropic medications.1/ We commend the County for its establishment of the day treatment program at MCJ; however, the program is far too small to treat the number of people who are in serious need of non-psychotropic treatment. In addition, FIP is inadequate as a forensic inpatient unit. It lacks an adequate number of rooms, clinical staff, auxiliary services such as occupational therapy and education, and sufficient aides to observe ambulatory patients, which increases reliance on physical restraints.
As LASD and DMH staff (including management) have explicitly stated, the Jail currently lacks the staffing resources necessary to provide adequate treatment for inmates with serious mental illness. For example, there are only eight nurses providing mental health nursing care to over 800 mentally ill inmates at MCJ, and there is a severe shortage of psychiatrists. Our expert consultants found that the majority of problems in the Jail's provision of mental health care are the direct and predictable result of inadequate staffing. The Jail's staffing shortage is due not only to an inadequate number of budgeted positions,- the Jail also has problems filling positions already budgeted. In all types of mental health staffing (e.g.. psychiatrists, psychologists, therapists, nurses, psychiatric technicians, and administrative staff) there were many more positions budgeted than filled at the time of our tour. In addition, supervisory staff at MCJ stated that many current staff members are not working to their full potential. Others are being asked to perform tasks, such as mental health evaluations or crisis
1/ The County has informed us that since our site visit in August 1996, Jail Mental Health Services has begun daily visits to the acute units at MCJ. Response at 4. These visits appear to be in the nature of monitoring inmates' mental health condition. While such visits are important, they do not constitute treatment unless they involve actual treatment, such as counseling.

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intervention, for which they are not properly trained and educated. There is also a shortage of Spanish-speaking mental health staff.1/
2 . Sybil Brand Institute
At Sybil Brand, the mental health staff appeared strongly committed to providing mental health care other than psychotropic medications to the Jail's female mentally ill inmates. But their attempts at programming and therapy were overwhelmed by a lack of office and treatment space and inadequate staffing. The County reports that since June 21, 1997, Sybil Brand has been closed and all female inmates have been moved to Twin Towers. At the time of our tour, the Jail did not plan to move SBI's female inmates to Twin Towers, so we could not assess whether Twin Towers provided adequate office and treatment space for female inmates with mental illness. At Sybil Brand, treatment and office space was clearly inadequate. SBI's psychiatrist did not have adequate space to see inmates housed in the Correctional Treatment Center (CTC) or brought into the clinic area for examination. Nor was there adequate private or quiet space to conduct individual or group therapy. Individual counseling of mentally ill inmates at Sybil Brand was generally done cellside, between either one or two sets of bars. At the time of our SBI visit, no group therapy was being conducted because of the lack of space. Recreational therapy was also compromised by the lack of treatment space. Although the lack of treatment space was exacerbated by the use of the only dayroom in mental health housing as an 18-bed suicide observation dorm, a dorm-setting should be maintained in housing for suicidal inmates, as the benefits of a dorm setting for such inmates outweigh the loss in treatment space. Nevertheless, a. Jail's mental health program should not be forced to choose between providing two services as important as treatment and appropriate housing for suicidal inmates because of a lack of space.
SBI's medical area, including its CTC, was also inadequate for mental health treatment. The Director of LASD's Medical
The County has recently informed us that approximately seventeen new mental health staff members have been hired since June 30, 1996. It is unclear how many of these seventeen staff members were hired since our tour, nor have we been informed what positions these staff members have filled. Given the severity of mental health staffing shortages at the time of our tour, the retirement of MCJ's chief psychiatrist, and the County's recent statement that it is currently reviewing staffing strategies to implement a plan to provide "appropriate staffing levels for service delivery at the Twin Towers Correctional Facility and elsewhere in the system, " Response at 7, it appears that mental health staffing continues to be inadequate.

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Services agreed with us that CTC rooms were generally unsafe for mental health purposes. Only one CTC room had a bed affixed to the ground. There were hazards such as horizontal bars on the windows, peeling drywall, and protruding boxes. Still, this was where all actively suicidal (those who have recently attempted suicide) or psychotic inmates were housed, unless the Jail was able to place them in Metropolitan State Hospital, Patton, or MCJ's FIP. There are usually more inmates who need beds at one of these facilities outside the Jail than there are beds available.
If more treatment and office space becomes available at Twin Towers, the housing of female inmates at Twin Towers is almost certain to result in improved mental health care for the Jail's female inmates. However, this potential for improvement in mental health care can only be realized if the additional treatment space is combined with procedures and staffing adequate to provide minimally acceptable care.
3. Pitchess Detention Center
The Pitchess Detention Center (PDC), which includes the East, North, South, and North County Correctional Facilities, houses the majority of the Jail's inmates. However, there is no mental health treatment available at any of these four facilities other than the administration of psychotropic medications and crisis intervention. Inmates with serious mental illnesses at any of the PDC facilities other than NCCF have an especially difficult time accessing the treatment that is available at PDC.
4. Administration Of Medication And Diagnosis
Our expert consultants found that, throughout the Jail, medications were improperly prescribed, their effects improperly monitored, and documentation of their use and effect incomplete, inaccurate, and often illegible. Mental health staff also appear to be misdiagnosing some inmates. For example, at NCCF, all of the inmates our expert consultants interviewed had been diagnosed by Jail psychiatrists as having a bipolar disorder. Our expert consultants talked with a number of inmates who, despite having been diagnosed as having a bipolar disorder, appeared to our experts not to have this disorder. They found that based on the sample of inmates they interviewed, "it is likely that the bipolar disorder diagnosis is being overused." Expert Report at 45.
The poor treatment received by one seriously mentally ill inmate illustrates the deficiencies in the administration of medications and diagnosis, as well as other deficiencies in the Jail's mental health services system. Records indicate that the inmate, a woman with a history of serious mental health problems, was doing well when transferred from Patton State Hospital to SBI

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in June 1996, pending release from the Jail system. However, after only three days this inmate decompensated while at SBI and had to be transferred to FIP. Two days later after the transfer she was observed having a seizure, and a few days later the inmate died.
From our expert consultants' review of available medical records, there appear to have been numerous serious problems with the mental health care this inmate received. It appears that the inmate did not receive the proper dosage of prescribed medications. An improper medication may have resulted in the inmate's dangerous decompensation and the use of restraints. According to the coroner's report, the inmate appears to have died of a pulmonary embolism. It also appears that the inmate may have had a medical illness, in addition to her mental health problems, that was not treated. In addition, it appears that a diagnosis of neuroleptic malignant syndrome was considered and testing was ordered to determine the proper diagnosis, but the testing does not appear to have been carried out. It is unclear whether this was due to a lack of adequate staffing, poor communication, and/or some other problem. The inmate's mental health records from Patton appear to have not arrived at the Jail until four days after her admission. Charting also was haphazard. For example, the inmate's medical chart indicates that the inmate was pronounced dead at 2035 hours, but also indicates that CPR was begun and doctors called to her cell at 2100 hours.
The deficiencies in the administration of medications and diagnosis of mental illnesses appears directly linked to the Jail's severe shortage of psychiatrists. Based on their collective experience, our expert consultants believe that the maximum caseload for a typical Jail psychiatrist should be approximately 75-100 inmates. Due to the high volume of inmates coming through the County's jail system, they believe that Los Angeles County Jail psychiatrists should have a caseload at the lowest end of that range. This ratio would allow a psychiatrist to prescribe medication, adequately monitor and document its administration, and evaluate inmates to determine whether they need medication or other mental health services. These functions currently are not adequately performed by the psychiatrists in the Jail because of their overwhelming caseloads. By the Jail's own estimate, there are approximately 1200 male inmates receiving psychiatric services, but only seven full-time-equivalent (FTE) psychiatrists, one of whom is also in an administrative role - - a ratio of one psychiatrist for every 171 identified mentally ill male inmates. At SBI, there is, at most, one FTE psychiatrist available, with an average caseload of 415 women, including more than 300 inmates on psychotropic medications, and many more who, in the view of our expert consultants, "desperately need to be seen and likely medicated." Expert Report at 40.

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Civil Rights Litigation Clearinghouse, http://clearinghouse.wustl.edu. Document JC-CA-0002-0003, Findings Letter, CRIPA Investigation of
Mental Health at the Los Angeles County Jail.
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inmates in mental health, housing. It also appears that an inmate in mental health housing cannot be classified pro se, and that without this classification the inmate does not have access to the Jail's law library. The County, itself, has acknowledged that staffing levels and physical plant factors, "do in fact, challenge the provision of the minimal [California Code of Regulations] Title 15 requirements for the inmates," and that audits of recreation, out-of-cell time and Title 15 compliance at all Jail facilities have been completed. We are encouraged by the County's statement that "[c]orrective action is being taken to ensure that compliance is achieved and that neither staffing nor so-called 'deputy attitude' preclude mandatory compliance and service provision to inmates." Response at 5-6.
The County agrees that "the high volume of inmate movement and jail crowding exacerbates conditions in the jails designed for housing less inmates," Response at 29-30, and responds to our expert consultants' assessment of current treatment inadequacies largely by noting anticipated staffing increases and the anticipated full opening of Twin Towers. The County states that Twin Towers "should-help improve conditions by providing treatment and office space and improved housing conditions," Response at 30, and explains that the Twin Towers design is more conducive to management of special housing inmates, that the inmates will be more likely to get exercise, recreation, and showers because these areas are adjacent to or easily accessible from inmate housing areas, and that no inmates will supervise other inmates. Response at 14.
Although we agree that the opening of Twin Towers could have a beneficial impact on treatment for the Jail's seriously mentally ill, it is uncertain whether this potential will be realized. First, it is our understanding that there is no set date for opening the medical tower at Twin Towers. Thus, although some areas of Twin Towers are open, the Twin Towers Correctional Treatment Center, including the much-needed increase in number of inpatient beds for mentally ill inmates, is reportedly currently unavailable. Second, many of the potential ,treatment benefits in opening Twin Towers' medical areas (increased treatment space, inpatient beds, etc.) can only be realized if combined with staffing adequate to provide minimally acceptable treatment. While touring NCCF we observed that its large, relatively new infirmary was empty except for one inmate. This is an unfortunate waste of needed health care beds that may be repeated at Twin Towers without adequate staffing. Finally, the County's intention "to move the most severely impaired mentally ill inmates to the Twin Towers in the next few months," Response at 14, does not address the needs of those inmates whose needs are only slightly less acute.
The County's plans regarding who will be housed at Twin Towers remain fluid. For example, although we were told

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throughout our tour that no female inmates would be housed at Twin Towers (with the exception of female inpatients of the facility's CTC), as of June 21, 1997, all female inmates were moved to Twin Towers. We understand and appreciate that there are numerous factors to consider when deciding who to house at Twin Towers, e.g.. the security benefits of housing inmates currently housed in dorms at East in smaller cell settings. However, regardless of whether and under what conditions Twin Towers is fully occupied, the County must provide adequate treatment to inmates with serious mental illness. Moreover, many of the treatment inadequacies can be remedied without waiting for mentally ill inmates to be housed at Twin Towers.
7. Non-release Of Inmates With Mental Illnesses
Despite the Jail's lack of adequate resources for mentally ill inmates, the Jail currently holds persons it believes to be mentally ill in custody for violations that would normally warrant release pending trial, on bond or on their own recognizance, if not for the fact that they are mentally ill. The County states that this is because California law permits the Sheriff's Department to hold a mentally disordered individual for 72-hour treatment and evaluation. Response at 9, 34. However, the statutes cited do not appear to mandate that the County hold or charge an individual, nor do they indicate that when an individual is held, he or she should or must be held in a correctional setting. Cal. Welf. & Inst. Code § 5150 (West 1996); Cal. Penal Code § 4011.6 (West 1996). In fact, California law mandates that a law enforcement officer transporting a mentally disordered person to a facility for evaluation cannot be instructed to keep or transport the individual to a jail solely because there is no acute bed available in a mental health facility. Cal. Welf. & Inst. Code § 5150.1 (West 1996). The County has provided no rationale for its policy of holding individuals with illnesses it cannot adequately treat, in a facility which is already overwhelmed, for allegedly committing misdemeanors that normally permit immediate pretrial release.
8. Special Clothing
The practice of clothing inmates identified as mentally ill in special jumpsuits adversely affects the inmates' treatment. Our experts had not seen this practice in any other system in the nation and found that it results in stigmatization and creates barriers to treatment (e.g., many inmates will not seek treatment due to the associated stigmatization). In addition, special clothing makes inmates in jumpsuits easy targets of predatory inmates. Although we agree with the County that special clothing may assist correctional officers in "exercising proper judgment," Response at 31, towards differently clothed inmates when they exhibit improper or bizarre behaviors, there are other, less therapeutically damaging ways to elicit appropriate custodial

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Civil Rights Litigation Clearinghouse, http://clearinghouse.wustl.edu. Document JC-CA-0002-0003, Findings Letter, CRIPA Investigation of
Mental Health at the Los Angeles County Jail.
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case the inmate, who was awaiting court-ordered placement in a County operated mental health facility, was discharged from FIP without the medication which had stabilized his severe depression and suicidal ideation. Despite repeated requests over a period of six days, the inmate never received the needed medications. At intake, the inmate admitted to a history of suicide attempts and mental illness, and had been housed in FIP under suicide watch for an extensive period. When discharged from FIP, the inmate was placed in normal mental health housing, rather than in a suicide observation cell. According to progress notes and other jail documentation, a jail social worker first saw the inmate four days after he had been discharged from FIP. The social worker reported that the inmate stated that he had been in FIP for six weeks where he had been stabilized by medication. The social worker noted that the inmate was anxious because he had not received his medications since he had been discharged from FIP. The social worker placed the inmate's name on the "psychline" list to be seen by the next day to enable the inmate to receive his medications. When the social worker returned two days later to see the inmate, he still had not received his medications. The inmate was agitated and asked the social worker if he could see the bugs crawling over the inmate's body. The social worker went to the clinic and informed the nurse for that area that the inmate had not received his medications for "4-5 days" and needed his medications immediately. The inmate hanged himself that evening, apparently without ever receiving the needed medication. Shortly before the inmate killed himself, he began shouting, loud enough to awake the inmates in the adjacent cell, that he had bugs on his body. If a deputy had responded he likely would have seen that the inmate was in need of immediate mental health crisis intervention. There is no explanation in the deputy's report, and there appears to have been no follow-up investigation of why no officer responded to the inmate's shouts or referred him to Jail Mental Health Services. According to the Jail's documentation, the last row safety check was 21 minutes before the inmate was discovered dead and "cold to the touch." The deputy that found the inmate hanging had trusties cut the inmate down and then waited for a second deputy to arrive to take the inmate's vital signs.
In the other case, an inmate who had previously attempted to kill himself succeeded in doing so soon after being removed from suicide observation for reasons the Jail cannot explain. Despite repeated statements to staff and inmates that he would kill himself, the inmate was removed from FIP and placed alone in a single cell in mental health housing. This inmate did not receive his prescribed medication for the two days prior to his suicide. According to jail documentation, the nurse did not give the inmate his medications on one occasion because another mentally ill inmate was throwing feces, and on the next occasion because the module was under lock-down. These are not acceptable reasons for not providing needed medication. Such occurrences

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are not uncommon in the Jail and mental health staff must be provided with adequate custody assistance and supervisory encouragement to enable them to provide necessary medical care under these difficult conditions. According to Jail documentation, the last safety check was almost forty minutes before the inmate was discovered dead.
The Jail also fails to respond adequately to suicide gestures and other inmate disturbances. In one instance, in which three inmates slit their wrists and several others tore clothing and flooded toilets, the Watch Commander responded by ordering all the inmates to remove their clothing until the row was mopped and cleaned. This appears to have lasted for at least several hours and perhaps more than a day. The County has offered no penological rationale for this response. In this same incident, the Jail characterized the three inmates slitting their wrists as "an attempt to disrupt operations." Response at 35. The Jail is currently investigating an allegation that a deputy challenged inmates to commit suicide. This challenge reportedly occurred after several inmates in the housing area had made suicide gestures. The Jail must recognize that suicide gestures are potentially life threatening and that correctional staff may incorrectly assess an inmate's motive for suicidal gestures. Custody staff should not be required to discern genuine from disingenuous suicide attempts. The Jail should treat all attempts as serious incidents, requiring at least a mental health consultation.
F. Physical Afe'ug'g And Mistreatment Of Mentally 111
Inmates who are mentally ill or housed in mental health housing are subject to an unacceptably high risk of physical abuse and other mistreatment at the hands of other inmates and custody staff. Moreover, the Jail does not adequately investigate allegations of abuse against its inmates.
We have received numerous reports from inmates and advocates regarding serious physical abuse of inmates in mental health housing by other inmates and by Sheriff's deputies, including kicks, punches, beatings, and sexual assaults. Although the Jail claims that it has discounted some of these claims, as discussed later, the investigation of these claims was inadequate and serious questions remain regarding the extent of physical abuse of mentally ill inmates. We agree with Special Counsel Merrick Bobb's finding that in the Jail "there is callous treatment [of inmates] at times, a problem that LASD management knows about but has not acted sufficiently aggressively to

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resolve." Los Angeles Sheriff's Department 6th Semiannual Report by Special Counsel Merrick J. Bobb & Staff at 11-13 (September 1996) .5./
The treatment received by one inmate indicates that excessive use of force and physical mistreatment of inmates with mental illnesses may be in part the result of inadequate training. Although we have not been able to review the entire record regarding this inmate, according to documents provided by the Jail, in early April 1997, Jail Mental Health Services requested that an inmate housed in mental health housing be sent to FIP for treatment as he had decompensated to the point where he refused to shower or go to court, was sleeping on the floor in trash and water, and was smearing feces on himself and his cell. The inmate had been refusing to take his medications for several days. A deputy told the inmate to stand up to be handcuffed and escorted to FIP, but the inmate refused. After various custody officials failed to convince the inmate to allow himself to be escorted to FIP, custody called for the extraction team, a team trained to remove non-compliant inmates from their cells. Custody also called the mental health unit to inform them that an extraction was about to be performed and ask that a mental health staff person observe the extraction. Less than ten minutes after the mental health observer arrived at the inmate's cell, the extraction team arrived. It is unclear whether deputies were already in the cell trying to remove the inmate when mental health staff arrived at the cell. According to the mental health observer, the inmate was shot twice in the legs with rubber bullets and dragged from his cell once he was subdued. According to FIP records, the inmate, who weighed approximately 375 pounds, was then hand-cuffed with his hands, behind his back, placed on his stomach and brought up to FIP on a stretcher. There are some reports that he was hog-tied. He died later that night. The Jail did not provide the coroner's report; therefore, it is not possible for us to state at this point how the inmate died. However, according to our expert consultant, due to the risk of positional asphyxia in such a large person, it is not a proper tactic to place an obese person on his stomach with hands tied behind his back. It is also unlikely that firing a direct hit with rubber bullets was appropriate in this situation. Further, it appears that the Jail did not attempt to involuntarily administer medication to the inmate in the cell, which is acceptable in psychiatric emergencies and which could have eliminated the need for most of the force used. According to our expert consultant, the Jail also should have allowed trained mental health officials adequate opportunity to persuade the
5./ The incidents of abuse and mistreatment by trusties and deputies of inmates in mental health housing discussed in Special Counsel Merrick Bobb's Semiannual Reports will not be reiterated here.

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inmate to leave his cell voluntarily. Because custody officers called the extraction team before calling down mental health staff to "observe" the extraction, and because the extraction was begun only fifteen minutes after the team's arrival, it appears that the Jail did not allow mental health staff adequate opportunity to persuade the inmate to leave his cell. According to our experts, there were several alternatives to the amount and type of force used to remove this inmate from his cell. It appears that the Jail failed to employ any of these tactics.
At the time of our tour the Jail was attempting to compensate for inadequate staffing (both custodial and mental health) by using inmate trusties as assistants in mental health housing. The practice of using inmate trusties in place of custodial or mental health staff is unacceptably dangerous. The potential for physical abuse and mistreatment is too high, and we, as well as the Jail, received allegations before our tour in August that this practice had resulted in incidents of serious abuse and injury at the Jail. In addition to physical abuse, there are reports that trusties deny food to some mentally ill inmates, steal their property, or steal money from them by using their vending machine cards for their own use. We have been told that as of August 21, 1996, the Jail no longer uses trusties to escort mentally ill inmates or in any way supervise their activities, although they are still used for food distribution and cell cleaning. Response at 8.
The Jail does not adequately investigate allegations of abuse towards mentally ill inmates. For example, in April 1996, the Jail was informed by the Department of Mental Health of numerous allegations of serious abuse of mentally ill inmates by deputies and trusty inmates. In August 1996, we were told that the investigation into allegations of abuse had still not been completed, and that we would be provided with the Jail's findings upon completion of the investigation. After repeated requests for the County's response to these allegations, the County finally provided a partial response in the form of a summary of its investigation in June 1997. The Sheriff's Department Internal Affairs Bureau investigators did not interview the alleged victims of the abuse, or the Patients' Rights Advocate who had presented the information to the Jail, until October 1996. The investigation was completed in May 1997, over one year after the custody division had received the allegations of abuse. It is clear even from the incomplete information provided that the Jail's response to these allegations was inadequate. The memorandum requesting inactivation of the investigation states that there was "insufficient information to substantiate any charges or to name any individual as a subject of the investigation." A review of the investigation summary however, indicates that there was adequate information to act upon. For example, numerous inmates in mental health housing alleged that they had bleach thrown on them by trusties, or had

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seen this happen to other inmates. The Supervising Line Deputy on the mental health housing module reportedly told the investigators that he "was aware of several bleach throwing incidents involving inmates and occasionally the suspect was a trusty." The Line Deputy reported that when the "incident involved a trusty, the trusty would be removed from inmate worker status" and a report would be written. It thus appears that the Jail's own supervisors acknowledged that such incidents had occurred, yet the investigators found these allegations unsubstantiated. It appears that investigators did not even review the Supervising Line Deputy's reports regarding these incidents.
Another inmate alleged in an affidavit that he was beaten in his cell by trusties and deputies. During an interview by Sheriff's investigators, the inmate recanted his allegations that deputies beat him, but repeated that he was beaten by trusties who escorted him to the showers. The Department of Mental Health had earlier provided photographs to investigators of the inmate's injuries, which had been taken at Metropolitan State Hospital upon his admission there from the Jail. Despite the inmate's statement, the supporting evidence, and the lack of any contradictory evidence, the Jail found that the charge that trusties had beat the inmate could not be substantiated.
Another inmate told investigators that he was beaten on the head by two female deputies who escorted him to his cell on his first day. Investigators do not appear to have attempted to identify the deputies through normal investigatory techniques, such as checking who was on duty in that area on that day, or showing the victim pictures of female deputies in the jail to see whether he could identify the individuals he alleged beat him. In another incident, an inmate named one deputy that had allegedly allowed a trusty to beat an inmate in mental health housing and named another who had allegedly allowed a trusty to throw water on inmates during the evenings. Although it appears that the investigators interviewed the two named deputies, there is no indication that they interviewed other deputies who were on duty with these deputies and may have been witnesses, or checked into the background of the deputies to see whether there were other reports of similar allegations.
It also appears that more information would have been available to Internal Affairs if it had not delayed its investigation for months and if investigators had not failed to interview available witnesses. For example, although the Jail received these allegations in April of 1996, it appears that Internal Affairs did not begin its investigation until October of 1996. By this time, fourteen of the twenty-one mental health inmates involved in the allegations could not be located. It is likely that if the investigation had begun earlier, more of these individuals could have been located.

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Civil Rights Litigation Clearinghouse, http://clearinghouse.wustl.edu. Document JC-CA-0002-0003, Findings Letter, CRIPA Investigation of
Mental Health at the Los Angeles County Jail.
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Semiannual Report by Special Counsel Merrick J. Bobb & Staff at 23 (April 1997). We agree with the County's Special Counsel that "[t]here is too great a risk of erroneous releases, over-detentions, misclassifications, and grim failures to provide medical and mental health care. We cannot stress enough to the Board of Supervisors and the LASD how critically deficient is the current [jail information] system for medical and mental health care. " XsL. at 24.
The County's current practice of maintaining a separate medical record at each facility for the same inmate has a serious negative impact on mental health care. Maintaining several medical/mental health records for each inmate exacerbates communication problems, creates unnecessary duplication of work, and increases the likelihood that important medical information will be missed. Each time an inmate is transferred to a new facility, a new medical chart is created. Our expert consultants found that it was often necessary to look in several records in order to find the answer to questions as basic as why an individual was restrained. Multiple records create delays of days or even weeks before information from an inmate's medical record at one facility can be transferred to medical staff at another. In some instances, medical information is not transferred at all.
During our tour, we observed problems with the mental health staff's ability to access an inmate's medical records. For example, at SBI the psychiatrist sometimes did not have access to an inmate's mental health chart when he reviewed a patient's medication, and mental health workers did not always know what medication an inmate was taking. We are told that the Jail is now maintaining integrated inpatient (for CTC/FIP patients) and outpatient records at the men's facilities and has integrated mental health and medical charts at SBI. Response at 32. This should resolve some of the problems we observed regarding insufficient access to medical records.
Medical charting is deficient. Our expert consultants reported that they found inadequately documented mental health charts at every facility. The charts contained little or no basic information concerning assessments, treatment planning, or laboratory assessments of medication use. Our expert consultants found that it was sometimes impossible to tell from charts whether an individual had been properly medicated. They attributed the lack of documentation regarding treatment planning to the lack of treatment services, other than psychotropic medication use, generally available to inmates. The County states that the Jail's Medical Services Quality Assurance Program audits "medical related entries" in inmates' medical/mental health records for legibility and relevance. Response at 7. Our expert consultants' review of medical and mental health records indicates that these audits thus far have been unsuccessful at

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Mental Health at the Los Angeles County Jail.
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deficiencies have a severe negative impact on mental health services, including discontinuity of health service, poor coordination of effort, waste, and on occasion, danger to inmates.
Understaffing directly contributes to communication failures. Due to staffing shortages, clinicians often must choose between communicating and documenting important information, or providing mental health care. Some communication problems result from the LASD's inadequate record keeping system. The Director of DMH stated that it is often difficult to find a specific mentally ill person in the Jail, even if you know the person is somewhere in the system. Inmates are transferred frequently and the Jail's record keeping system is not adequate to keep up with these transfers. This results not only in "losing" mentally ill inmates, but also in inappropriate or unnecessary transfers. We were told of numerous incidents of inmates being sent from NCCF to MCJ for mental health care only to be sent back as soon as they had completed the long bus ride.
Communication between facilities is similarly inadequate. When an inmate who has already been identified as needing medical or mental health care is transferred to another facility, medical/mental health services at the new facility is not made aware that the inmate is on his way or has arrived. Instead, medical/mental health services at the new facility must hope that the inmate again self-identifies during intake and then contact the sending facility to inquire about the medical history or medication orders for that inmate. Thus, even if an inmate does self-identify again at the new facility, he is placed on the next available physician or psychiatric line to await re-evaluation, rather than receiving uninterrupted treatment. An inmate who does not self-identify will likely not receive medication or treatment at the new facility even if he was receiving medication and treatment while at another Jail facility. This results in inconsistent treatment and premature cessation of treatment, which can be dangerous. We found numerous instances in which an inmate was classified as mentally ill at the sending facility and sent to the receiving facility for treatment, only to be classified as not mentally ill and immediately returned to the sending facility.
The Jail does not have a settled mental health caseload roster or list. Despite the fact that the County had ample advance notice of our visit, it took several days after our arrival for the Jail to create and provide us with a list of the approximate number of inmates currently housed in mental health housing or receiving psychotropic medications. The Jail does create a daily census of the FIP and day treatment programs. We are told the Jail has begun creating a census of MCJ's Forensic Outpatient program. However, without a census of all inmates at every facility who are receiving mental health services, it is

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difficult for the Jail to keep track of mentally ill' inmates or ascertain the amount of resources required to treat them.
The LASD and DMH have serious communication problems that significantly hamper the provision of mental health care in the Jail. There is currently no clear understanding of each department's responsibilities, nor does there appear to be a mutually acceptable process for decision making and conflict resolution. In addition, DMH supervisors do not communicate DMH objectives adequately to DMH jail staff, which diminishes DMH's ability to provide adequate mental health care in the Jail.
J. Inadequate Mental Health Quality Assurance
The lack of any quality assurance program for mental health services in the Jail prevents the Jail from making itself aware of problem events and issues, understanding their causes, and developing mechanisms to avoid preventable injury and death. Although the County states that the Jail's Chief Physician "prepares documentation for his [mortality] findings," and that an overview of deaths is completed annually, Response at 33, this written material is not an adequate mortality review. We were told by the Jail's Chief Physician during our tour that written mortality reviews are never completed. Moreover, as the County appears to concede, Response at 9, the mental health documentation necessary to support a quality assurance system does not even exist in at least one facility, SBI.
The Los Angeles County diversion programs, Systemwide Mental Assessment Response Team (SMART) and Mental Evaluation Team (MET), and the County court/alternative sentencing programs, are effective in diverting mentally ill offenders from the Jail system, decreasing strain on the Jail, and connecting individuals with mental illness to the mental health services in the community. In addition, these programs can provide valuable training to deputies about mentally ill inmates, as exhibited by the Jail's new program of having deputies "ride-along" with MET.
From our review of documents provided by the Jail and from conversations with officers on MET and SMART, it appears that many law enforcement officers may not be aware of MET and SMART. Education for officers regarding how to utilize these programs would increase the programs' value. The Jail's new ride-along policy for deputies working with mentally ill inmates will likely assist in educating officers about how to use the diversion programs.

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III. RECOMMENDED REMEDIAL MEASURES
1. Each inmate entering the Jail should be individually and privately asked questions appropriate to determine whether the inmate has or had a mental illness, has attempted suicide, or has suicidal propensities. This screening should be completed by an appropriately trained individual and should be documented on the medical services data base form, or comparable medical screening device, for every incoming inmate. The Jail's screening process should not rely on an inmate self-reporting his or her mental illness in a group setting.
2. An adequate and timely mental health evaluation, including a medical evaluation, should be completed and properly documented by a qualified and appropriately trained professional for each inmate screened positive for possible mental illness. Incoming inmates in need of crisis mental health care should receive it immediately upon intake. A reasonably quiet and private area should be available for the mental health evaluation at intake.
3. The Jail should ensure continuity of treatment to individuals identified as mentally ill prior to entering the Jail. Inmates identified as mentally ill at holding facilities or elsewhere, or already receiving psychotropic medications, should have this treatment continued uninterrupted upon entering the Jail.
4. Mental health staff should make rounds in non-mental health housing modules in all facilities on a regular basis to identify inmates who may have been missed during screening or have decompensated while in jail. Mental health rounds should include pre-classification housing, administrative segregation, and other special housing areas, as well as general population housing. The Jail should facilitate and encourage communication between deputies and mental health staff in order to ensure that inmates in need of mental health services are referred to Mental Health. This referral system should allow and encourage referral of all inmates with apparent mental illness to receive mental health services, regardless of whether the inmate's mental illness is disruptive to the Jail (e.g., severely depressed or withdrawn inmates). The Jail should institute a confidential self-referral system by which inmates can request mental health care without revealing their request to correctional officers.

MISSING PAGE
Civil Rights Litigation Clearinghouse, http://clearinghouse.wustl.edu. Document JC-CA-0002-0003, Findings Letter, CRIPA Investigation of
Mental Health at the Los Angeles County Jail.
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12. The County should ensure a sanitary and humane environment for all mentally ill inmates and all inmates housed in mental health housing. This includes, but is not limited to, seclusion and isolation units and cells, which may house inmates with mental illness.
13. The County should ensure that all inmates with mental illness or housed in mental health housing receive adequate recreation, exercise, access to courts, and shower time. Inmates with mental illness or housed in mental health housing should not be denied access to recreation, exercise, showers, privileges, services, programs, education, or work, based solely on their status as mentally ill or on their placement in mental health housing. The determination that an inmate with mental illness poses a clinical risk of dangerousness to self or others.that precludes the provision of any right, service or program normally afforded to a general population inmate, should be made by a qualified professional on an individual basis and should be recorded in the inmate's file.
14. Inmates with mental illness should not be dressed in • special clothing identifying them as mentally ill.
15. Inmate trusties should never be placed in a supervisory position or used as escorts for mentally ill inmates or inmates in mental health housing. Inmate trusties should be carefully selected and screened before being assigned trusty positions. Where trusties are allowed to work in mental health housing, they should be closely monitored.
16. Staff should not be permitted to use derogatory language towards mentally ill inmates. Allegations of derogatory language towards mentally ill inmates should be promptly and thoroughly investigated. Staff using derogatory language or otherwise taunting or abusing mentally ill inmates should be promptly and appropriately disciplined.
17. Staff should not be permitted to physically or mentally abuse inmates with mental illness. Allegations of abuse of mentally ill inmates or inmates in mental health housing should be promptly and thoroughly investigated and staff members found to have abused inmates should be promptly and appropriately disciplined.
18. The Jail should create and/or fill staffing positions to provide the following care:

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a. Adequate psychiatric care, including: evaluating inmates for mental health services needs; admission into inpatient facilities; and prescribing, monitoring and documenting medication administration. All facilities should have a psychiatrist available, at least by telephone, twenty-four hours per day to evaluate and prescribe psychotropic medications in emergency situations. Psychiatric evaluation of inmates in the Jail requesting mental health care should be completed on a timely basis.
b. Adequate twenty-four hour medical and mental health screening of all incoming inmates at all intake/reception areas.
c. Adequate evaluation on a timely basis of inmates who screen positive for possible mental illness, at all intake/reception areas.
d. Adequate twenty-four hour crisis intervention, including transfer to special medical housing units, administration of psychotropic medications, provision of therapy treatment, and special observation, at all facilities.
e. Adequate correctional assistance to mentally ill inmates to ensure that they receive adequate exercise/recreation and hygienic care; that trusties are never used to escort or supervise mentally ill inmates; and that adequate suicide/mental health observation is maintained on a twenty-four hour basis.
f. Adequate mental health treatment to all mentally ill inmates, including therapy, preparation of individual treatment programs, discharge/transfer planning, and administration of medications, seven days per week at all facilities.
g. Adequate twenty-four hour care in all inpatient units, including, but not limited to, suicide observation and appropriate monitoring and documentation of physical restraints, and exercise at least every two hours for inmates in restraints.
h. Adequate clerical, supervisory and administrative assistance to support mental health services and assist in ensuring adequate documentation, supervision, coordination and communication of mental health services at all Jail facilities.

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All staff should be properly trained and qualified for every function/duty they are expected to perform. Staffing should include sufficient numbers of bilingual clinicians trained to provide mental health care, including evaluations and therapy, to all inmates who do not speak sufficient English.
19. The County should implement mandatory pre- and continuing in-service training for correctional staff in the identification and custodial care of mentally ill inmates, including, but not necessarily limited to: interpreting and responding to aberrant or bizarre behaviors, recognizing and responding to indications of suicidal thoughts, proper suicide observation, recognizing common side-effects of psychotropic medications, professional and humane treatment of mentally ill inmates, and response to mental health crises, including suicide intervention and cell extractions. Officers assigned to mental health modules should receive more advanced training than those assigned to non-mental health housing.
20. The County should create and implement a management information system that allows prompt, up-to-date, and complete access to every inmate's medical/mental health record at all facilities, twenty-four hours per day. There should be a single, integrated medical/mental health record for each inmate rather than a separate record at each facility.
21. Documentation in inmates' medical/mental health records should provide complete, accurate, and legible information regarding an inmate's mental health, including but not limited to: assessments, treatment planning, administration and effect of medications, requests for and results of laboratory tests, and inmate progress or decompensation.
22. The Jail's inmate tracking system should permit mental health and correctional staff to locate promptly specific mentally ill inmates. The tracking system should also permit mental health or correctional services to ascertain quickly and accurately the total number of inmates receiving mental health care, including psychotropic medications, or housed in mental health housing.
23. Communication between the Jail's facilities should allow for consistent classification and treatment of inmates with mental illness. Sending facilities should notify receiving facilities when they are sending an inmate with mental illness. The Jail should develop a

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system to classify inmates consistently between facilities in order to minimize transfers due to disagreement between facilities regarding proper classification.
24. Suicide observation cells and dormitories should be maintained in a manner that is safe and will not exacerbate a suicidal inmates' mental condition. Inmates under suicide observation should be housed within sight and sound contact of staff.
25. Suicide watch procedures should be modified to provide for five minute and one-on-one suicide watch as well as fifteen minute suicide watch. Observation should be documented.
26. The County should ensure that an inmate observed to be potentially suicidal receives immediate crisis intervention, including placement in a safe setting, and is evaluated in a timely manner by a qualified mental health professional to determine whether and what level of suicide observation is required. An inmate under suicide observation should be evaluated by a qualified mental health professional prior to being removed from mental health observation.
27. Suicide intervention procedures should permit correctional staff to administer appropriate first-aid measures immediately. All correctional officers should be trained in first aid and cardiac pulmonary resuscitation, cutdown techniques and emergency notification procedures in the event of hanging. Officers should be permitted to enter cells singly under some circumstances and should have cut down tools available.
28. The Jail should implement and document a continuous quality improvement program for mental health services in the Jail. This program should monitor the quality of mental health care, through, for example, clinical review of mental health records and peer review. The program should specify the procedures for medical and administrative review in the event of suicides, suicide attempts, mutilations, and other critical incidents. Chart reviews, mortality reviews, deliberations, and subsequent actions taken, should be thoroughly and accurately documented. The continuous quality improvement program should ultimately improve all aspects of mental health care in the Jail.
29. The County should continue its diversion and court alternative sentencing programs, and if possible expand

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:

these programs, to reduce the number of mentally ill individuals unnecessarily detained in the Jail. County law enforcement officers should be educated regarding the availability of these programs and encouraged to use MET and SMART.

IV. RESOLUTION OF ISSUES

Pursuant to the Civil Rights of Institutionalized Persons Act, the Attorney General may initiate a lawsuit to correct deficiencies at an institution forty-nine days after appropriate officials are notified of them. 42 U.S.C. § 1997b(a)(l). We will, however, seek to resolve the issues raised above in the same cooperative spirit that has characterized the investigation to date. We look forward to your response to these findings and recommendations and to detailed discussions leading to a final resolution of these issues.

Isabelle Katz Pinzler Acting Assistant Attorney General
Civil Rights Division
cc: Sheriff Sherman Block Los Angeles Sheriff's Department
Ms. Areta Crowell Director Los Angeles County Department
of Mental Health
DeWitt Clinton III, Esquire Los Angeles County Counsel
Chief Barry King Los Angeles Sheriff's Department

 
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Memorandum of Agreement Between the United States and Los Angeles County, California Regarding Mental Health Services at the Los Angeles County Jail

TABLE OF CONTENTS I. INTRODUCTION II. DEFINITIONS III. GENERAL PROVISIONS IV. SUBSTANTIVE PROVISIONS
A. Intake B. Evaluation C. Referrals D. Treatment E. Medication Administration F. Environmental Conditions G. Suicide Prevention H. Medical Records and Communication I. Staffing and Training J. Quality Assurance K. Abuse and Mistreatment V. CONSTRUCTION, IMPLEMENTATION, AND MONITORING OF COMPLIANCE

I. INTRODUCTION
In August of 1996, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 et seq., the United States Department of Justice ("DOJ") toured the Los Angeles County Jail ("the Jail") with experts in the field of correctional mental health services. On September 5, 1997, DOJ issued a

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letter reporting its findings based on the tour of its experts, the County's response to the tour, and the additional information received. DOJ concluded that mental health care at the Jail violated the inmates' constitutional rights.
In its findings letter, DOJ detailed numerous alleged constitutional deficiencies with regard to mental health care, including inadequate (1) intake screening and evaluation, (2) diagnosis, (3) referral to mental health professionals, (4) treatment plans, (5) administration of medications, (6) suicide prevention, (7) tracking and medical record keeping, (8) staffing, (9) communication, and (10) quality assurance. The report also noted that the County had allegedly mistreated and abused mentally ill inmates, including using excessive force and improper restraint practices.
Since DOJ issued its findings letter, the parties have attempted to work cooperatively to resolve the concerns outlined in the letter. After its initial tour in June of 1996, DOJ has conducted several follow up investigatory inspections of the Jail and has continued to find inadequate mental health services.
The parties to this Memorandum of Agreement ("the Agreement") recognize the constitutional rights of inmates confined at the Jail. After discussions and negotiations, and in order to avoid potential litigation concerning the mental health services at the Jail, the parties have agreed to the provisions set forth in this Agreement. The parties have engaged in good-faith negotiations to reach this Agreement. The parties agree that the provisions of this Agreement will ensure that reasonable and adequate mental health care services are provided at the Jail.
Fulfillment of the terms of this Agreement, voluntarily negotiated and entered into by DOJ and Los Angeles County, is intended to resolve all remaining issues relating to mental health services at the Jail.
II. DEFINITIONS
1. "The Parties" shall refer to the County and the United States of America.
2. "The County" shall refer to Los Angeles County, the Los Angeles County Sheriff's Department; the Los Angeles County Department of Mental Health, and the agents and employees of the Sheriff's Department and Department of Mental Health.
3. The term inmate(s) shall refer to one or more individuals, male and/or female, sentenced to, incarcerated in, detained at, or otherwise confined at the Jail.
4. "Qualified professional" shall refer to an individual qualified to render the requisite and appropriate care, treatment, judgment(s), training and service, based on credentials recognized in the specific field.
5. "Competency-based training" means training deemed successfully completed by a staff member only when that staff member demonstrates to a trainer his or her ability or competency to perform a specified skill through an active hands-on demonstration of such skill.
III. GENERAL PROVISIONS
6. The facilities that are at issue in this case are "institutions" as that term is defined in 42 U.S.C. § 1997(1).

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7. Los Angeles County owns and funds the operation of the Jail. In their official capacity, the Sheriff of Los Angeles County, and the Los Angeles County Department of Mental Health are responsible for overseeing and/or providing mental health services to the inmates at the Jail.
8. The County is responsible for assuring the fulfillment of the responsibilities and obligations imposed by this Agreement upon County employees, independent contractors, departments or other sub-units of the County government.
IV. SUBSTANTIVE PROVISIONS
A. Intake
1. The County will maintain adequate twenty-four hour mental health screening of all inmates at the Inmate Reception Center ("IRC").
2. Each inmate entering IRC shall be individually and privately asked questions appropriate to determine whether the inmate has or had a mental illness, has attempted suicide, or has suicidal propensities.
3. Intake screening at IRC shall be completed by an appropriately trained individual, and shall be documented in the appropriate medical record for incoming inmates.
4. Incoming inmates screened at IRC who are in need of emergency mental health care shall receive such care immediately after intake at IRC.
5. The Jail's screening process for mental illness shall not rely solely on an inmate's report that he or she does not have a mental illness.
6. A reasonably quiet and private area shall be available for the mental health evaluation at IRC.
B. Evaluation
7. Within 24 hours of admittance to IRC (excluding weekends and legal holidays as long as an urgent evaluation is not indicated), the County shall provide an adequate mental health care evaluation of inmates who screen positive for possible mental illness at IRC. Within 72 hours of admittance to IRC, the County shall provide a mental health care evaluation to inmates admitted to IRC on the weekends or legal holidays (unless an urgent evaluation is indicated). If the evaluation identifies a serious mental illness, the evaluation shall result in a brief initial treatment plan.
8. A qualified and appropriately trained professional shall, within 14 days of admittance to IRC, complete and properly document an adequate mental health evaluation, including a medical evaluation if necessary, for each inmate screened positive for possible mental illness.
C. Referrals
9. The County shall refer general population inmates who may be mentally ill to a mental

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health professional.
10. Mental health staff shall make weekly rounds in locked down non-mental health housing modules (e.g. administrative segregation, disciplinary segregation) at the Jail to identify inmates who may have been missed during screening or who have decompensated while in the Jail.
11. The Jail will maintain a confidential self-referral system by which inmates can request mental health care without revealing the substance of their request to correctional officers.
D. Treatment
12. The County shall provide adequate mental health treatment to all inmates determined to be mentally ill.
13. The County shall ensure continuity of appropriate medicine to individuals identified as mentally ill who were receiving medicine prior to entering the Jail.
14. An individual, comprehensive, written, mental health treatment plan shall be prepared within 14 days by a qualified and appropriately trained mental health professional for every seriously mentally ill inmate. Changes to and compliance with the treatment plan shall be accurately documented in the inmate's medical/mental health record.
15. The County shall ensure adequate therapy and counseling for all mentally ill inmates who need such care. This includes adequate space for treatment, adequate staff to provide treatment, and adequate therapeutic programming.
16. The County shall provide adequate twenty-four hour crisis intervention for inmates, including transfer to special medical housing units, administration of psychotropic medications, provision of therapy treatment, and special observation, for inmates.
17. Inmates shall have access to appropriate licensed in-patient care when clinically appropriate.
18. Unless contraindicated, the County shall ensure that all inmates with serious mental illness and housed in the most intensive levels of outpatient mental health housing be offered at least 10 hours per week of structured out of cell therapeutic or programmatic activity and 15 hours of recreation per week. Unless clinically contraindicated or the inmate is in administrative segregation, no inmate in the Twin Towers Correctional Facility ("TTCF") with serious mental illness shall be locked down more than 19 hours per day. Inmates with mental illness or housed in mental health housing shall not be denied jail privileges or programs based solely on their status as mentally ill or on their placement in mental health housing.
19. The determination that, as a result of his or her mental illness, an inmate poses a clinical risk of dangerousness to self or others that precludes the provision of any right, service or privilege, shall be made by a qualified professional in consultation with correctional staff on an individual basis and shall be recorded in the inmate's records.
20. Inmate trusties shall never be placed in a supervisory position or used as escorts for

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mentally ill inmates or inmates in mental health housing. Inmate trusties shall be carefully selected and screened before being assigned trustie positions. Where trusties are allowed to work in mental health housing, they shall be closely monitored.
E. Medication Administration
21. The County shall ensure that a full range of appropriate psychotropic medications is available at the Jail and that psychotropic medications are properly prescribed, monitored and documented by appropriately trained mental health professionals.
22. The County shall ensure that all medications are appropriately administered and monitored by licensed health care professionals.
F. Environmental Conditions
23. The County shall ensure a sanitary and humane environment for all mentally ill inmates and all inmates housed in mental health housing. This includes, but is not limited to, seclusion and isolation units and cells which may house inmates with mental illness.
24. The County shall maintain a sufficient amount of adequate mental health housing at every appropriate level of care for every inmate in need of mental health housing. However, it is not necessary that every mentally ill inmate be segregated into mental health housing.
G. Suicide Prevention
25. The County shall ensure that inmates observed to be potentially suicidal receive appropriate crisis intervention, (including placement in a safe setting and evaluations in a timely manner), by a qualified mental health professional to determine whether and what level of suicide observation is required.
26. An inmate under suicide observation shall be evaluated by a qualified mental health professional prior to being removed from mental health observation.
27. Suicide intervention procedures shall permit correctional staff to administer appropriate first-aid measures immediately. All correctional officers shall be trained in first aid and cardiac pulmonary resuscitation ("CPR") cutdown techniques and emergency notification procedures in the event of hanging. Officers shall have cut down tools available.
28. Suicide watch procedures shall provide for fifteen minute suicide watch and may be modified to provide for five minute suicide watch with the concurrence of custody administration and staff. Suicide watch must be documented.
29. Suicide observation cells and dormitories shall be maintained in a manner that is safe and will not exacerbate a suicidal inmate's mental condition. Inmates under suicide observation should be within sight of staff.
H. Medical Records and Communication
30. Documentation in an inmate's medical/mental health record shall provide complete, accurate, and legible information regarding an inmate's mental health, including but not

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limited to: assessments, treatment planning, administration and effect of medications, requests for and results of laboratory tests, and inmate progress or decompensation.
31. The County may create and implement a computer system that allows prompt, up-todate, and reasonable access to every inmate's medical/mental health record who is housed at TTCF, twenty-four hours per day.
32. There may be an electronic integrated medical/mental health record for each inmate.
33. The County shall create and implement a Management Information System adequate to manage the inmates' mental health records.
I. Staffing and Training
34. The County shall provide sufficient mental health staffing to ensure timely access to adequate mental health treatment and meet the obligations and provide the services listed in this Agreement. Except for staffing for the women's case load population and the Forensic Inpatient Program, mental health staffing shall be no lower than one psychiatrist per 100 inmates who require medication. Staffing for the women's case load population shall be enhanced due to higher utilization rates of mental health services. Staffing for the Forensic Inpatient Program shall ensure timely access to adequate treatment and shall minimally meet licensure standards currently governing such program.
35. A psychiatrist shall be available, at least by telephone, twenty-four hours per day to evaluate and prescribe psychotropic medications in emergency situations.
36. Staffing shall include sufficient numbers of bilingual clinicians trained to provide mental health care, including evaluations and therapy, to all inmates who do not sufficiently speak or understand English.
37. The County shall provide adequate clerical, supervisory and administrative assistance to support mental health services and assist in maintaining adequate documentation, supervision, coordination and communication of mental health services at the Jail.
38. All staff shall be properly trained for every function/duty they are expected to perform.
39. The County shall implement mandatory orientation and continuing competency based in-service training for correctional staff in the identification and custodial care of mentally ill inmates, including, but not necessarily limited to: (a) interpreting and responding to aberrant or bizarre behaviors, (b) recognizing and responding to indications of suicidal thoughts, (c) proper suicide observation, (d) recognizing common side-effects of psychotropic medications, (e) professional and humane treatment of mentally ill inmates, and (f) response to mental health crises, including suicide intervention and cell extractions. The County shall require annual refresher training.
40. The County shall document all training.
J. Quality Assurance
41. The County shall implement and document a continuous quality improvement program

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for mental health services in the Jail. The continuous quality improvement program shall monitor the quality of mental health care.
42. The quality assurance program shall specify the procedures for medical and administrative review in the event of suicides, suicide attempts, mutilations, and other critical incidents.
K. Abuse and Mistreatment
43. Staff shall not be permitted to physically, verbally, or mentally abuse inmates with mental illness. Allegations of abuse of mentally ill inmates or inmates in mental health housing shall be promptly and thoroughly investigated and staff members found to have abused inmates shall be appropriately disciplined.
44. Physical restraints used for mental health therapeutic reasons must be consistent with community standards of care.
V. CONSTRUCTION, IMPLEMENTATION, AND MONITORING OF COMPLIANCE
45. This Agreement shall become effective on signature by the parties as a Memorandum of Agreement only and shall not be considered or constructed as a Consent Decree.
46. The County may hire an independent expert psychiatrist(s) or consultant(s) as a Monitor(s) to assess compliance with the Agreement. The Monitor(s) shall jointly be selected by the County and DOJ. The County shall provide such Monitor(s) with adequate assistance to make an assessment of compliance, including hiring additional independent expert consultants. Any additional expert consultants must be approved and be acceptable to both the County and DOJ. The County shall pay the Monitor(s) and any additional expert consultants for such monitoring services. The Monitor(s) shall submit a report to DOJ and the County assessing compliance with this Agreement within 45 days of any on-site compliance visit and shall make such on-site assessments and report at least twice annually. The Monitor(s) shall not be replaced without approval of the United States, and any Monitor(s) or additional consultants shall not be selected without the written consent of the United States and the County. In the event the County chooses not to select a Monitor(s) or the County and the United States are unable to agree upon a Monitor(s), the United States shall continue its current investigation of the Jail pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, and the County shall continue providing the United States and its expert consultants with full and open access as described in Paragraphs 47-50 of this Agreement.
47. Every ninety (90) days following the signing of this Agreement and until the Agreement is fulfilled, the County shall submit to the Monitor(s) and the United States a status report stating whether the County is complying with each and every term of this Agreement. The report shall include, as appropriate, documentation, certifications, receipts and such other information as requested by the Monitor(s) and/or United States to assist in the evaluation of compliance with the terms of this Agreement.
48. The status reports, at a minimum, shall describe the actions that the County has taken up to and including the current reporting period to implement this Agreement, and shall specifically refer to the provisions of this Agreement upon which they report.

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49. The County shall maintain sufficient records to document their compliance with all terms of this Agreement. The County shall also maintain any and all records required by or developed under this Agreement.
50. The Monitor(s) and/or DOJ shall have access to and, upon request, receive copies of any document and/or any databases directly related to the implementation of this Agreement, except confidential peace officer personnel files. The Monitor(s) and/or United States shall have access to Jail staff, including private interviews with consenting inmates, and staff, as necessary to assess compliance with this Agreement.
51. The County shall implement the terms of this Agreement. This Agreement shall become subject to termination at any time two years subsequent to its signing if the County has substantially complied with all requirements of this Agreement and substantial compliance has been maintained for at least one year.
52. Nothing in this Agreement shall preclude DOJ from initiating a civil action pursuant to 42 U.S.C. § 1997.
53. If the County expands the Jail or outsources any of the services covered under this Agreement, such expanded facility and/or outsourced services shall be covered under this Agreement.
Agreed to by:
For the County
LEROY D. BACA Sheriff Los Angeles County
MARVIN J. SOUTHARD Director Department of Mental Health Los Angeles County
KEVIN C. BRAZILE Assistant County Counsel Los Angeles County
For the United States
RALPH F. BOYD, JR. Assistant Attorney General Civil Rights Division
DEBORAH W. YANG United States Attorney Central District of California
STEVEN H. ROSENBAUM

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Chief Special Litigation Section
MELLIE H. NELSON Deputy Chief Special Litigation Section
WILLIAM G. MADDOX JIM EICHNER Attorneys Special Litigation Section Civil Rights Division U.S. Department of Justice P.O. Box 66400 Washington, DC 20035

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 U.S. Department of Justice
JMS:LES:CST:KKD:RMLM:JH:EJ:PZ DJ 168-12C-43
June 4, 2014
VIA ELECTRONIC AND FIRST-CLASS MAIL
Anthony Peck, Esq. Deputy County Counsel 4700 Ramona Blvd. Monterey Park, CA 91754
Stephanie Jo Reagan, Esq. Principal Deputy County Counsel Los Angeles County Department of Mental Health 550 South Vermont Avenue Los Angeles, CA 90020
RE: Mental Health Care and Suicide Prevention Practices at Los Angeles County Jails
Dear Mr. Peck and Ms. Regan:
We write to report our conclusions with regard to Los Angeles County’s compliance with the Memorandum of Agreement (“MOA”) that requires adequate mental health care and suicide prevention at the Los Angeles County Jail System (“Jails”). Since the entry of the MOA twelve years ago, there has been significant improvement in the delivery of mental health services. However, serious systemic deficiencies remain with regard to some aspects of the Jails’ mental health program. Based on our review, we conclude that the County violates the Eighth and Fourteenth Amendments of the United States Constitution by failing to provide adequate mental health services and protect prisoners from serious harm and risk of harm at the Jails due to inadequate suicide prevention practices. Consistent with the practice of our long-standing investigation of the Jails pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997, we write to update our conclusions of September 5, 1997 regarding mental health treatment and suicide prevention at the Jails and to discuss the minimum remedial steps necessary to address the identified deficiencies.
We notified the County of continuing weaknesses in the Jails’ mental health services during the 12-year tenure of the MOA, including through numerous reports from the Department of Justice’s long-standing experts, Joel Dvoskin, Ph.D., and Jeffrey L. Metzner, M.D. In the face of these ongoing problems and the ineffectiveness of the MOA to ensure that prisoners with mental illness are protected from suicide and other harms, we propose to enter into negotiations with the County regarding a court enforceable agreement to substitute for certain critical terms of

the MOA. The affected MOA provisions are: Suicide Prevention (§§ IV.G.25-29), Intake (§ IV.A.5), Referrals (§ IV.C.9), Treatment (§ IV.D.12 & 15-19), Medication Administration (§ IV.E.22), Environmental Conditions (§ IV.F.23-24), and Quality Assurance (§ IV.J.42). We are prepared for the following provisions related to mental health care and treatment to continue as part of the MOA: Evaluation (§ IV.B.7), Referrals (§§ IV.C.10-11), Treatment (§§ IV.D.13), Medication Administration (§ IV.E.21), Staffing and Training (§§ IV.I.34-35), and Quality Assurance (§ IV.J.41). As discussed below, the Department of Justice will cease monitoring those MOA provisions with which the County has achieved and maintained substantial compliance: §§ IV.A.1-4, A.6, B.8, D.14, D.20, H.30-33, and I.36-40. Despite our conclusions regarding constitutional violations at the Jails, we wish to commend the County on the considerable progress it has made in terms of mental health services at the Jails, especially with respect to increased mental health staffing, since our initial review in 1997.
The Department of Justice acknowledges that many of the prisoners confined to the Jails who have mental illness were failed by other systems. The delivery of mental health services in the corrections environment is difficult and presents unique challenges. Many of the prisoners may well be safely and more effectively served in community-based settings at a lower cost to the County. The remedies that we seek in order to ensure that the conditions in the Jails meet the minimum required by the Constitution – that ensure that prisoners are safe and that staff are not placed at an unreasonable risk of harm – can be implemented more effectively if the number of prisoners needing mental health services is reduced.
In considering solutions to this problem, we strongly encourage the Sheriff, the Mental Health Director, and the County to consider alternatives to incarceration for those prisoners with mental illness who can be supervised in the community without compromising public safety. We understand that the County Board of Supervisors recently voted unanimously to undertake an analysis of diversion programs for arrestees with mental illness in the County and the availability of beds in a non-jail setting to support the population.1 The United States applauds the County’s interest in increased community-based treatment and alternatives to incarceration for individuals with mental illness. While the United States cannot require measures to address the population pressures, we would consider any steps taken voluntarily as an important part of the solution to the issues we address in this letter. These measures would also be consistent with meaningful steps the County is taking to increase rehabilitative options for youth in the community as part of our amended MOA with the County involving its youth probation camps.
Our conclusions with regard to suicide prevention and mental health treatment at the Jails are summarized below, followed by our compliance assessment of the remaining MOA provisions.
I. SUMMARY OF CONCLUSIONS
We made the following factual determinations:

1

Abby Sewell, L.A. County Supervisors Vote to Move Forward on $2-billion Jail Plan, L.A. Times, May 6,

2014, available at http://www.latimes.com/local/lanow/la-me-ln-jail-plan-vote-20140506-story.html#.

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• There is inadequate mental health care to prevent prisoners from becoming suicidal, to identify suicidal prisoners, or to prevent prisoners from going into crisis.
• The County has failed to take necessary steps to address a dramatic increase in the number of suicides and suicide incidents in the Jails. In 2012, there were four completed suicides. In 2013, there were ten prisoner suicides and one more suicide in January 2014. Based on our review, many of the suicides that occurred in the last two years were preventable. In addition, the Jails reported a more than 20 percent increase in suicide “incidents” in 2013, when a total of 366 suicide “incidents” were recorded. While the Jails’ characterization of self-harm is undefined and inconsistent, it appears that “incidents” includes suicide attempts evidencing a discernible intent to commit suicide and those requiring a certain level of medical intervention after the suicidal behavior is discovered. Indeed, one of these critical incidents occurred at the Jails at least every seven days from January through September 2013. The number of suicides and selfharming behaviors, together with the numerous procedural and policy lapses surrounding many of these incidents, give us reasonable cause to believe that prisoners remain at significant risk of serious harm.
• The Jails do not provide appropriate custodial supervision for prisoners, including those on the mental health caseload and those who have been identified as having a heightened risk of suicide. Remarkably, about 44% of those who self-harmed were housed in mental health housing at the time of the incident, indicating a lack of adequate custodial supervision for even those prisoners who require higher levels of attention. We found repeated lapses in the Jails’ safety checks, which evidence a serious risk of harm to prisoners from suicidal behavior, as well as violence and other prohibited behavior.
• Prisoners with mental illness do not receive adequate supervision and are housed in conditions that present, rather than prevent, a risk of suicide. Deputies do not consistently perform timely, thorough safety checks. Living conditions in general are deficient (dimly lit, vermin-infested, noisy, unsanitary, cramped and crowded), most acutely at Men’s Central Jail but also at the Century Regional Detention Facility and in certain areas of the Twin Towers Correctional Facility, and create an environment that may contribute to prisoners’ mental distress. Often, suicide precautions are punitive in nature, even depriving some prisoners of a mattress to sleep on.
• Custody staff, the Medical Services Bureau, and the Department of Mental Health often operate in silos when addressing suicide incidents and risks, maintaining separate charts and even separate investigatory reports. The lines of communication between these entities are flawed, and at times non-existent. Our review of the Jails’ suicide incidents demonstrated that this lack of communication, or miscommunication, between medical, mental health, and custody staff resulted in critical breakdowns in the custody and care of prisoners at the Jails.
• In spite of the increase in suicides in the Jails, there remains a persistent failure on the part of the Jails’ command staff to critically review and appraise the contributions, intended or not, of its policies, staffing, and custody practices, to the suicides and suicide
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attempts that are occurring. Fifteen suicides in 25 months produced almost no discernible change in the Jails’ custodial practices. Critical incident reviews related to suicides are replete with inaccurate and incomplete information and do not identify or seek to remedy systemic problems. This failure to review, appraise, revise, and ultimately, to enforce the Jails’ own policies, is reflected in the overall escalation of suicide incidents and preventable prisoner deaths. This is a system failure that negates the Jails’ good custody policies and increases the risk of harm to prisoners.
These factual determinations provide us with reasonable cause to conclude that the Jails violate prisoners’ constitutional rights to be protected from harm, Farmer v. Brennan, 511 U.S. 825, 833 (1994), and serious risk of harm, Helling v. McKinney, 509 U.S. 25, 33-35 (1993).2
II. BACKGROUND
The County entered into the MOA with the United States following an investigation by the Civil Rights Division pursuant to CRIPA. CRIPA authorizes the Department of Justice to seek equitable relief where jail conditions violate the constitutional rights of prisoners in state and local detention facilities. Because a monitor was not selected to oversee the implementation of the MOA, the Department of Justice continued its investigation into conditions at the Jails with expert consultants to ensure compliance with the MOA. See MOA § V.46. The MOA does not preclude the Department of Justice from initiating a civil action under CRIPA to protect the constitutional rights of prisoners at the Jails. MOA § V.52.
As discussed below, during the 12-year tenure of the MOA, the County has achieved sustained, substantial compliance with certain provisions of the MOA. However, our compliance reviews have identified grave concerns with regard to the Jails’ suicide prevention practices and mental health treatment.3
On March 25-28 and June 25-28, 2013, we conducted on-site inspections at the Jails with our long-standing experts, Drs. Dvoskin and Metzner, to assess the County’s MOA compliance. We determined the need to conduct additional review with regard to suicide prevention at the Jails. On September 23-26, 2013 and January 7-10, 2014, we conducted on-site inspections with Margaret E. Severson, our expert consultant in suicide prevention. In conjunction with each visit, we reviewed an extensive number of documents, including policies and procedures, the Jails’ quality improvement documentation, investigative reports, incident reports, population data, staff training materials, and the Jails’ suicide review files. Consistent with our pledge of transparency and to provide technical assistance where appropriate, we conveyed our preliminary observations to County and Jail officials and legal counsel for the County and Sheriff’s Department at the close of the first three visits. At the conclusion of the January 2014 visit, we

2

Additional information and detail supporting our conclusions is included in the attached expert report of

expert Margaret E. Severson and monitoring report from Drs. Dvoskin and Metzner.

3

This letter does not address provisions in MOA § IV.K, Abuse and Mistreatment, as that subject will be

discussed in a separate letter related to our investigation of use of force and protection from harm at the Jails.

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informed County officials that we would provide detailed conclusions to the County in writing. This report details our assessment of the Jails’ MOA compliance, and non-compliance, as well as separately highlighting our conclusions on the Jails’ suicide prevention practices.
III. CONCLUSIONS OF INADEQUATE MENTAL HEALTH CARE AND SUICIDE PREVENTION PRACTICES
We conclude that Los Angeles County, including the Sheriff’s Department and the Department of Mental Health, violates prisoners’ constitutional right to adequate suicide prevention practices, which is required as a part of the Jails’ legal obligation to meet the serious mental health care needs of all prisoners. These deficiencies pose a substantial risk of serious harm to prisoners in violation of the Fourteenth Amendment’s due process protections for pretrial detainees, as well as the Eighth Amendment’s protections for those convicted of a criminal offense.4 Farmer, 511 U.S. at 832-834. In defining the scope of prisoners’ Eighth and Fourteenth Amendment rights, the Supreme Court has held that corrections officials must take reasonable steps to guarantee inmates’ safety and provide “humane conditions” of confinement. Id. at 832; Bell v. Wolfish, 441 U.S. 520 (1979) (holding pre-trial detainees protected by Fourteenth Amendment). Conditions must satisfy prisoners’ basic needs, including their needs for mental health care. Farmer, 511 U.S. at 832-834; Estelle v. Gamble, 429 U.S. 97, 103-05 (1976); Hoptowit v. Ray, 682 F.2d 1237, 1253 (9th Cir. 1982), abrogated on other grounds by Sandin v. Conner, 515 US 472 (1995); Gibson v. County of Washoe, Nev., 290 F.3d 1175, 11871188 (9th Cir. 2002). These obligations include the duty to protect prisoners against reasonable risk of self-harm. Helling, 509 U.S. at 32-34 (right to care extends to preventing “unreasonable risk of serious damage to [a prisoner’s] future health”); Conn v. City of Reno, 591 F.3d 1081, 1095–96 (9th Cir. 2010), vacated, 131 S. Ct. 1812 (2011), reinstated in relevant part, 658 F.3d 897 (9th Cir. 2011) (“A heightened suicide risk or an attempted suicide is a serious medical need.”); Cabrales v. County of Los Angeles, 864 F.2d 1454, 1461 & n. 2 (9th Cir. 1988) (applying the “deliberate indifference” standard to a § 1983 claim by the mother of a pretrial detainee who committed suicide in detention, and explaining that “the fourteenth amendment due process rights of pretrial detainees are analogized to those of prisoners under the eighth amendment”), vacated on other grounds, 490 U.S. 1087, 109 S.Ct. 2425, 104 L.Ed.2d 982 (1989), opinion reinstated, 886 F.2d 235 (9th Cir. 1989).
The most recent suicide demonstrates the Jails’ failure to take reasonable steps protect prisoners with mental illness from the risk of suicide and illustrates the systemic deficiencies in the Jails’ suicide prevention practices detailed in this letter. “Alan”5 was assessed as actively suicidal upon intake to the Jails in early 2014; he acknowledged a history of medical and mental health problems and a previous suicide attempt. The next morning, he underwent a mental health evaluation and was housed in the Twin Towers high observation unit with an order for no mattress, no sharps, and 15-minute checks. At 11:45 a.m., Alan met with a mental health supervisor and voiced thoughts of suicide, including: “I just feel like dying … I won’t care if I

4

For the sake of clarity, in this letter we refer to all individuals housed in the Jails, including pre-trial

detainees and individuals who have been convicted of a criminal offense, as “prisoners.”

5

We use pseudonyms to protect against disclosing personally-identifying information.

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die. If I had a rope I would just hang myself.” Corrections officials have an obligation to act when there is a strong likelihood that a prisoner will engage in self-injurious behavior, including suicide. Funtanilla v. Rubles, 5 Fed. Appx. 590, at **1 (9th Cir. 2001) (finding allegations that, while he was in suicide prevention cell, prison guard observed prisoner cutting his arm and left him there for two hours covered in his own blood, were sufficient to allege deliberate indifference on part of prison officials); Van Orden v. Caribou County, 546 Fed.Appx. 647, 649 (9th Cir. 2013) (“Because Bannister actively manifested her suicidality in the hours immediately preceding her suicide, we hold that the district court erred in concluding that no reasonable jury could find that Downs and Long were subjectively aware of a substantial risk of serious harm to Bannister.”). However, when Alan was apprised of potential interventions, including the punitive restrictions of suicide watch at the Jails, it was noted that he “changed his mind.”
Immediately following Alan’s interview, mental health staff noted in his electronic medical record that he should be housed with a cellmate in double-man housing and a psychiatric note reads “no longer having suicide thoughts.” Mental health staff relayed the order for doubleman housing verbally to custody staff, who then documented the order. Alan hanged himself later that day from the top bunk in his solely occupied double-man cell. When Alan was discovered, safety checks had not been completed for nearly three hours. Lemire v. California Dept. of Corrections and Rehabilitation, 726 F.3d 1062, 1076-77 (9th Cir. 2013) (holding that fact issues precluded summary judgment on Eighth Amendment failure to protect and substantive due process claims against warden and captain who knowingly withdrew all floor staff from prison building which housed mentally ill inmates, leaving inmates unsupervised for over three hours, during which time an inmate committed suicide). The Assistant Sheriff over the Jails recently indicated that several Jail practices were not followed with regard to Alan’s suicide.6 However, as discussed below, our investigation concluded that the circumstances of Alan’s death, including inadequate mental health care, deficient suicide precautions, and lax custody supervision, are far too common in the Jails.
The Jails are in the midst of a trend of ongoing systemic problems, which include: (1) supervision lapses and violations of security check policies and procedures; (2) incomplete information collection and communication in intake assessments and evaluations; (3) poor documentation in the medical records, in the deputies’ incident reports, and in the Jails’ critical incident reviews; (4) inadequate mental health treatment; (5) inattention to custody-related contributors to the suicides; and (6) an overall failure to adequately investigate and respond to the suicides that have occurred and the system failures that repeatedly come to light after a suicide.
A. Inadequate Intake Screening and Identification of Individuals with Mental Illness and at Risk for Suicide.
Constitutionally minimum standards require jails to have a program to “identify, treat, and supervise” prisoners at risk of suicide. Coleman v. Wilson, 912 F. Supp. 1282, 1298 n.10 (E.D. Cal. 1995) (noting that identifying prisoners at risk of suicide is one of the six basic

6

Rina Palta, Suicidal LA Jail Inmate, Later Found Dead, Was Left Alone for Hours, Southern California

Public Radio, May 5, 2014, available at http://www.scpr.org/news/2014/05/05/43961/la-jail-inmate-who-committed-

suicide-was-not-check/.

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components of a minimally adequate prison mental health care delivery system). Identification of persons at risk for suicide and self-injury can and does occur at any point during their incarceration. However, formal mechanisms to identify suicidal prisoners must be in place and a regular part of the custodial process that begins at the pre-booking phase of a person’s detention and extends through the initial screening, classification, the history and physical examination, and the prisoner and staff sick call request process. Madrid v. Gomez, 889 F. Supp. 1146, 125657 (N.D. Cal. 1995) (“While a functioning sick call system can be effective for physical illnesses, there must be a ‘systemic program for screening and evaluating prisoners in order to identify those who require mental health treatment.’”) (internal quotations omitted).
After years of consultation with and technical assistance from Drs. Dvoskin and Metzner, the Jails’ mental health and suicide prevention policies and procedures are largely adequate as written, including intake forms for screening for mental health needs and prisoners’ suicide risk. However, implementation and practice diverge from the written policies in a manner that poses a risk to prisoners.
1. The Jails’ Screening Process Inappropriately Excludes Some Prisoners.
The Department of Justice did identify at least one particularly critical deficiency with regard to the Jails’ intake screening policies. It appears some prisoners are excluded or delayed from the Jails’ screening process by policy when they are held in one of the Jail system’s lockup facilities. In 2012, two days after his arrest, “Brian” hanged himself in the Century Regional Detention Facility (“CRDF”) lockup. As a matter of policy, Brian did not receive a mental health screening upon his arrest or admission to a pre-arraignment housing unit in CRDF. The official arrest report indicates that Brian was detained on domestic violence charges for reportedly choking his victim and stating “you don’t think I won’t kill you right now, right here? I have nothing to live for!” However, it is unclear if any of this information was actually passed on to the Jails’ staff when he was admitted, as the arresting/transporting officer’s space for comments on the Jails’ Arrestee Medical Screening Form is blank and the questions about mental health and suicide conditions are marked “no.” Brian had the word “Suicidal” as part of two tattoos, the significance of which is unknown because there is nothing in the death review documents that refers to or attempts to explain these tattoos. The Jails’ electronic medical record includes information from a previous intake screening two months prior to Brian’s death, which states that he reported a history of medical, mental health, and substance abuse problems, including diagnoses of schizophrenia and depression, and auditory hallucinations. The Jails’ policy omitting Brian from the screening is constitutionally deficient. Coleman, 912 F. Supp. at 1298. In this case, given Brian’s significant mental health history and the suicidal statements he made upon his arrest, an adequate screening may have prevented his death.
2. The Jails Do Not Obtain or Disseminate Complete Information Upon Intake.
There are a series of screenings upon intake to the Jails, which are designed to identify prisoners who are in need of medical or mental health care or who may be at risk for suicide or self-harm. Unfortunately, often they are not filled out completely or adequately incorporated into the prisoners’ electronic medical record. As a result, intake screening is insufficient to identify and protect individuals at risk for suicide.
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When a prisoner is brought into the Jails, the arresting or transporting officer is asked to complete the “Outside Agency Medical Declaration” on the Arrestee Medical Screening Form by answering three questions, including: “Is any person in your agency aware of any medical or mental condition, prescribed medication taken by or in possession of this arrestee, or any medical problem or injury regarding this arrestee?” In reality, an answer to this question is rarely found on the form. Out of a sample of 26 suicide incidents reviewed by the Department of Justice, 16 of these Agency Declarations are entirely blank, and an additional seven only list the prisoner’s name. While the instructions for completing this portion of the form have changed slightly over time, the rate of completion does not appear to have changed. It appears there is no enforcement of the requirement that arresting or transporting officers fill out this form.
The Arrestee Medical Screening Form also asks the arresting officer to describe the prisoner’s behavior, whether medical treatment was sought, and whether the prisoner has a history of mental illness or suicidal behavior. It is unclear exactly who is expected to give all of the information and who actually completes the form. Importantly, this form is not made part of the Jails’ electronic medical record; instead, it is placed into a “hard chart” that becomes part of the Medical Services Bureau’s property. The Jails’ mental health staff are not automatically informed of the contents of the hard chart and the breakdown of communications can contribute to the trajectory of prisoner self-injury. Our review of completed suicides from 2012 and 2013 indicates that arresting officers often have information that could prove valuable to the Jails’ custody and mental health staff in their suicide prevention efforts. Moreover, when the arresting officers do have information that indicates a prisoner is at a heightened risk of suicide, the officers have a legal obligation to report such information. Conn, 591 F.3d at 1097 (finding that officers’ failure to report to jail that prisoner wrapped a seatbelt around her neck and made suicidal statements en route to the jail constituted a factual issue as to whether the officers’ omissions caused the eventual suicide).
For example, “Christopher” committed suicide at the Jails in 2013. Christopher was admitted to the Jails, six days before his death, after being arrested at his home while reportedly drunk, combative, and actively suicidal. Christopher hanged a noose in his garage but was stopped from hanging himself by a family member and, before finally being subdued by officers after a series of forceful attempts to control him, reportedly said he was going to “commit suicide by cop.” The police report states that he was placed on a suicide watch at a local police lockup, where he was taken immediately after his arrest. Christopher’s Arrestee Medical Screening Form reads “no” throughout the first page, but the second page references his suicidal thoughts. This form was not placed into or referenced in the electronic medical record; instead, it was filed in the hard chart. It appears that the Jails’ mental health staff also did not receive the Behavioral Observation and Mental Health Referral form filled out by lockup staff. Like the arresting agency screening, that form was placed in the hard chart. Therefore, the Jails’ mental health staff were apparently not aware of the critical circumstances of Christopher’s arrest at the time of his mental health intake evaluation. Later that day, a nurse made an entry into the electronic medical record that Christopher “made statements that he wanted to kill himself,” referencing the arrest report, but mental health staff never received the full arrest documentation relating Christopher’s recent suicidal actions and statements. Christopher denied suicidal ideation, past and present, on intake. He was initially assigned to high observation mental health housing, but
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was transferred to a medical isolation cell three days later due to a tuberculosis scare. Shortly thereafter, he was found hanging from a light fixture during a security check.7
In addition, our review of the Jails’ suicide incidents revealed that when these forms are filled out, there are often inconsistencies between information on the Arrestee Medical Screening Form and the 15 Questions Screening Form that is used upon intake at the Inmate Reception Center. This may be a testament to the importance of multiple screenings, but it may also be evidence of the arresting agency’s rush to leave the prisoner at the Jails, poor training, a lack of accountability in making sure the forms are complete when the prisoner is formally accepted into the Jails, and communication lapses. In the case of “Dean,” the Arrestee Medical Screening Form was marked “yes” for risk of suicide, but the 15 Questions Screening Form was marked “no” for currently suicidal. In response to 15 Questions Screening, Dean answered “yes” to having a history of mental health problems, to the use of psychotropic medications, and to having a history of suicidal behavior. Dean also had a history of at least seven psychiatric hospital admissions, including a hospitalization for anxiety and depression just two months before his intake screening. Dean had also been previously incarcerated in the Jails about two months prior to his intake screening and he was housed in mental health housing at that time. But at intake, mental health staff found that Dean did “not meet the criteria for mental health services” or suicide precautions. Eleven days after his admission to the Jails, Dean hanged himself in his single cell in non-mental health housing.
This breakdown may be a further reflection of the “silo approach” that divides the Sheriff’s Department from the County Department of Mental Health’s Jail Mental Health Services. The two entities have separate policies and procedures and such policies do not consistently reference each other or the Jails’ “unit orders.” The Department of Mental Health’s policy on suicide prevention reads, in part, “Inmates booked into the [ ] Reception Centers are initially screened … through observation, interview, administration of a screening tool, 15 Questions (15Q), review of pertinent medical records from prior incarcerations, and reports from arresting or transporting officers regarding potential suicide risk.” Policy 70.7, Suicide Prevention §4.1.1 (emphasis added). Based on our review, this policy is not enforced with regard to arresting or transporting officers. Further, it is unclear who has the authority to enforce this mental health policy, given that the arresting or transporting officers do not report to the mental health staff. A better approach would be to integrate medical and mental health related policies and procedures into the relevant Sheriff’s Department unit orders, by merging or explicitly cross-referencing them.
B. Insufficient Supervision of Prisoners with Mental Illness and Suicide Risk.
Prisoners with mental illness and those who are identified as being at risk for suicide do not receive adequate supervision and are housed in conditions that present, rather than prevent, a risk of suicide. Correctional facilities have a duty to ensure that the conditions of confinement

7

In contrast to most critical incident reviews, which do not indicate any remedial measures, the review for

Christopher’s death includes both a recommendation for a review of the policies and procedures regarding safety

checks “to ensure that procedures were followed” and a recommendation for refresher training regarding completing

a Behavioral Observation and Mental Health Referral form. The Sheriff’s Department also issued Information

Bulletin #2013-09, entitled “Handling of Suicidal Inmates,” to all custody staff.

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do not pose a substantial risk of serious harm to prisoners by heightening the risk of suicide. Van Orden, 546 Fed.Appx. at 648.
Due to changes in State law, the prisoner population of the Jails has increased dramatically in recent years: from 14,500 prisoners in October 2011 to approximately 19,000 in September 2013. While population levels of this number are not historically unusual for the Jails, the result has been an increase in both the number of prisoners on the mental health case load and the acuity of the prisoners’ mental illness. The Jails’ mental health staff reported significant increased severity of mental illness among prisoners generally, which has affected all areas of service. While it is commendable that the Jails have seen a significant increase in the number of mental health staff during this time, it is clear that the custody deputy staffing level is not sufficient to provide adequate supervision for prisoners, including those at heightened risk for suicide. “Inadequate staffing can create an objective risk of substantial harm in a [correctional] setting that is sufficient to satisfy the objective prong of the deliberate indifference test.” Lemire, 726 F.3d at 1076 (citing Hoptowit, 682 F.2d at 1251).
1. Deficient Prisoner Supervision Policies and Practices.
Perhaps as a result of understaffing, poor supervision is apparent throughout the Jails, which increases the risk of harm to prisoners from suicidal behavior, as well as violence, sexual assault, and the inability to access medical care in a timely manner. This runs afoul of the Jails’ obligation to provide a reasonable level of safety to prisoners. Farmer, 511 U.S. at 832. The lack of supervision is evident even in the “safer” housing units of the Jails, such as the open units at CRDF, that are more amenable to good supervision and prisoner management. Some areas of the Jails reported frequent lockdowns as a result of staffing shortages. In various areas of the Jails, which house general population as well as prisoners on the mental health case load, general security checks are conducted only every 60 minutes, as opposed to every 30 minutes. This is contrary to generally accepted correctional standards and allows ample time for prisoners to engage in suicidal behavior, as well as violence and other prohibited activities. In general, prisoners should not be left unsupervised for 60 minutes at a time, regardless of their classification level. See Lemire, 726 F.3d at 1077 (citing Hoptowit, 682 F.2d at 1249) (noting that prisoners should not be left unsupervised for more than 30 minutes and that those with mental illness are at heightened risk to suffer harm when left unsupervised for extended periods).
Custody supervisory staff and deputies repeatedly mentioned the inconsistent operation of the Title 15 scanner system, which is supposed to verify that regular security checks are made as required. In the suicides we reviewed, we observed a repeated failure over the last two years to complete the mandated Title 15 safety checks. For example, the Jails’ critical incident review revealed that the Jails’ electronic scanners were not working on the day that “Frieda” committed suicide by hanging in 2012, thus there is no confirmation of when custody safety checks were completed in Frieda’s unit. No documents contain a clear statement about the probable time of Frieda’s death and, due to the lack of clarity about the security checks that may have been completed on the day of her death, it cannot be determined how long Frieda was hanging before being discovered. When the electronic system is not operational, written documentation of safety checks indicates that the checks are not consistently made. When checks are documented, the name of the deputy making the check and the time of the check completion are frequently
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missing. We also noted some instances of handwritten checks documented at exact time intervals throughout a housing unit, which calls into question the veracity of the documentation and violates generally accepted correctional standards requiring staggered checks.
In many of the recent suicides, the security checks are not even documented on an hourly basis. For example, the documentation surrounding “Gary’s” 2013 suicide show that he was last seen at 6:21 p.m. and then discovered hanging at 8:30 p.m. There are also units of the Jails where deputies do not actually walk through the unit to complete their security checks, such as the dormitories in Men’s Central Jail, and other units where supervision is accomplished by walking along the enclosed guard walk rather than along the halls of the cellblocks. In many areas of the Jails, when the security checks, including suicide checks, are conducted, they are not staggered, which facilitates the possibility of a planned suicide occurring during the known period without observation between checks.
The “K6G” housing units house gay, bisexual, transgender, and intersex (“GBTI”) prisoners. Jail officials indicated that there were more suicide attempts among this population when housed in single cells and that since designating these dormitories for GBTI prisoners, suicide behaviors have decreased. Despite this explanation and an apparent acknowledgment that GBTI prisoners may be at a heightened risk for suicide, deputies not only register security checks only at 60 minute intervals in the K6G dormitories, but checks are “completed” from the vantage point of the control room, rather than actually walking through the housing areas. As there are 140 persons housed in each of the two dormitories, it is virtually impossible to see very deep into the bunk areas, which take up the majority of the space within the dormitories. Consequently, without direct supervision or actual walkthrough security rounds, the deputies must rely on the prisoners to report problems within the units. In another 2013 death, “Henry” committed suicide in K6G module 4400, which is an administrative segregation cell rather than a dorm, by hanging himself with a noose fashioned from a county issued shirt. Prisoners on the B row of module 4400 informed deputies of a “man down,” in D row. Ten minutes later, deputies requested assistance for a “possible suicide attempt.” The Jails conducted a “safety check audit” that found only 43% compliance with safety check requirements in this module on the day of Henry’s death.
2. Inadequate Supervision for Individuals on Suicide Precautions.
The problems of inadequate supervision extend even to those prisoners with most demonstrated risk of self harm. In 2012, “Elliot” committed suicide at the Jails. During his intake screening five weeks before his death, Elliot reported suicide attempts a few months prior and treatment with anti-psychotic, anti-anxiety, and anti-depressant medication. A Jail psychologist referred him to the forensic in-patient program. After a deputy reported that Elliot was “covered with feces and urine” and had “unpredictable behavior,” a Jail psychiatrist determined Elliot to be incoherent, and he was sent out to the hospital for treatment and observation. Elliot returned from the hospital six days later, was placed in medical housing in Twin Towers, and received a sheet, two blankets, and a shirt and pants, even though he was identified as being at risk for suicide. Approximately three weeks later, he was found with a sheet tied around his neck.
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The timing and frequency of safety checks is not clear from any documentation provided for Elliot’s suicide. The Medical Services Bureau incident review suggests that at the time of Elliot’s suicide, he was housed in a room monitored by cameras, but the responsibility for watching monitors had not been established nor assigned to any specific employee. According to medical staff, the current practice is that “everyone” looks at the monitor. It is important to note that there are cell areas not captured on the video monitor, even though “close observations” are ordered on all patients housed in a monitored room. Accordingly, even if a specific employee is assigned to monitor the camera constantly, video monitoring may not be enough to prevent the recurrence of a similar suicide event. Video monitoring is never an adequate substitute for live staff supervision, especially when a prisoner requires direct supervision due to a medical, mental health, or suicide risk.
The command staff in some instances looks to solve custody problems by using mental health staff to perform security functions like watching monitors and assisting with safety checks. Following the 2014 suicide of Alan, the suggestion was made to have mental health staff present on the high observation housing units 24 hours a day to provide supervision of prisoners. This is inappropriate. While we commend the Jails’ commitment to increased mental health coverage, mental health staff are not a substitute for corrections staff. Custody deputies have primary responsibility for the safety and security of the prisoners and the institution; mental health staff is responsible for the identification of mental health needs and the provision of services and treatment to address those needs. Custody and mental health staff must work collaboratively in the effort to operate a safe and secure Jail system, and do so with a healthy dose of respect for their respective expertise and responsibilities.
C. Custodial Disregard for Clinical Recommendations on Suicide Precautions.
Clinical staff also expressed some frustration that their clinical opinions are ignored or overruled, for example, when they have completed suicide risk assessments and recommended no change in housing. Housing decisions must always be a collaborative effort based on information provided by custody, medical, and mental health staff. When clinical staff determines an inmate is suicidal, the first line of intervention is generally to increase restrictions, including moving the prisoner to “suicide housing,” instituting full suicide precautions, and providing medication. However, if there were opportunities for mental health staff to suggest and consider other and ancillary treatment alternatives, it may be that less physical movement in the system could be realized. At present, threats of suicide and actions of self-harm result in a prisoner’s movement to suicide precautions in designated areas of the Jails, and subsequently to a brief stay in moderate or high observation housing. Finding a space for a highly suicidal prisoner can be challenging in part because of all this movement.
A lack of appropriate housing for suicidal prisoners and a disregard of housing recommendations by mental health staff may have contributed to Elliot’s suicide, discussed above. The Jails’ electronic medical record reveals inconsistencies about the use of suicide precautions with Elliot. Upon his return from the hospital, a note in the record indicates that a suicide blanket was ordered, and then cancelled. A week later, a nurse noted that he is on suicide watch. Six days before his death, a psychiatrist, who diagnosed him with Schizoaffective Disorder, wrote that Elliot would be transferred to high observation psychiatric housing, and
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noted many warnings had been given about his psychiatric condition and risks for violence. The transfer did not occur and there is no explanation for this failure in the documents we reviewed. On the day prior to his suicide, Elliot was seen at his cell by mental health staff, who noted that Elliot was naked and his clothes were not in his cell. There is no documentation or follow up, but at some point he was given a sheet, which he used to carry out his suicide the following day.
It is especially significant that even though mental health staff should be able to insist that safety checks be completed at intervals not longer than five minutes for prisoners in need, there seems to be little commitment by custody staff to seeing that these enhanced checks are accomplished. As discussed above, housing and supervision decisions must take into account information from mental health staff. When a mental health clinician finds that a prisoner is suicidal and recommends enhanced monitoring, disregard for such a recommendation can be evidence of deliberate indifference to a prisoner’s safety. Clouthier v. County of Contra Costa, 591 F.3d 1232, 1244-45 (9th Cir. 2010). In a jail system with an increasing number of suicides and suicide incidents, the need for more intensive levels of prisoner supervision is critical. Madrid, 889 F. Supp. at 1259 (emphasizing the need for “adequate monitoring . . . on far more than just isolated occasions, particularly in the [isolation units]”). Inadequate custody staffing is not an excuse for refusing to provide more intense levels of prisoner surveillance.
D. Unsafe Housing of Prisoners at the Jails.
The general lack of adequate supervision is especially troubling given the hazardous conditions that exist in nearly every housing unit in the Jails, including bars, open bunks, wide mesh vent covers, hidden corners, small cell windows, and other known suicide risks. Living conditions in general are deficient (dimly lighted, vermin-infested, noisy, unsanitary, cramped and crowded) and create an environment that may contribute to prisoners’ mental distress. The County has a constitutional duty to ensure that conditions in the Jails constitute adequate shelter and to maintain sufficient sanitation for prisoners. Johnson v. Lewis, 217 F.3d 726, 731-32 (9th Cir. 2000). While these rights are guaranteed for all prisoners, hazardous environmental conditions can pose a particularly significant threat for prisoners who are vulnerable to mental health decompensation or suicide risk. Redman v. County of San Diego, 942 F.2d 1435, 1443 (9th Cir. 1991) (citing Colburn v. Upper Darby Township, 838 F.2d 663, 669 (3d Cir.1988) (holding that corrections officials may be constitutionally liable when they “know or should know of a particular vulnerability,” such as a prisoner in severe emotional distress, and fail to protect the prisoner from that vulnerability).
Mental health line staff complained that many of the cells are very dirty and that steam cleaners were not routinely being used to clean feces-smeared cells. Contraband that can be used for self-harm (plastic bags, broken plastic spoons) is readily visible throughout the housing areas. These conditions provide ample opportunity for suicidal actions. For example, the Supplemental Assessment Team Area in the Twin Towers Correctional Facility houses prisoners who require additional evaluation for mental health challenges within 24-72 hours of their admission or identification. Although these areas are designated as high observation housing, with single and two-man cells intended to house prisoners who are in crisis, the cells are not suicide resistant.
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E. Suicide Precautions at the Jails are Unnecessarily Punitive and Clinically Inappropriate.
Prisoners on suicide precautions often face arguably punitive restrictions, regardless of whether they are clinically indicated. When on a suicide watch, prisoners are not allowed to have pencils, combs, and other potentially harmful instruments, including paper, which some inmates have reportedly used to choke themselves. Prisoners placed on suicide watch are generally issued suicide resistant gowns, one or two suicide resistant blankets, and a mattress, absent explicit instructions to withhold one or more of these items. However, prisoners and line mental health staff reported that in practice, it was very common for prisoners to be denied access to mattresses, ostensibly because they were too easily torn. It was also reported by mental health staff that prisoners in high observation housing were not consistently permitted eyeglasses, hairbrushes, or thermal underwear, though custody staff disputed some of these allegations. The Jails should allow prisoners to retain their eyeglasses unless there is a documented and adequate clinical reason for removal, such as if the prisoner recently used eyeglasses to injure himself. In general, property restrictions should be individualized, documented, and necessary.
Suicidal gestures and comments are commonly countered with the threat of housing changes, the use of restraints, and limitations on privileges until the prisoner denies suicidal ideation, at which time the mental health staff lower the prisoner’s risk level precipitously and virtually ignore the prisoner’s risk history. The danger of moving quickly from high observation housing to merely bi-weekly contact with mental health staff is demonstrated by numerous recent suicides at the Jails. When Jail staff discontinue suicide precautions despite a reasonable inference that the prisoner is still at risk for self-harm, the staff demonstrate deliberate indifference to the prisoner’s suicide risk. Clouthier, 591 F.3d at 1244-45. Even in some of the Jails’ designated “step-down units,” it was reported that prisoners are allowed out of their cells only one to two hours per day and are required to eat in their rooms. This is grossly inappropriate. In the absence of an individualized and documented clinical reason, inmates in the step-down unit should spend the majority of the day out of their cells, including therapeutic programming, organized activities, meals, and unstructured time in the day room. When suicide precautions are unnecessarily harsh, it raises the risk that some prisoners who are actually suicidal will be hesitant to admit their suicidality. These prisoners report that they would prefer to “take their chances” rather than experience what they regard as the punitive conditions of suicide watch. This was true in the previously cited example of Alan’s death.
F. Therapeutically Inappropriate Environment for Prisoners with Mental Illnesss.
Severe restrictions are not confined to prisoners on suicide watch (or disciplinary sanctions). In some of the high observation housing units for female prisoners, women moved into the day room for treatment groups or other functions have one arm restrained with handcuffs extended from a chain secured to the floor while seated individually at tables. This approach to prisoner management may be a reflection of the low level of security staffing throughout the women’s housing units rather than a necessary safety-structural requirement for delivering appropriate assessment and treatment services. Well-regarded and evidence-supported womencentered treatment approaches would support the delivery of services in an environment that
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allows for group interaction, the building of connections, and the minimizing of the kinds of physical and emotional restraints that prove counterproductive to women’s health. See, e.g., Covington, S.S. & Bloom, B.E., Gender-Responsive Treatment and Services in Correctional Settings, Women and Therapy, 29(3/4), 9-33 (2006); Epperson, M., Wolff, N., Morgan, R., Fisher, W., Frueh, B.C., and Huening, J., The Next Generation of Behavioral Health and Criminal Justice Interventions: Improving Outcomes by Improving Interventions, New Jersey: Rutgers (2011). Similar restrictive handcuffing policies are followed at Twin Towers. While specific prisoners may at certain times require a higher degree of restraint in order to participate in therapy, such determinations must be made and documented on an individualized basis in accordance with the prisoners’ specific mental health and safety needs.
Additionally, prisoners have inadequate access to recreation on many high observation housing units. Prisoners who exhibit mental illness are frequently housed in their own single cells, which increases their isolation and opportunity for self-harm. Despite the fact that they are not in any high-custody or segregation status, many prisoners with serious mental illness in Men’s Central Jail spend as many hours per day in their small, four-man cells as segregation prisoners spend in single-man cells. Isolation or extended 22-hour cell confinement of prisoners with serious mental illness is not appropriate.8
Finally, the unacceptable, unsanitary, and unsafe conditions at the Jails, including the punitive nature of suicide precautions, are exacerbated by inappropriate and unprofessional behavior by deputies. The Eighth Amendment’s prohibition on the unnecessary and wanton infliction of pain includes the intentional infliction of psychological pain. Jordan v. Gardner, 986 F.2d 1521, 1525 (9th Cir. 1993). We received reports, from both prisoners and staff, of deputies using obscene and derogatory language towards prisoners with mental illness. Verbal abuse of prisoners is unacceptable and can contribute to increased mental distress and suicidal ideation, especially for prisoners with mental illness. It is impossible to establish a therapeutic milieu if prisoners with mental illness are harassed and disrespected consistently by the deputies assigned to supervise them.
G. Deficient Tracking, Reporting, Investigations, and Suicide Reviews Contribute to Sustained Deficiencies in Suicide Prevention Practices.
The suicide prevention sub-committee review process is broken and ineffective. At present, nowhere in the review process are custody personnel or practices effectively scrutinized. In most of the cases reviewed, that scrutiny should have been focused on: (1) the repeated

8

As one court noted, long periods of isolation for those with serious mental illness can be “the mental

equivalent of putting an asthmatic in a place with little air to breathe.” Madrid, 889 F. Supp. at 1265-66; see also

Brown v. Plata, 131 S. Ct. 1910, 1933 (2011) (acknowledging the concern that prolonged isolation may result in

inappropriate delays of mental health care); Wilson v. Seiter, 501 U.S. 294, 304 (1991) (holding that when

conditions of confinement combine to “have a mutually enforcing effect that produces the deprivation of a single,

identifiable human need” they violate the Eighth Amendment); Hoptowit v. Ray, 682 F.2d 1237, 1247 (9th Cir.

1981) (“[T]he court must consider the effect of each condition in the context of the prison environment, especially

when the ill effects of particular conditions are exacerbated by other related conditions.”); Coleman, 912 F. Supp. at

1320-21; Casey v. Lewis, 834 F. Supp. 1477, 1547-49 (D. Ariz. 1993) (describing the inappropriate use of isolation

for prisoners with serious mental illness because “[d]uring lockdown, inmates are provided improper mental health

care or no mental health care”).

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violation of suicide and safety check procedures; (2) the adequacy of the custody staffing in the units where the suicides occurred; (3) the placement of suicidal inmates into single cells, which can be done by custody staff without consulting prisoner classification or mental health staff; (4) the persistent submission of incomplete and poorly documented incident reports; and (5) the continued accessibility of instruments (plastic bags, plastic spoons, razor blades) that can be used to complete a suicide or effect a suicide attempt. The obfuscation inherent in not seeking and critically examining all the documentation around a death, the absence of corrective measures taken to add custody staff to housing units, the unwillingness to monitor and enforce policy adherence, and the lack of insistence on precise and accurate reports of critical incidents all signal a system destined to experience more of these incidents. The escalation in suicides and suicide attempts between 2012 and 2013 are evidence of this trajectory. An increased rate of suicides without meaningful change or remedial measures to address significant and known inadequacies in suicide prevention practices is evidence of on-going constitutional violations. Coleman v. Brown, 938 F. Supp.2d 955, 974 (E.D. Cal. 2013) (finding an “ongoing violation of the Eighth Amendment” where the suicide rate has not declined and majority of prison suicides involve longstanding, known deficiencies).
1. Inadequate Tracking and Documentation of Suicides and Suicide Attempts.
First, the labeling and recording procedures used to document suicide incidents are not consistent, which creates uncertainty about the nature of the suicide incidents that occurred system-wide. When asked for clarification as to who characterizes the type of self-harm behavior (as threats, gestures, attempts, and completions) when they occur, the Jails’ mental health authorities acknowledged that they do not have clear working definitions for attempts, gestures, and threats. At present, the categorization appears to be done on the basis of discernible intent to commit suicide and on the level of medical intervention required after the suicide behavior is discovered. Thus, a prisoner caught in the process of creating a noose may not be classified as having made a suicide attempt or gesture. The fact that a suicide attempt or gesture did not result in actual, physical harm does not negate the Jails’ obligation to take precautions against the heightened risk evidenced by suicidal behavior. Conn, 591 F.3d at 1095 (citing Doty, 37 F.3d at 546). All suicidal or self-injurious events must be taken seriously and included in the Jails’ data collection, review, and response to critical incidents. Tracking and analysis of attempts and gestures enables correctional facilities to identify and correct system weaknesses. It is unclear if the Jails have any data or analysis of suicidal gestures that occur in the Jails system.
Moreover, there is a sustained failure to adequately report the details of suicide incidents, including attempts, that occur in the Jails. Even with completed suicides, deputies’ reports lack substantive detail and are rarely signed with the time of completion noted. For example, “Jack” committed suicide by hanging in 2013. A prisoner worker found Jack hanging from an air vent in his cell at 10:15 p.m. After the worker reported the suicide, the events thereafter were apparently recorded on a video, but the video has been lost. There are no relevant times listed on the reports detailing this critical incident, beginning with the notification of the hanging until Jack was pronounced dead. The suicide critical incident review contains a note that the Title 15 scanner was “not available” to log security checks. The autopsy report states that Jack was last checked at 9:00 p.m. It appears some time was wasted during the intervention period when the
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responding officer had to open the housing door for other officers to enter, but none of the documentation is clear with regard to any times. None of the reports written by the many responding deputies are time stamped or dated, nor are the times of report completion noted. All of the deputies’ reports look very similar in detail and in language. There are no photographs of the suicide scene in the critical incident review or in the other materials reviewed, although our review revealed that such photographs are routinely taken by the Sheriff’s Department and Coroner’s investigators.

Even without any guidelines for categorization of incidents, mental health staff determined that 75 out of 281 suicide incidents from January 1, 2013 through September 21, 2013 qualified as “critical incidents.” All but three of these incidents involved people who had been seen by the mental health staff sometime prior to the incident. Importantly, no more than seven days passed between critical incidents. This demonstrates a system replete with on-going problems related to suicide prevention, but also a system in which serious problems are not being effectively addressed. In short, there is a need to more accurately and systematically define and record information relative to the suicide attempts that occur in the Jails. Further, the opportunity for self harm and the influence of traumatic exposure (and the possibility of contagion effects) should be investigated as suicide risk reduction efforts proceed. Accurate information on the number, type, and facts surrounding “suicide incidents” must be available to the suicide review sub-committee so the members can recommend comprehensive and effective remedial measures in response to a prisoner suicide.

2. Ineffective, Inaccurate, and Incomplete Suicide Mortality Reviews.

Although the Jails have a system in place to review prisoner suicides, the process is incomplete and inaccurate. The review process is not managed by supervisory staff with sufficient authority to hold staff accountable and mandate change to remediate problems. Members of the review committee do not work collaboratively to ensure complete and accurate dissemination and analysis of information. The final reviews are missing critical information that could enable the review team to better formulate conclusions about the actions leading up to the prisoner’s death.

Currently, the review process begins within 24 hours of a suicide and continues with meetings 7 days after the suicide and again at one month after the death.9 For a suicide review process to yield life-saving benefits, a ranking official must lead the inquiries, some of which are (or should be) directed at other ranking officials. In contrast, the Jails’ suicide review process, including the drafting of a written critical incident review, is largely led by a team of deputies and one sergeant, who have neither the rank nor the power to fully investigate and document their findings. These officers, good-intentioned as they may be, have neither the authority nor experience to question the supervision and security practices of employees of equal or higher rank. The sub-committee works as a trifurcated body, such that Sheriff’s Department custody officials work separately from the Medical Services Board officials, who work separately from the Jails’ mental health staff in compiling and reviewing the materials. Unfortunately, the three entities do not always share their materials with each other. A custody deputy compiles and

9

Prior to approximately September 2013, a single suicide review was conducted approximately 30 days after

a suicide.

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writes the final critical incident review document, and mental health staff on the sub-committee do not see the file prior to the final review meeting at which it is discussed. Mental health staff have no input or involvement in the draft document. The sub-committee does not include interviews of, or direct input from, the clinical staff that actually saw or provided on-going services to the prisoner involved. This results in missing, incomplete, and potentially inaccurate information in the review process, and a sense of disenfranchisement among the clinical staff. There is a major gap in the communication between the custody and mental health divisions of the Jails, which should both play a critical role in mortality and morbidity reviews.
The written reviews are not completed in a timely manner, often taking eight months or more to complete. Indeed, two years after many of the prisoner suicides detailed in this letter, none of the critical incident reviews are complete because they still do not contain final signatures denoting approval. The Sheriff’s Department attributes these delays to the wait for an autopsy report from the Coroner’s Office. However, the Assistant Chief Coroner for the Los Angeles Coroner’s Office confirmed that most autopsies are completed within a maximum of six weeks after the death. The autopsy report often contains critical information for the Jails’ custody staff and mental health providers. Many of the autopsy reports are missing completely from the Jails’ critical incident reviews. The Jails’ inexplicable failure to obtain such reports in a timely manner impedes the ability to complete timely investigations of custodial suicides, which in turn delays the implementation of changes that might emerge from such investigations.
In addition to the missing autopsy reports, the critical incident reviews are missing other significant information. The specific interventions used when a suicide attempt was discovered and the timing of each phase of the intervention (i.e., when CPR started, when medical and custody staff were notified, when they responded, when mental health staff were notified, when the paramedics were called, etc.) is obscure or absent from the review documentation. The fact that this information can often be found in separate records not available to the deputies completing the critical incident reviews further emphasizes the breakdown in communication during this process. In the end, assessing an accurate timeline of discovery-interventionresolution is nearly impossible through the Jails’ official review process due to missing, incomplete, or in some cases inaccurate documentation. In general, the County’s documentation practices are inadequate.
The many errors in the critical incident reviews, errors of both omission and inaccurate recording, create suspicion with regard to their veracity. For example, the final critical incident review for the suicide of Dean is marked by errors in facts and appears to be the product of cutting and pasting from another suicide that occurred prior to Dean’s death. Inconsistencies and errors in his age, his record of incarceration in the Jails, and in the dates of the critical incident review meetings make the entire review document questionable. Apparently none of these errors were noted by members of the review committee, as they remained in the critical incident review three months after Dean’s death.
3. Lack of Remedial Response to Suicide Reviews.
Importantly, the Jails’ suicide reviews fail to identify lapses in practice or policy and therefore do not result in comprehensive or effective remedial measures to correct identified
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deficiencies. The critical incident reviews of suicides consistently end with the same or similar conclusions: a finding that no medical, mental health, or custody systems or practice issues contributed to the prisoner’s suicide. Remedial measures, when advised, suggest custody briefings and written reminders to custody staff or revisions in policy - but the substance of these recommendations is not detailed. These conclusions and recommendations are rote, noncommittal, and cursory. Even where there is a clear contributory problem, such as when nursing staffing dropped to 20 personnel below the staffing level on the day of “Kyle’s” 2013 suicide, the critical incident review did not include a recommendation to address the deficiency. Rarely are custody staffing deficiencies detailed in the files, even though there is a form (the Watch Commander’s Incident Form) that requires this detail. Finally, the Jails’ summary of the suicide reviews, compiled in an incomplete document called the 2012-2013 LASD Inmate Suicides Summary and Synopses, is little more than a cursory view of the incidents and as such, is not a useful document to form the basis for action. The omission of critical reviews of custody responses to suicide incidents is suspect. The absence of recommendations geared toward enforcing existing policies and unit orders by (1) enhancing staffing levels, (2) providing effective training in report writing and documentation, and (3) taking definitive action when safety checks procedures are repeatedly violated, suggest that the critical incident review process, while perhaps well intended, amounts to little more than a bureaucratic exercise. The evidence of this is in plain sight: these same problems have happened repeatedly and more frequently over the 25-month period encompassing 15 suicides.
For example, in the case of Brian, discussed above, the documents we reviewed demonstrated numerous lapses. For instance, Brian was admitted into the Jails without undergoing the screening designed to prevent and identify acute health problems; the transporting officers failed to report his thoughts of having “nothing to live for;” and Jails staff failed to enforce its admission policy related to information from the arresting/transporting officer. There are gaps in the deputies’ documentation of the suicide itself, including the response times of the three deputies who arrived on the scene, which make it difficult to evaluate the effectiveness of the response. A deputy’s report notes that, on the shift prior to this suicide, Brian was “yelling, banging and kicking his cell door throughout the night,” but it is not known if mental health staff were notified of Brian’s level of agitation. In addition, even a cursory look at the electronic medical record would have revealed Brian’s significant psychiatric history. Despite these deficiencies, the Jails’ critical incident review of the suicide did not identify any remedial action regarding medical, mental health, training, and policy and procedures. The conclusions and recommendations in the critical incident reviews for Elliot, Dean, Henry, Kyle, and Michael are similarly lacking: no critical findings and no remedial action or training is suggested.
Even in the rare cases where the critical incident review actually includes or implies a critical finding, insufficient remedial measures are recommended. This is clear in the case of “Lily,” who committed suicide in the Jails in 2013, on the anniversary of a family member’s death, a year after she was charged with murdering family members. Lily had a significant history of mental illness and suicidal ideation. As the anniversary of the deaths drew near, her psychotic depression intensified, her auditory and visual hallucinations were more prominent, and her psychologist noted that Lily talked of her alleged victims’ visits, of hearing their voices, and reminded the psychologist of the anniversaries of their deaths, but there is no apparent
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increase in her level of supervision. At 11:00 a.m. the deputy completing cell checks in her unit noticed that Lily had not changed sleeping positions since the prior safety check, which is recorded as having occurred 38 minutes earlier, at 10:22 a.m. Lily, lying face down with blankets over her head, did not respond when called and, when the deputy entered the cell, Lily did not respond to the flashlight used to “nudge her left thigh.” The deputy left the cell and requested that medical staff respond. Lily was found with a plastic bag over her head at 11:04 and pronounced dead at 11:20 a.m. The critical incident review reveals that the deputy, when observing that Lily had not moved, had a discussion with another deputy and with a prisoner prior to taking further action, and that when she nudged Lily with the flashlight, she realized she was “stiff.” There are no times listed in the deputies’ incident reports until Lily’s death is pronounced. The unit activity log shows a Title 15 check completed at 9:20 and then not again until 10:22. The 15 minute safety check log sheets that relate to prisoners in certain cells are preprinted in quarter hours (e.g., 11:00; 11:15; 11:30; 11:45) so that the deputy does not fill in the exact time of the safety check. Obviously, the deputy cannot observe all prisoners subject to these frequent safety checks at the same time, so the logs are necessarily inaccurate. A memorandum from a training officer indicated his findings that the deputy “failed to perform a thorough and complete assessment of the inmate as taught by the custody headquarters’ training staff.” However, in the end, no remedial actions were recommended for custody services, medical services, mental health, or for training. The critical incident review does recommend a policy and procedures review, related to: (1) the barcodes that accurately scan the time and location of a Title 15 check to ensure veracity and to create a record, and (2) plastic bags not being permitted in cells of those classified as high security or mental health risks. In fact, plastic bags have been removed from some housing areas, but there is no indication of a change with regard to tracking of required safety checks or any recommendations regarding Lily’s insufficient level of supervision and the inadequate response by mental health staff to her worsening condition. Lily’s death was preventable. As with the other suicides that have occurred in this system, there were specific points where therapeutic and security responses and interventions that could have saved her life should have happened and did not.
The suicide and critical incident reviews consistently evidence a complete neglect of critical analysis with regard to custody practices. Concerns about the timing, frequency, and adequacy of safety checks, while sometimes mentioned, at most result in referrals to the Internal Affairs Bureau for investigations. Unfortunately, investigations of suicides at the Jails are inadequate and untimely. The Sheriff’s Department investigates its own jail suicides, using Sheriff’s detectives to do so, and the resulting investigations are often incomplete and superficial. Assigning the investigation to an outside law enforcement or justice-system agency would not only avoid the appearance of bias in the investigation, but would open the door to a more critical and meaningful review of the circumstances of the death. Moreover, many Internal Affairs Bureau inquiries remain active even one year after a death, which negates the possibility for a timely impact that might prevent further suicides.
The lack of a comprehensive, self-critical, and remedial mortality and morbidity review process allows obvious and on-going deficiencies to continue unabated in violation of the Constitution. Coleman, 938 F. Supp.2d at 974. For example, on most days, the Sheriff’s Department transports many prisoners to criminal (and presumably some civil) courts located throughout the complex Los Angeles County land mass. Sheriff’s deputies indicated that suicide
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incidents occur with some regularity in the court holding cells. In 2013, “Michael” hanged himself in the court holding area. While there is scant information about Michael, because he was held in a local lockup prior to his court appearance and had not been screened by the Jails, apparently he asked to see someone from mental health. Significantly, the Jails’ mental health staff are not responsible for prisoners as they are transported to and from courts and held in court holding cells. Further, mental health staff indicated that they are not informed of self-harm incidents when they occur during court movement. Consequently, there is a large segment of the Jails’ population that on any given day may be influenced or affected by self-harming behaviors and mental health staff, and perhaps custody housing staff as well, are unaware of it. This is a critical deficiency. Not only is intervention and follow-up warranted after any suicidal behavior, the behavior itself constitutes a risk for further suicide behavior. Moreover, the Jails’ documentation of suicide attempts in 2013, not including any incidents in the court holding cells, revealed that 48 percent (174) of those incidents occurred within one week of a court date. These facts indicate that the Jails need to do an in-depth look at their court transport and holding procedures and communication practices regarding prisoners’ behavior during such periods, as well as facilitating an appropriate alert or response to suicidal behavior that may be triggered by court proceedings. However, the Jails’ dysfunctional critical incident review process has neither identified nor addressed these issues.
H. Deficiencies in Mental Health Services Contribute to Inadequate Suicide Prevention.
Despite 12 years of monitoring by the Department of Justice, detailed reports by the Department’s experts, and consultation with those experts on policies, practices, and plans of correction, the deficiencies and examples noted above demonstrate that significant weaknesses remain with regard to mental health services at the Jails. The Eighth and Fourteenth Amendments both guarantee prisoners’ right to receive constitutionally adequate mental health care. Doty v. County of Lassen, 37 F.3d 540, 546 (9th Cir.1994). In addition to failing to comply with the Jails’ constitutional obligation to provide for the serious mental health needs of its prisoners, these systemic problems contribute to and allow for the Jails’ dangerous conditions for suicidal prisoners.
In addition, our meetings with the Jails’ psychiatrists and direct service providers (clinical social workers and counterparts), suggest that mental health services, within the Jails, are offered within a fairly traditional medical model, focusing on diagnostic assessments, treatment with medications if indicated, and limited follow up, rather than on a public health model that includes a broader preventive agenda focusing on larger population issues in addition to individual pathology.10 As we emphasized previously, we strongly encourage the County to embrace both alternatives to incarceration for individuals with mental illness and augment its efforts to provide a robust community care network to provide mental health services to the

10

The 2012 Surgeon General’s report National Strategy for Suicide Prevention: Goals and Objectives for

Action, available at http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/index.html,

speaks to the public health approach in suicide prevention. Also see, the 2001 publication: Mental Health: Culture,

Race, and Ethnicity A Supplement to Mental Health: A Report of the Surgeon General available at:

http://www.ncbi.nlm.nih.gov/books/NBK44243/.

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public, which may decrease the number of individuals who are arrested as a result of behavior stemming from untreated mental illness.
Following their most recent review of the Jails, Drs. Dvoskin and Metzner expressed considerable concern with the Jails’ inability to progress in some areas, particularly those related to providing adequate mental health treatment and programming to prisoners on the Jails’ mental health caseload, especially for prisoners who are not in mental health housing. Breakdowns in mental health services are evident in the suicides we reviewed. For example:
• Elliot committed suicide after 61 days in custody. During his intake screening, he reported suicide attempts a few months prior and treatment with anti-psychotic, antianxiety, and anti-depressant medication. The coroner’s report included significant mental health history, including diagnoses of schizophrenia and bipolar disorder, auditory hallucinations, panic and anxiety disorders, substance abuse, and the initiation of numerous 72-hour holds. However, even months after the suicide, the Jails’ psychiatrists were not aware of the coroner’s report or of this significant history for a prisoner who was their patient for two months.
• In the 2012 death of Frieda, the Jails’ 15 Questions Screening Form reflects a history of suicidal behavior and mental health problems. Although Frieda was referred for psychiatric evaluation on intake, she was not seen until four days later, and then only by a social work intern. The intern evaluated Frieda, noted her history of having a Posttraumatic Stress Disorder, but indicated that her “symptoms do not appear outstanding enough to warrant [moderate observation housing].” The medical notes do not indicate any supervisory review of the intern’s evaluation. Frieda hanged herself, while housed alone, two weeks after admission to the Jails. The autopsy report reveals that Frieda had a significant history of depression and three or four suicide attempts over several years, yet there is no indication of any substantive contact with the Jails’ mental health staff following her intake.
• In late 2012, Nicole committed suicide at the Jails with a lethal overdose of prescription psychotropic medications. Nicole was admitted to the Jails directly from a hospital emergency room after a serious suicide attempt on charges of murdering a family member. All of her screening interviews and documentation noted suicidal intent, with the 15 Questions Form indicating “extremely suicidal.” After telling the mental health staff at intake that she would be better off dead than alive, she was referred to the forensic in-patient unit. Shortly thereafter, Nicole was placed in four-point leather restraints and she remarked to the nurse on duty that she was “deeply sad.” There is no indication in the medical record about why Nicole was placed in four point restraints, nor is there documentation of what, if any, other less restrictive alternatives were considered or tried prior to applying the four-point restraints. Ninety minutes after being placed in full-body restraints, Nicole insisted that she was not going to hurt herself, was released from the restraints, placed on a 30 minute close observation, and given a safety gown and blanket. This abrupt change in supervision and attention, without any sort of step-down or transition, is contrary to generally accepted professional standards. Nicole was diagnosed with Mood Disorder NOS, Depressive Disorder NOS, rule/out Major
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Depressive Disorder, and rule/out Bipolar Disorder, and placed in a single cell. Over the next three months, there are only three instances of mental health staff notes found in the medical records and several group activity notations. These records note that Nicole is consistently depressed. On one occasion, Nicole was sent to a local hospital for complaints of “dizziness.” While there, she was prescribed a psychotropic medication. The dosage of this medication was increased when she returned to the Jails. Nicole was noted to be “med compliant.” Nicole saw a psychologist again a week before her death, who observed her to be depressed and evidencing “…a psychotic process.” Despite this observation, Nicole was not scheduled to be seen again until two weeks later. However, she ingested a fatal overdose of her prescribed medication a week before her next appointment.11
These examples, and those discussed in the previous sections, demonstrate that, despite some significant improvement during the tenure of the MOA, the Jails are not providing adequate mental health treatment in a consistent manner. In addition to the areas detailed in the discussion above, such as deficient screening and crisis intervention, the Jails are failing to comply with their obligations to provide: adequate treatment and referrals for prisoners in general population; sufficient in-patient care for those in need; adequate treatment to prisoners refusing medication; sufficient discharge planning; appropriate therapy and clinical contacts; and appropriate medication administration practices.
1. Insufficient Treatment for Prisoners in General Population.
Due to the increase in the Jails’ population overall, and the accompanying increase in prisoners with mental illness, there are now nearly 1000 male prisoners who are seriously mentally ill or otherwise in need of psychotropic medication who are currently housed in nonmental health housing in different areas of the Jails. In response, the Jails have increased mental health staffing and the hours of mental health coverage in these areas of the Jails. Unfortunately, each of the six full-time psychiatrists serving these areas requires an escort deputy to bring prisoners to and from their offices, or to escort psychiatrists to housing units, and to provide security supervision. Prior to July 2013, the deputies assigned to the Jail Mental Health Evaluation Teams were serving this function, which left six of the teams without a deputy for the majority of the day shift. As a result, we strongly recommended that the Jails consistently assign one full-time deputy or equivalent to each psychiatrist, in addition to the deputies assigned to the mental health teams, in order to maximize their productivity while adhering to the team model that has been so successful.
In addition, the threshold for custody referrals for prisoners in need of mental health care in the non-mental health housing units, particularly those in the Men’s Central Jail, is too high, basically waiting until the prisoner is in psychiatric crisis. Custody staff should be alerted (e.g., through shift briefing trainings) to look for less obvious signs of increasing emotional distress, so that mental health referrals can occur earlier.

11

Despite the autopsy report finding of an overdose of prescription psychotropic medications, the Jails’

critical incident review lists Nicole’s cause of death as suicide from an overdose of “Tylenol/aspirin.”

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2. Insufficient Access to In-Patient Care When Clinically Appropriate.
The Jails do not have enough in-patient beds to provide appropriate licensed in-patient care to the current population of prisoners with mental illness. While it is commendable that the Jails’ mental health staff is attempting to address the problem by mandating daily psychiatric contact for prisoners awaiting transfer to in-patient care, this is not an acceptable alternative to additional in-patient beds. The Jails’ mental health staff estimate that the current population requires approximately 200 additional in-patient beds. The Jails do not have sufficient in-patient care capacity to provide an adequate level of care to prisoners with serious mental illness. As such, the County should explore alternative options for treating and housing these prisoners in a setting that can meet their needs.
3. Inadequate Mental Health Treatment for Prisoners Refusing Medication.
In some areas of the Jails, psychiatrists decline to order psychotropic medications or continue to meet with a prisoner if a prisoner discloses an intention to refuse medication, even if the prisoner appears to suffer from an obvious or previously diagnosed mental illness. Unfortunately, this can result in prisoners with serious mental illness failing to be entered onto the mental health caseload. It is important to note that prisoners might initially refuse psychiatric medication, but later agree to take it at the urging of the treatment team. Thus, it may be useful to consider either ordering medications that will be refused, or ordering a follow-up psychiatric evaluation. Regardless, all prisoners with serious mental illness should be routinely followed by mental health staff, even if they are refusing medication and other treatment.
As demonstrated by several of the suicide incidents, some prisoners in mental health crisis do not receive adequate intervention. Moreover, the County must examine the policies and practices with regard to involuntary medication when clinically indicated, including related guardianship issues. The increase in population has made it difficult to transfer all prisoners in need to appropriate housing.
4. Insufficient Discharge Planning.
In order to facilitate the provision of adequate mental health treatment, the County committed to Corrective Action Plan 4.7, which requires the Jails to improve discharge planning and linkage to Service Area mental health providers and aftercare services. While discharge planning for prisoners in male mental health housing appears reasonably adequate, discharge planning for prisoners with a serious mental illness in non-mental health housing is very scarce. We also received reports of inadequate discharge planning at CRDF. The Jails need to remedy this issue and ensure adequate discharge planning for all prisoners in need of mental health care in the community, regardless of their housing location, as part of the Jails’ obligation to provide adequate mental health treatment.
5. Inappropriate and Insufficient Therapy and Clinical Contacts.
The MOA requires that prisoners with serious mental illness who are housed in the most intensive levels of outpatient mental health housing be offered at least 10 hours per week of structured out of cell therapeutic or programmatic activity and 15 hours of recreation per week. Meeting the 10 hours per week of structured therapeutic activity threshold remains a challenge,
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related in part to medication noncompliance issues for a subset of high observation housing prisoners who are refusing to attend therapies. As discussed above, the Jails should explore potential avenues related to involuntary medication practices, including guardianship issues, and assessing the quality/relevance of certain offered group activities. Having the ability to involuntarily medicate prisoners on a nonemergency basis, where clinically indicated, could be clinically very beneficial to many prisoners who are significantly impaired due to their mental illness. The Jails must also improve efforts to provide the required weekly recreation time, particularly at CRDF, where women in the high observation housing unit reported that they were not offered any outdoor recreation time. Additionally, prisoners with mental illness should be allowed to participate in the Jails’ educational and work programs, where appropriate.
Group treatments in some housing units are three hours in duration, which is too long for both the prisoners and for the therapists. This results in prisoners refusing to participate and also diminishes the effectiveness of group treatment. We recommend that structured out-of-cell group activities should generally be about 90 minutes in duration and not longer than two hours.
In some high observation housing units, most clinical contacts occur at cell front, and much less often in the dayroom. While frequent cell front contacts can assist in providing emotional support and creating a therapeutic alliance, they are no substitute for private and confidential mental health treatment. This is not adequate treatment and indicates both a lack of adequate treatment space and, potentially, a reflection of custody staffing deficiencies that limit the ability to safety transport prisoners for clinical contacts. These staffing deficiencies obstruct the prisoners’ opportunities for unstructured out of cell time and outdoor recreation, which can negatively impact their mental health status.
6. Inappropriate Medication Administration Practices.
Lack of adequate supervision is not only a problem with custody staff. During the Department of Justice’s September 2013 on-site review of the Jails, we observed a nurse during medication rounds in a high observation housing unit, where medical staff are aware of the prisoners’ heightened risk level. The nurse would bring a paper cup to the prisoner in her cell and tell the prisoner to fill the cup with water and bring it back to the cell window or trap door, after which the nurse gave the prisoner her medication(s). The prisoners could turn their backs and walk away without conversation, which makes “cheeking” or otherwise saving one’s medications possible. In the case of Nicole, who likely stored up her medications to effect her overdose, the critical incident review contains no recommendations for, or even discussion of, potential remedial measures about the practices and protocols used for medication administration in the housing units. This practice is of concern not only because of the risk of suicide by medication overdose, but because Jails’ staff report that in shakedowns, stockpiled medications are frequently found, and that medications are used as a commodity for “sale” or trade between prisoners at the Jails.
IV. MINIMUM REMEDIAL MEASURES FOR DEFICIENT MENTAL HEALTH SERVICES AND SUICIDE PREVENTION ISSUES
Suicides can be prevented and suicide incidents reduced when medical, mental health, and custody services act together and in accord with their policy directives. Insisting on complete arresting officer information before accepting an inmate into the Jails; sharing
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information about prisoners’ risk conditions across disciplines; resisting the inclination to house persons with mental illnesses and those who have suicide ideation in single cells; ensuring that security and safety checks are performed and increasing the frequency of such checks in those units where persons at elevated risk for suicide are likely to be found; having an accurate, participatory death review process; and scrutinizing the practices of all the Jails’ divisions, including custody, will likely go a long way to reduce the rising number of suicide incidents in the Jails.
The above conclusions demonstrate how the Jails’ non-compliance with the existing MOA provisions related to suicide prevention (§§ IV.G.25-29), including certain mental health provisions related to Intake (§ IV.A.5), Referrals (§ IV.C.9), Treatment (§ IV.D.12 & 15-19), Medication Administration (§ IV.E.22), Environmental Conditions (§ IV.F.23-24), and Quality Assurance (§ IV.J.42), poses a serious risk of harm to prisoners. These current MOA provisions roughly encompass the Jails’ duties to provide adequate screening and suicide risk assessment upon intake, properly evaluate prisoners identified as suicidal, ensure appropriate crisis intervention and emergency response for prisoners who attempt suicide, properly monitor and observe prisoners who are at risk for suicide, provide safe housing for suicidal prisoners, administer medications in a manner that does not pose an unreasonable risk of suicide attempts, and ensure an adequate morbidity and mortality review to identify problems and potential remedial measures. In order to address the deficiencies outlined above, the existing MOA provisions must be replaced with a court-enforceable remedy that addresses these subject areas but provides greater detail and structure in order to ensure adequate suicide prevention practices at the Jails.
The reduction of the number of prisoners with mental illness confined to the Jails may be essential to the effective implementation of remedies. The United States welcomes the efforts that the County has begun to create diversion programs to keep people safely supervised in the community rather than confined to the Jail. We encourage the County to expand these programs.
In order to rectify the deficiencies identified in this letter, a court-enforceable agreement should require the Jails to implement, at a minimum, the following remedial measures:
A. Custody Practices and Staffing Related to Suicide Prevention and Safety of Prisoners with Mental Illness.
1. The Sheriff’s Department must develop, implement, and enforce an effective policy and procedure for obtaining relevant and available information on prisoners’ mental health status and suicide risk from the arresting or transporting officer upon intake to the Jails.
2. The Sheriff’s Department must conduct an appropriate and objective assessment of custodial staffing needs throughout the Jails, with particular consideration of staffing in housing areas for prisoners with mental illness and high observation housing units, including suicide observation.
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3. The Sheriff’s Department must ensure that custodial safety checks are completed and documented in accordance with policy and legal requirements, at least every 30 minutes in general population and appropriately staggered, and more frequently as necessary due to the prisoner needs (including for prisoners on suicide watch), environmental challenges posed by the facilities, or requests by medical or mental health care staff.
4. Custodial safety checks must be completed in a manner that allows deputies to view each prisoner in a housing unit in order to assure prisoner well-being and security within the unit.
5. The Sheriff’s Department must develop, implement, and enforce an effective policy and procedure for unit contraband searches on a regular but staggered basis.
6. The Sheriff’s Department, in consultation with the Department of Mental Health, must develop advanced training curricula for special management housing, including moderate observation housing, high observation housing, and suicide watch, and ensure that deputies assigned to these areas receive adequate training in identifying mental health symptoms, assessing suicide risk, using appropriate communication strategies when dealing with prisoners in mental health crises, and in effective crisis intervention techniques.
7. The Sheriff’s Department, in consultation with the Department of Mental Health, must revise the deputy suicide prevention training to include adequate training on response to suicide incidents, including a hands-on simulation experience that incorporates the challenges that often accompany a jail suicide, such as cell doors being blocked by a hanging body and delays in securing back-up assistance.
8. The Sheriff’s Department must notify the Jails’ medical and mental health staff of any crisis or suicide incident that occurs during court transport or in a court holding cell, including providing relevant incident reports.
9. Cameras cannot substitute for deputy staffing. However, if a cell is designated for constant monitoring by camera, then designated custody staff must be assigned to view the monitors in those areas where cameras have been placed in the cells.
10. Any prisoner brought directly to CRDF and held pre-arraignment must be screened by the Jails’ medical and, if indicated, mental health staff prior to being placed in the pre-arraignment unit.
11. The Sheriff’s Department must consider housing recommendations from medical and mental health staff, including recommendations for “no change in housing,” when considering a change to a prisoner’s housing unit or classification level following potential suicidal ideation, gesture, or incident, or other indication of mental health issues.
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12. The Sheriff’s Department must ensure that any relevant information regarding a prisoner’s medical or mental health status or history (for example, from the arrest report) is communicated to medical and mental health staff for inclusion in the prisoner’s electronic medical record.
B. Mental Health and Medical Care Treatment and Suicide Prevention.
1. The Department of Mental Health shall include deputies on the relevant housing units as members of the treatment team and shall advise such deputies of any prisoner’s special handling needs.
2. Mental health staff and custody staff, working collaboratively, must ensure adequate crisis intervention for prisoners exhibiting signs of mental health crisis.
3. Mental health staff must consider, and revise as necessary and consistent with legal requirements, Jail policies and procedures related to involuntary medication of prisoners in acute stages of a mental health crisis.
4. Every prisoner seen for ongoing services by mental health staff must have a treatment and an individualized discharge plan in the electronic medical record. When services are discontinued, a brief discharge summary should also be made in the electronic medical record to allow for an expedient review of the prisoner’s history should he or she be readmitted to the Jails at another time.
5. Excluding restraints used for transport (handcuffs), prisoners should only be subjected to mechanical restraint in response to a mental health crisis when necessary based on an individualized assessment: if the prisoner poses an immediate and serious risk of harm to him/herself or others; after a graduated range of less restrictive measures has been exhausted or considered in a clinically justifiable manner; for reasons other than as punishment, for convenience of staff, or in the absence of or as an alternative to treatment; and in accordance with applicable written policies, procedures, and plans governing restraint use.
6. If the Department of Mental Health subjects a prisoner to restraint in response to a mental health crisis, mental health staff must ensure the prisoner receives therapeutic services to remediate any effects from the episode(s) of restraint.
7. The Department of Mental Health must provide adequate mental health treatment to all prisoners with mental health needs, including those who refuse medication.
8. The Department of Mental Health must develop and implement an adequate policy and procedure for seeking involuntary medication of prisoners when clinically appropriate.
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9. The Sheriff’s Department must refer prisoners from general population who are demonstrating a potential need for mental health care to the Department of Mental Health for evaluation.
10. The Department of Mental Health must ensure adequate therapy and counseling for all prisoners with mental illness, including those housed in general population.
11. The Department of Mental Health must provide adequate 24 hour crisis intervention for prisoners, including transfer to special housing units, administration of psychotropic medications, provision of therapy treatment, and special observation.
12. Unless contraindicated, all prisoners with serious mental illness and housed in the most intensive levels of outpatient mental health housing must be offered at least 10 hours per week of structured out of cell therapeutic or programmatic activity and 10 hours of unstructured out of cell time, including recreation, per week.
13. Unless clinically contraindicated or the prisoner is in administrative segregation, no prisoner with serious mental illness shall be locked down more than 19 hours per day. Prisoners with serious mental illness in segregated placements shall be offered adequate therapeutic and recreational out-of-cell treatment, consistent with their security levels and treatment needs.
14. Prisoners with mental illness or housed in mental health housing shall not be denied jail privileges or programs based solely on their status as mentally ill or on their placement in mental health housing.
15. The Sheriff’s Department must provide adequate space for treatment and individual and group therapy and programming.
16. The Department of Mental Health must ensure adequate access to appropriate licensed in-patient care when clinically appropriate, either in the Jails or in another appropriate facility.
17. The Department of Mental Health must provide adequate discharge planning and linkage to community mental health providers and aftercare services for prisoners on the mental health case load.
18. Mental health staff and custody staff, working collaboratively, must ensure that conditions of suicide watch are not unnecessarily punitive. Property restrictions must be individualized, documented, and necessary to accommodate the prisoner’s mental state and behavior. Prisoners on suicide watch shall be provided mattresses, including suicide-resistant mattresses when warranted, unless providing a mattress is clinically contraindicated. Orders to remove a prisoner’s mattress must be documented in the electronic medical record.
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19. Intermediate steps between highly restrictive suicide precautions (e.g., mechanical restraints, suicide protective gowns and blankets, and constantly monitored cells) and the discontinuation of suicide precautions shall be developed, knowing that “recovery” from depression and suicide ideation is a process that extends beyond the moment when an inmate no longer admits to suicide ideation.
20. The Medical Services Bureau and the Department of Mental Health must consolidate and manage prisoner medical and mental health records to ensure that all relevant information is available to all health service providers.
21. All intake forms, including the 15 Question screening form and the Arrestee Medical Screening Form, must be included in the electronic medical record.
22. Supervisors shall periodically review clinician notes and entries in the electronic medical records to independently assess and ensure accuracy and veracity of the notes.
23. Medication administration procedures must be adequate to prevent prisoners from hoarding medications or from deviating from the prescribed medication regimen without the knowledge of medical and mental health staff.
24. Relevant custody, medical, and mental health staff shall meet on a regular basis to ensure coordination and communication regarding the needs of prisoners in mental health housing.
25. Jails staff must ensure that prisoners in mental health housing have equal access to educational and work programs, and that adequate translation services are readily available for prisoners requiring mental health services.
C. Suicide Tracking, Investigation, and Review Process.
1. The Sheriff’s Department, working collaboratively with the Department of Mental Health, shall develop and implement a consistent method for categorizing, documenting, and tracking suicide gestures and attempts. Information on all such incidents must be included in the prisoners’ electronic medical records.
2. The Sheriff’s Department, the Medical Services Bureau, and the Department of Mental Health must work collaboratively to review each prisoner death. Written mortality reviews shall be prepared by a Sheriff’s Department official of appropriate rank.
3. Prisoner death reviews must include accurate and complete information surrounding the prisoner death, including time-stamped and signed reports from deputies and medical and mental health staff relevant to the incident.
4. Prisoner death reviews must be completed in a timely manner.
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5. Autopsy reports shall be sought from the coroner’s office within six weeks of a prisoner death, and Jails staff must conduct prompt and regular follow up to receive any reports still outstanding after six weeks. Findings from autopsy reports must be incorporated into the final written suicide review, including another subcommittee meeting to assess the autopsy report, if necessary.
6. Suicide review reports should include an approximate time of death and an accurate timeline regarding the discovery of the prisoner and any responsive actions or medical interventions.
7. If available, suicide review reports shall include and maintain any relevant video recordings of the incident or response, and photographs of the scene. The County shall document the chain of custody for all evidence related to a prisoner death, including relevant videos and photos.
8. The Sheriff’s Department must ensure an accurate, complete, and unbiased investigation of suicides that occur in the Jails. This may involve an arrangement with a neighboring jurisdiction, district attorney’s office, or private organization to conduct or facilitate the investigation.
9. Each suicide review shall identify any deficiencies in custodial, medical, or mental health practices or policies that may have contributed to the suicide and recommend remedial measures, including policy revisions, re-training, or staff discipline, to address the deficiencies. The subcommittee shall designate a member to follow up on each recommendation to ensure implementation.
10. The suicide review process shall result in data-driven efforts to identify and address systemic issues. The subcommittee shall collect data on suicide attempts and incidents, including location, method, and deficiencies (lack of staffing, missed security checks, inadequate mental health contacts, etc.) in order to target problems for remediation.
D. Environmental Conditions.
1. The Sheriff’s Department shall conduct a systematic review of all housing, with particular emphasis on moderate observation housing, high observation housing, and areas in which suicide watch is conducted, and identify and address suicide hazards.
2. The Sheriff’s Department shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. Such policies should include oversight and supervision, including meaningful inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.
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3. The Sheriff’s Department shall implement a preventive maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, and sink units are adequately maintained and installed.
4. The Sheriff’s Department shall ensure adequate lighting in all prisoner housing, programming, and work areas.
5. The Sheriff’s Department shall ensure adequate pest control throughout the housing units, medical units, kitchen, and food storage areas.
6. The Sheriff’s Department shall ensure that all prisoners have access to needed hygiene supplies.
V. COMPLIANCE ASSESSMENT OF REMAINING MOA PROVISIONS
With regard to the remaining provisions of the MOA related to mental health care, and the associated Corrective Action Plans developed by the Jails in conjunction with Drs. Dvoskin and Metzner, the Jails have made considerable progress. The Jails have achieved and sustained substantial progress, meaning the Jails have achieved compliance with most, or all, components of those requirements, with the following MOA provisions: §§ IV.A.1-4, A.6, B.8, D.14, D.20, H.30-33, and I.36-40. As such, we will no longer conduct compliance assessments on those provisions and the Jails are not required to report on those areas. While our conclusions confirm continued problematic practices in certain areas connected to some of these MOA provisions, those concerns are discussed in our conclusions regarding mental health treatment and suicide prevention and shall be addressed with the remedial measures set out above.
The remaining MOA provisions related to mental health care, excluding those implicated by the suicide prevention conclusions, are in partial compliance and will require further monitoring and consultation. A brief review of the Jails’ compliance status with regard to the remaining MOA provisions, §§ IV. B.7, C.10-11, D.13, E.21, I.34-35, and J.41, follows. The monitoring report from Drs. Dvoskin and Metzner contains a more detailed review of the Jails’ MOA and Corrective Action Plan compliance, as well as additional recommendations for achieving compliance.
§ IV.B. Evaluation
7. Within 24 hours of admittance to IRC (excluding weekends and legal holidays as long as an urgent evaluation is not indicated), the County shall provide an adequate mental health care evaluation of inmates who screen positive for possible mental illness at IRC. Within 72 hours of admittance to IRC, the County shall provide a mental health care evaluation to inmates admitted to IRC on the weekends or legal holidays (unless an urgent evaluation is indicated). If the evaluation identifies a serious mental illness, the evaluation shall result in a brief initial treatment plan.
Partial Compliance.
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Subject to the discussion above regarding screening issues identified in relation to our suicide prevention conclusions, much of the reception and screening process at the Jails continues to function well. There is some evidence, in an effort to avoid false-negative screening results, that mental health staff are now over-identifying too many prisoners for follow-up assessment. Any attempt to remedy this problem should be addressed carefully. Overcorrection could result in an increase in false negative conclusions, which have far more dangerous consequences.
§ IV.C. Referrals
10. Mental health staff shall make weekly rounds in locked down non-mental health housing modules (e.g. administrative segregation, disciplinary segregation) at the Jail to identify inmates who may have been missed during screening or who have decompensated while in the Jail.
Partial Compliance.
Currently, the mental health teams conduct rounds throughout the male non-mental health housing areas and respond to crises and referrals. Given the dramatic increase in the number of prisoners with mental illness living in non-mental health housing throughout the system, it is a challenge to provide adequate treatment to everyone in need. We identified many prisoners in non-mental health housing who were currently experiencing symptoms of serious mental illness, particularly in the Men’s Central Jail. Every prisoner with mental illness housed in the Men’s Central Jail non-mental health housing should be seen at least once every month by a psychiatrist to ensure that the prisoner’s mental health status is not deteriorating in the difficult environment at Men’s Central Jail. We also recommend consideration of creating a mental health housing unit for prisoners believed to be vulnerable due to the nature of their charge or other reasons, who are currently segregated in Men’s Central Jail.
In addition, it is important that the Jails take into account any impact that a prisoner’s mental health status may have on his or her actions that contributed on the behavior leading to an assignment to administrative or disciplinary segregation. To the extent that mental health staff identify individuals in locked down non-mental health housing who ought to be moved, either because segregation is having a negative impact on the prisoner’s mental state or because the prisoner’s disciplinary infraction was due to his or her mental health diagnosis, the Sheriff’s Department must consider such mental health recommendations with regard to a prisoner’s housing assignment. Custody staff must also consult with mental health staff when an inmate with mental health issues is subject to discipline.
11. The Jail will maintain a confidential self-referral system by which inmates can request mental health care without revealing the substance of their request to correctional officers.
Partial Compliance.
To address this MOA provision, the County committed to Corrective Action Plan 4.17, which requires the Jails to provide reasonable access to clinicians and psychiatrists through a self-referral process. The Jails’ own data indicate compliance with regard to prisoners in most male mental health housing, but there is inconsistent information regarding compliance for
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prisoners in CRDF and a need for a quality assurance initiative to track access for prisoners who are not in mental health housing.
§ IV.D. Treatment
13. The County shall ensure continuity of appropriate medicine to individuals identified as mentally ill who were receiving medicine prior to entering the Jail.
Partial Compliance.
While we found greater consistency with regard to medication continuity, a minority of prisoners continued to experience two- to three-day delays in receiving their medications following the initial orders by the psychiatrist.
20. Inmate trusties shall never be placed in a supervisory position or used as escorts for mentally ill inmates or inmates in mental health housing. Inmate trusties shall be carefully selected and screened before being assigned trustie positions. Where trusties are allowed to work in mental health housing, they shall be closely monitored.
Sustained Compliance.
While this provision is in sustained compliance, we note that in some areas of the Jails, such as the K6G dormitory units and CRDF, prisoners must use trustees to submit their medical and mental health request slips to designated deputies for collection. An alternative method of collection must be implemented so that other prisoners are not assigned the responsibility to collect and deliver these sensitive medical documents.
§ IV.E. Medication Administration
21. The County shall ensure that a full range of appropriate psychotropic medications is available at the Jail and that psychotropic medications are properly prescribed, monitored and documented by appropriately trained mental health professionals.
Partial Compliance.
The Jails’ quality improvement initiatives demonstrate that policies and procedures have been successfully implemented with regard to bridging medication orders and timely renewal of psychotropic medications. Issues remain with regard to obtaining relevant laboratory studies, but the Jails are appropriately addressing the problem. The Jails’ quality improvement studies were generally consistent with prisoner reports relevant to medication management issues. However, a minority of prisoners continued to experience two- to three-day delays in receiving their medications following the initial orders by the psychiatrist.
§ IV.I. Staffing and Training
34. The County shall provide sufficient mental health staffing to ensure timely access to adequate mental health treatment and meet the obligations and provide the services listed in this Agreement. Except for staffing for the women's case load population and the Forensic Inpatient Program, mental health staffing shall be no lower than one psychiatrist per 100 inmates who require medication. Staffing for the women's case load population shall be enhanced due to
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higher utilization rates of mental health services. Staffing for the Forensic Inpatient Program shall ensure timely access to adequate treatment and shall minimally meet licensure standards currently governing such program.
Partial Compliance.
As mentioned above, in response to the increased population of the Jails due to changes in State law, the number of mental health services staff at the Jails has increased. The current mental health staffing is sufficient and the number of vacancies has remained low. In most areas, the Jails have attained full compliance with the staffing requirements for psychiatry, including an acceptable level of psychiatric staffing enhancement for the women’s population. The psychiatrist-to-patient ratio in non-mental health housing is approximately 1:73, as compared to earlier finding of 1:350. However, we reiterate our concerns with regard to staffing in CRDF, especially the lack of a dedicated Jail Mental Evaluation Team.
35. A psychiatrist shall be available, at least by telephone, twenty-four hours per day to evaluate and prescribe psychotropic medications in emergency situations.
Partial Compliance.
Psychiatric coverage and the number of vacancies remain low. However, the low level of custody staffing is negatively impacting the psychiatrists’ ability to evaluate and treat prisoners in a timely manner. Until this issue is resolved, psychiatrists will be hampered from providing adequate treatment.
§ IV.J. Quality Assurance
41. The County shall implement and document a continuous quality improvement program for mental health services in the Jail. The continuous quality improvement program shall monitor the quality of mental health care.
Partial Compliance.
The quality improvement process continues to improve. The Jails have implemented many quality improvement initiatives, some of which have yielded timely and effective results. For example, one quality improvement study regarding continuity of psychiatric medications on a particular unit revealed that a significant problem was being caused because of the need for an additional high-volume printer, and the problem was easily remedied. This is a wonderful example of how quality improvement projects are supposed to work; the team analyzed and identified the source of the problem and an inexpensive solution that had previously been missed, to the detriment of psychiatric care. As a result, medication continuity and psychiatric care was dramatically improved. However, the Jails need to broaden efforts not only to identify problem areas for additional quality improvement initiatives, but to ensure remedial actions are taken as a result of these studies. In addition, the discrepant information obtained relevant to the involvement by mental health line staff in the quality improvement process is very concerning.
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VI. CONCLUSION
We applaud the cooperative and productive partnership the CoUnty has formed and continued with the Department of Justice with regard to reforms at the Los Angeles County Jail System. We also commend the strides made in most areas ofMOA compliance. As discussed, this commitment and demonstrated improvement allows us to recommend removing the provisions in sustained compliance from further MOA monitoring by the Department of Justice. However, given the gravity of the conclusions with regard to the Jails' deficient suicide prevention program and the serious harm posed as a result, we recommend that the County negotiate with the Department of Justice regarding the terms of a court:,enforceable settlement governing remedial suicide prevention measures at the Jails. We hope to continue working with County officials in an amicable and cooperative fashion to resolve our outstanding concerns regarding the Jails.
Please note that this assessment is a public document. It will be posted on the Civil Rights Division's website. We are obligated to advise you that, in the event that we are unable to reach a resolution regarding our concerns with regard suicide prevention, the Attorney General may initiate a lawsuit pursuant to CRIPA to correct deficiencies of the kind identified in this letier anytime following the date that is 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working cooperatively with you. The lawyers assigned to this investigation will be contacting the County to discuss this matter in further detail. Please contact us if you have any questions. You may reach Jonathan Smith at (202) 514-5393, Luis Saucedo at (202) 598-0482, or Robby Monteleone at (213) 894-2458.

Sincerely,

~ J'r~.---­ Birotte,
United States Attorney Central District of California

cc: Beong-Soo Kim, Esq. Jones Day
Attachments

- 36-

 
 Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 1 of 22
ACCO,(JEMx),CLOSED,DISCOVERY,MANADR,RELATED−G
UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA (Western Division − Los Angeles)
CIVIL DOCKET FOR CASE #: 2:15−cv−05903−DDP−JEM

United States America v. County of Los Angeles et al Assigned to: Judge Dean D. Pregerson Referred to: Magistrate Judge John E. McDermott Related Case: 2:75−cv−04111−DDP Cause: 42:1981 Civil Rights
Plaintiff

Date Filed: 08/05/2015 Date Terminated: 09/03/2015 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States America

represented by Luis E Saucedo US Department of Justice Civil Rights Division − Special Litigation Section 950 Pennsylvania Avenue NW Washington, DC 20530 202−598−0482 Fax: 202−514−4883 Email: luis.e.saucedo@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Matthew Edward Nickell AUSA − Office of US Attorney Civil Division 300 North Los Angeles Street Suite 7516 Los Angeles, CA 90012 213−894−8805 Fax: 213−894−7819 Email: matthew.nickell@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Geoffrey Daniel Wilson AUSA − Office of US Attorney Civil Division 300 North Los Angeles Street Room 7516 Los Angeles, CA 90012 213−894−2420 Fax: 213−894−7819 Email: geoffrey.wilson@usdoj.gov TERMINATED: 07/22/2016

Joanna Berney Hull AUSA − Office of the US Attorney 300 North Los Angeles Street Room 7516 Los Angeles, CA 90012 213−894−6585 Fax: 213−894−7819 Email: joanna.hull@usdoj.gov TERMINATED: 08/01/2018

Robyn−Marie L Monteleone AUSA − Office of US Attorney Civil Division 300 North Los Angeles Street Suite 7516 Los Angeles, CA 90012 213−894−2458 Fax: 213−894−7819 Email: USACAC.Civil@usdoj.gov TERMINATED: 07/22/2016

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 2 of 22

V. Intervenor Plaintiff Teresa Powers

represented by Alisa Louise Hartz Public Counsel 610 South Ardmore Avenue Los Angeles, CA 90005 213−359−2977 Fax: 213−385−9089 Email: ahartz@publiccounsel.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
Anne K Richardson Public Counsel 610 South Ardmore Avenue Los Angeles, CA 90005 213−385−2977 Fax: 213−385−9089 Email: arichardson@publiccounsel.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
Gary Lee Blasi Public Counsel Law Center 610 South Ardmore Avenue Los Angeles, CA 90005 213−385−2977 Fax: 213−385−9089 Email: gblasi@publiccounsel.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
Grant A Davis−Denny Munger Tolles and Olson 355 South Grand Avenue, 35th Floor Los Angeles, CA 90017 213−683−9100 Email: grant.davis−denny@mto.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
L Adelaide Anderson Public Counsel 610 South Ardmore Avenue Los Angeles, CA 90005 213−385−2977 Fax: 213−385−9089 Email: aanderson@publiccounsel.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
Mark D Rosenbaum Public Counsel Law Center 610 South Ardmore Avenue Los Angeles, CA 90005 213−385−2977 Fax: 213−385−9089 Email: mrosenbaum@publiccounsel.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
Bradley S Phillips

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 3 of 22

Munger Tolles and Olson LLP 350 South Grand Avenue 50th Floor Los Angeles, CA 90071−3426 213−683−9100 Fax: 213−687−3702 Email: brad.phillips@mto.com ATTORNEY TO BE NOTICED

Emily Rose DiMento Murphy UC Hastings College of the Law 200 McAllister Street San Francisco, CA 94102 415−565−4648 Fax: 415−565−4865 Email: murphyemily@uchastings.edu ATTORNEY TO BE NOTICED

Thomas P Clancy Munger Tolles and Olson LLP 350 South Grand Avenue Suite 5000 Los Angeles, CA 90071−1560 213−683−9207 Fax: 213−683−5137 Email: Thomas.Clancy@mto.com ATTORNEY TO BE NOTICED

Intervenor Plaintiff David Penn

represented by Alisa Louise Hartz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Anne K Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Gary Lee Blasi (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Grant A Davis−Denny (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

L Adelaide Anderson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Mark D Rosenbaum (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Bradley S Phillips (See above for address) ATTORNEY TO BE NOTICED

Emily Rose DiMento Murphy (See above for address) ATTORNEY TO BE NOTICED

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 4 of 22

Intervenor Plaintiff Timothy Polk
Intervenor Plaintiff Mark Sarni

Thomas P Clancy (See above for address) ATTORNEY TO BE NOTICED
represented by Alisa Louise Hartz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Anne K Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Gary Lee Blasi (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Grant A Davis−Denny (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
L Adelaide Anderson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Mark D Rosenbaum (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Bradley S Phillips (See above for address) ATTORNEY TO BE NOTICED
Emily Rose DiMento Murphy (See above for address) ATTORNEY TO BE NOTICED
Thomas P Clancy (See above for address) ATTORNEY TO BE NOTICED
represented by Alisa Louise Hartz (See above for address) TERMINATED: 09/07/2017 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Anne K Richardson (See above for address) TERMINATED: 09/07/2017 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Gary Lee Blasi (See above for address) TERMINATED: 09/07/2017

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 5 of 22

LEAD ATTORNEY ATTORNEY TO BE NOTICED

Grant A Davis−Denny (See above for address) TERMINATED: 09/07/2017 LEAD ATTORNEY ATTORNEY TO BE NOTICED

L Adelaide Anderson (See above for address) TERMINATED: 09/07/2017 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Mark D Rosenbaum (See above for address) TERMINATED: 09/07/2017 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Bradley S Phillips (See above for address) TERMINATED: 09/07/2017 ATTORNEY TO BE NOTICED

Emily Rose DiMento Murphy (See above for address) TERMINATED: 09/07/2017 ATTORNEY TO BE NOTICED

Thomas P Clancy (See above for address) TERMINATED: 09/07/2017 ATTORNEY TO BE NOTICED

Intervenor Plaintiff Derrick Thomas

represented by Alisa Louise Hartz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Anne K Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Gary Lee Blasi (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Grant A Davis−Denny (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

L Adelaide Anderson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Mark D Rosenbaum (See above for address)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 6 of 22

LEAD ATTORNEY ATTORNEY TO BE NOTICED

Bradley S Phillips (See above for address) ATTORNEY TO BE NOTICED

Emily Rose DiMento Murphy (See above for address) ATTORNEY TO BE NOTICED

Thomas P Clancy (See above for address) ATTORNEY TO BE NOTICED

Intervenor Plaintiff Darsel Whitfield

represented by Alisa Louise Hartz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Anne K Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Gary Lee Blasi (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Grant A Davis−Denny (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

L Adelaide Anderson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Mark D Rosenbaum (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Bradley S Phillips (See above for address) ATTORNEY TO BE NOTICED

Emily Rose DiMento Murphy (See above for address) ATTORNEY TO BE NOTICED

Thomas P Clancy (See above for address) ATTORNEY TO BE NOTICED

Intervenor Plaintiff Royal Williams

represented by Alisa Louise Hartz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 7 of 22

Anne K Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Gary Lee Blasi (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Grant A Davis−Denny (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

L Adelaide Anderson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Mark D Rosenbaum (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Bradley S Phillips (See above for address) ATTORNEY TO BE NOTICED

Emily Rose DiMento Murphy (See above for address) ATTORNEY TO BE NOTICED

Thomas P Clancy (See above for address) ATTORNEY TO BE NOTICED

Intervenor Plaintiff Lepriest Valentine

represented by Alisa Louise Hartz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Anne K Richardson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Gary Lee Blasi (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Grant A Davis−Denny (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

L Adelaide Anderson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Mark D Rosenbaum

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 8 of 22
(See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Bradley S Phillips (See above for address) ATTORNEY TO BE NOTICED
Emily Rose DiMento Murphy (See above for address) ATTORNEY TO BE NOTICED
Thomas P Clancy (See above for address) ATTORNEY TO BE NOTICED

V. Defendant County of Los Angeles

represented by Gregory F Hurley Sheppard Mullin Richter and Hampton LLP 650 Town Center Drive 4th Floor Costa Mesa, CA 92626−1993 714−513−5100 Fax: 714−513−5130 Email: GHurley@sheppardmullin.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Amie S Park Los Angeles County Counsel Office 500 West Temple Street 6th Floor Los Angeles, CA 90012 213−893−5939 Fax: 213−626−2105 Email: apark@counsel.lacounty.gov ATTORNEY TO BE NOTICED
Bradley J Leimkuhler Sheppard Mullin Richter and Hampton LLP 650 Town Center Drive 4th Floor Costa Mesa, CA 92626−1993 714−513−5100 Fax: 714−513−5130 Email: bleimkuhler@sheppardmullin.com ATTORNEY TO BE NOTICED
Justin W Clark Lawrence Beach Allen and Choi PC 100 West Broadway Suite 1200 Glendale, CA 91210−1219 818−545−1925 Fax: 818−545−1937 Email: jclark@lbaclaw.com TERMINATED: 10/21/2015 ATTORNEY TO BE NOTICED
Karen C Joynt Office of County Counsel Los Angeles County 500 West Temple Street Room 605 Los Angeles, CA 90012

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 9 of 22

213−974−0811 Fax: 213−626−2105 Email: kjoynt@counsel.lacounty.gov ATTORNEY TO BE NOTICED

Michael J Chilleen Sheppard Mullin Richter & Hampton LLP 650 Town Center Drive 4th Floor Costa Mesa, CA 92626−1993 714−513−5100 Fax: 714−513−5130 Email: MChilleen@sheppardmullin.com ATTORNEY TO BE NOTICED

Paul B Beach Lawrence Beach Allen and Choi PC 100 West Broadway Suite 1200 Glendale, CA 91210−1219 818−545−1925 Fax: 818−545−1937 Email: pbeach@lbaclaw.com TERMINATED: 10/21/2015 ATTORNEY TO BE NOTICED

Rodrigo A Castro−Silva Office of County Counsel Los Angeles County 500 West Temple Street Room 605 Los Angeles, CA 90012 213−974−1804 Fax: 213−626−7446 Email: rcastro−silva@counsel.lacounty.gov ATTORNEY TO BE NOTICED

Tiana J Murillo Office of the County Counsel County of Los Angeles 500 West Temple Street 6th Floor Los Angeles, CA 90012 213−974−4329 Email: tmurillo@counsel.lacounty.gov TERMINATED: 09/02/2016

Defendant
Jim McDonnell Los Angeles County Sheriff, in his official capacity

represented by Gregory F Hurley (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Amie S Park (See above for address) ATTORNEY TO BE NOTICED

Bradley J Leimkuhler (See above for address) ATTORNEY TO BE NOTICED

Justin W Clark (See above for address) TERMINATED: 10/02/2017 ATTORNEY TO BE NOTICED

Karen C Joynt (See above for address)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 10 of 22
ATTORNEY TO BE NOTICED
Michael J Chilleen (See above for address) ATTORNEY TO BE NOTICED
Paul B Beach (See above for address) TERMINATED: 10/02/2017 ATTORNEY TO BE NOTICED
Rodrigo A Castro−Silva (See above for address) ATTORNEY TO BE NOTICED

Date Filed 08/05/2015 08/05/2015 08/05/2015 08/05/2015 08/05/2015 08/05/2015 08/05/2015
08/06/2015 08/18/2015
08/20/2015
08/20/2015

# Docket Text
1 COMPLAINT No Fee Required − US Government, filed by Plaintiff United States America. (Attorney Robyn−Marie L Monteleone added to party United States America(pty:pla))(Monteleone, Robyn−Marie) (Entered: 08/05/2015)
2 CIVIL COVER SHEET filed by Plaintiff United States America. (Monteleone, Robyn−Marie) (Entered: 08/05/2015)
3 NOTICE of Related Case(s) filed by Plaintiff United States America. Related Case(s): CV 12−00428−DDP(SHx) (Monteleone, Robyn−Marie) (Entered: 08/05/2015)
4 STIPULATION for Settlement filed by Plaintiff United States America. (Attachments: # 1 Settlement Agreement, # 2 Proposed Order)(Monteleone, Robyn−Marie) (Entered: 08/05/2015)
5 NOTICE OF ASSIGNMENT to District Judge Andre Birotte, Jr. and Magistrate Judge John E. McDermott. (ghap) (Entered: 08/05/2015)
6 NOTICE TO PARTIES OF COURT−DIRECTED ADR PROGRAM filed. (ghap) (Entered: 08/05/2015)
7 TEXT ONLY ENTRY: Judge Andre Birotte Jr. is participating in a pilot project regarding the submission of SEALED DOCUMENTS. All proposed sealed documents must be submitted, via e−mail, to the Judge's Chambers email at AB_chambers@cacd.uscourts.gov. Please refer to the Judge's procedures and schedules for detailed instructions for submission of sealed documents. THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (cb) (Entered: 08/05/2015)
8 ORDER TO REASSIGN CASE due to self−recusal pursuant to General Order 14−03 by Judge Andre Birotte, Jr. Case transferred from Judge Andre Birotte, Jr to the calendar of Judge Fernando M. Olguin for all further proceedings. Case number now reads as CV15−05903 FMO (JEMx). (mg) (Entered: 08/06/2015)
9 ORDER RE TRANSFER PURSUANT TO GENERAL ORDER 14−03 −Related Case− filed. Related Case No: CV75−04111 DDP. Case transferred from Judge Fernando M. Olguin to Judge Dean D. Pregerson for all further proceedings. The case number will now reflect the initials of the transferee Judge CV15−05903 DDP (JEMx). Signed by Judge Dean D. Pregerson. (mg) Modified on 9/25/2015 (jy). (Entered: 08/19/2015)
10 Notice of Appearance or Withdrawal of Counsel: for attorney Karen C Joynt counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Karen Joynt as counsel of record for Defendants for the reason indicated in the G−123 Notice. Filed by Defendants County of Los Angeles. (Attorney Karen C Joynt added to party County of Los Angeles(pty:dft), Attorney Karen C Joynt added to party Jim McDonnell(pty:dft))(Joynt, Karen) (Entered: 08/20/2015)
11 Notice of Appearance or Withdrawal of Counsel: for attorney Karen C Joynt counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Rodrigo A. Castro−Silva as counsel of record for Defendants for the reason indicated in the G−123 Notice. Filed by Defendants County of Los Angeles. (Joynt, Karen) (Entered:

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 11 of 22

08/21/2015 09/03/2015 09/03/2015 09/25/2015
09/25/2015
09/28/2015
09/29/2015 09/29/2015 09/29/2015 09/29/2015

08/20/2015)
12 Notice of Appearance or Withdrawal of Counsel: for attorney Geoffrey Daniel Wilson counsel for Plaintiff United States America. Adding Geoffrey D. Wilson as counsel of record for The United States of America for the reason indicated in the G−123 Notice. Filed by Plaintiff The United States of America. (Attorney Geoffrey Daniel Wilson added to party United States America(pty:pla))(Wilson, Geoffrey) (Entered: 08/21/2015)
13 ORDER APPROVING AND ENTERING JOINT SETTLEMENT AGREEMENT AS AN ORDER 4 by Judge Dean D. Pregerson (lc) (Entered: 09/03/2015)
14 JOINT SETTLEMENT AGREEMENT REGARDING THE LOS ANGELES COUNTY JAILS; AND STIPULATED ORDER OF RESOLUTION by Judge Dean D. Pregerson (Made JS−6. Case Terminated.) (lc) (Entered: 09/03/2015)
15 Notice of Appearance or Withdrawal of Counsel: for attorney Paul B Beach counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Paul B. Beach as counsel of record for County of Los Angeles and Los Angeles County Sheriff Jim McDonnell, in his official capacity only for the reason indicated in the G−123 Notice. Filed by DEFENDANTS County of Los Angeles and Los Angeles County Sheriff Jim McDonnell, in his official capacity only. (Attorney Paul B Beach added to party County of Los Angeles(pty:dft), Attorney Paul B Beach added to party Jim McDonnell(pty:dft))(Beach, Paul) (Entered: 09/25/2015)
16 Notice of Appearance or Withdrawal of Counsel: for attorney Justin W Clark counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Justin W. Clark as counsel of record for County of Los Angeles and Los Angeles County Sheriff Jim McDonnell, in his official capacity only for the reason indicated in the G−123 Notice. Filed by DEFENDANTS County of Los Angeles and Los Angeles County Sheriff Jim McDonnell, in his official capacity only. (Attorney Justin W Clark added to party County of Los Angeles(pty:dft), Attorney Justin W Clark added to party Jim McDonnell(pty:dft))(Clark, Justin) (Entered: 09/25/2015)
17 NOTICE OF MOTION AND MOTION to Intervene filed by Movants Teresa Powers, David Penn, Timothy Polk, Mark Sarni, Derrick Thomas, Darsel Whitfield, Royal Williams, Lepriest Valentine. Motion set for hearing on 10/26/2015 at 10:00 AM before Judge Dean D. Pregerson. (Attachments: # 1 Declaration Index of declarations ISO Motion to intervene Vol 1 of 2, # 2 Declaration Index of declarations ISO Motion to intervene Vol 2 of 2, # 3 Notice of Lodging of Proposed Complaint in Intervention; Proposed Complaint in Intervention, # 4 Notice of Interested Parties, # 5 Proposed Order Proposed Order, # 6 Certificate of Service) (Attorney Bradley S Phillips added to party Teresa Powers(pty:mov), Attorney Bradley S Phillips added to party David Penn(pty:mov), Attorney Bradley S Phillips added to party Timothy Polk(pty:mov), Attorney Bradley S Phillips added to party Mark Sarni(pty:mov), Attorney Bradley S Phillips added to party Derrick Thomas(pty:mov), Attorney Bradley S Phillips added to party Darsel Whitfield(pty:mov), Attorney Bradley S Phillips added to party Royal Williams(pty:mov), Attorney Bradley S Phillips added to party Lepriest Valentine(pty:mov)) (Phillips, Bradley) (Entered: 09/28/2015)
18 NOTICE of Appearance filed by attorney Bradley S Phillips on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Phillips, Bradley) (Entered: 09/29/2015)
19 NOTICE of Appearance filed by attorney Bradley S Phillips on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Phillips, Bradley) (Entered: 09/29/2015)
20 NOTICE of Appearance filed by attorney Bradley S Phillips on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Phillips, Bradley) (Entered: 09/29/2015)
21 NOTICE of Appearance filed by attorney Bradley S Phillips on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Phillips, Bradley) (Entered: 09/29/2015)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 12 of 22

09/29/2015 09/29/2015 09/29/2015 09/29/2015 09/29/2015 09/29/2015
10/01/2015
10/05/2015
10/08/2015 10/08/2015 10/08/2015 10/09/2015 10/09/2015

22 NOTICE of Appearance filed by attorney Bradley S Phillips on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Phillips, Bradley) (Entered: 09/29/2015)
23 NOTICE of Appearance filed by attorney Bradley S Phillips on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Phillips, Bradley) (Entered: 09/29/2015)
24 NOTICE of Appearance filed by attorney Bradley S Phillips on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Phillips, Bradley) (Entered: 09/29/2015)
25 Notice of Appearance or Withdrawal of Counsel: for attorney Karen C Joynt counsel for Defendant County of Los Angeles. Adding Tiana J. Murillo as counsel of record for Defendants for the reason indicated in the G−123 Notice. Filed by Defendants County of Los Angeles. (Joynt, Karen) (Entered: 09/29/2015)
26 MINUTE ORDER IN CHAMBERS by Judge Dean D. Pregerson: COUNSEL ARE NOTIFIED, that on the Court's own motion, a STATUS CONFERENCE RE: MOTION TO INTERVENE FILED BY MOVANTS is hereby set for Thursday, October 1, 2015 at 11:30 AM. (lc) (Entered: 09/29/2015)
27 NOTICE OF ERRATA filed by Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. correcting NOTICE OF MOTION AND MOTION to Intervene 17 (Attachments: # 1 Declaration (Corrected) Index of Evidence ISO Motion to Intervene (Volume 1 of 2), # 2 Declaration (Corrected) Index of Evidence ISO Motion to Intervene (Volume 2 of 2))(Phillips, Bradley) (Entered: 09/29/2015)
28 MINUTES OF STATUS CONFERENCE RE: MOTION TO INTERVENE FILED BY MOVANTS(DOCKET NUMBER 17) held before Judge Dean D. Pregerson: Court and counsel confer as reflected on the record. The matter is continued to Friday, October 9, 2015 at 3:00 p.m. The briefing schedule for the Motion to Intervene will be discussed onFriday, October 9, 2015 at 3:00 p.m. Therefore, the Opposition is not due onMonday, October 5, 2015. Court Reporter: Maria Bustillos. (lc) (Entered: 10/01/2015)
29 Notice of Appearance or Withdrawal of Counsel: for attorney Emily Rose DiMento Murphy counsel for Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. Adding Emily R.D. Murphy as counsel of record for Teresa Powers; David Penn; Timothy Polk; Mark Sarni; Derrick Thomas; Darsel Whitfield; Royal Williams; Lepriest Valentine for the reason indicated in the G−123 Notice. Filed by Plaintiff−Intervenors Teresa Powers. (Attorney Emily Rose DiMento Murphy added to party Teresa Powers(pty:mov))(Murphy, Emily) (Entered: 10/05/2015)
30 STATUS REPORT TO THE COURT RE CONFLICT ISSUES filed by Defendants County of Los Angeles, Jim McDonnell. (Beach, Paul) (Entered: 10/08/2015)
31 STATUS REPORT (Further Status Conference) filed by Plaintiff United States America. (Monteleone, Robyn−Marie) (Entered: 10/08/2015)
32 NOTICE of Appearance filed by attorney Luis E Saucedo on behalf of Plaintiff United States America (Attorney Luis E Saucedo added to party United States America(pty:pla))(Saucedo, Luis) (Entered: 10/08/2015)
33 DECLARATION of Bradley S. Phillips re Status Report 30 In Response to Status Report By County Of Los Angelles filed by Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Phillips, Bradley) (Entered: 10/09/2015)
34 MINUTES OF STATUS CONFERENCE RE: MOTION TO INTERVENE FILED BY MOVANTS held before Judge Dean D. Pregerson: Court and counsel confer as reflected on the record. The MOTION TO INTERVENE 17 is hereby continued from October 26, 2015 to Tuesday, November 3, 2015 at 10:00 a.m., with the OPPOSITION to be filed not later than October 21, 2015, with the REPLY to be filed not later than October 28, 2015.Court Reporter: Lisa Gonzalez. (lc) (Entered: 10/09/2015)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 13 of 22

10/09/2015 10/09/2015 10/14/2015 10/15/2015
10/15/2015
10/15/2015
10/15/2015 10/16/2015 10/16/2015 10/16/2015

35 NOTICE OF LODGING filed Notice of Lodging of Proposed Revisions to Paragraph 34 re Order, Terminated Case 14 (Attachments: # 1 Proposed Revisions to Paragraph 34 and Appendices)(Murphy, Emily) (Entered: 10/09/2015)
36 NOTICE of Appearance filed by attorney Emily Rose DiMento Murphy on behalf of Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams (Murphy, Emily) (Entered: 10/09/2015)
37 NOTICE OF LODGING filed re Complaint (Attorney Civil Case Opening) 1 (Attachments: # 1 [First Amended Proposed] Complaint in Intervention, # 2 Legal Blackline Comparing First Amended Proposed Complaint and Original Complaint in Intervention)(Murphy, Emily) (Entered: 10/14/2015)
38 Notice of Appearance or Withdrawal of Counsel: for attorney Gregory F Hurley counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Gregory F. Hurley as counsel of record for County of Los Angeles and Los Angeles County Sheriff Jim McDonnell for the reason indicated in the G−123 Notice. Filed by defendant County of Los Angeles and Los Angeles County Sheriff Jim McDonnell. (Attorney Gregory F Hurley added to party County of Los Angeles(pty:dft), Attorney Gregory F Hurley added to party Jim McDonnell(pty:dft))(Hurley, Gregory) (Entered: 10/15/2015)
39 Notice of Appearance or Withdrawal of Counsel: for attorney Michael J Chilleen counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Michael J. Chilleen as counsel of record for County of Los Angeles and Los Angeles County Sheriff Jim McDonnell for the reason indicated in the G−123 Notice. Filed by defendant County of Los Angeles and Los Angeles County Sheriff Jim McDonnell. (Attorney Michael J Chilleen added to party County of Los Angeles(pty:dft), Attorney Michael J Chilleen added to party Jim McDonnell(pty:dft))(Chilleen, Michael) (Entered: 10/15/2015)
40 Notice of Appearance or Withdrawal of Counsel: for attorney Bradley J Leimkuhler counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Bradley J. Leimkuhler as counsel of record for County of Los Angeles and Los Angeles County Sheriff Jim McDonnell for the reason indicated in the G−123 Notice. Filed by defendant County of Los Angeles and Los Angeles County Sheriff Jim McDonnell. (Attorney Bradley J Leimkuhler added to party County of Los Angeles(pty:dft), Attorney Bradley J Leimkuhler added to party Jim McDonnell(pty:dft))(Leimkuhler, Bradley) (Entered: 10/15/2015)
41 EX PARTE APPLICATION for Extension of Time to File Opposition to Motion to Intervene filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Memorandum of Points & Authorities in Support of Ex Parte Application for Extension of Time, # 2 Declaration of Chilleen in Support of Ex Parte Application for Extension of Time, # 3 Proposed Order Granting Ex Parte Application for Extension of Time) (Hurley, Gregory) (Entered: 10/15/2015)
42 OPPOSITION re: EX PARTE APPLICATION for Extension of Time to File Opposition to Motion to Intervene 41 filed by Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration Rosenbaum, # 2 Exhibit A)(Davis−Denny, Grant) (Entered: 10/16/2015)
43 MINUTES (IN CHAMBERS) by Judge Dean D. Pregerson. COUNSEL ARE NOTIFIED the EX PARTE APPLICATION FOR EXTENSION OF TIME 41 is DENIED. The parties agreed to a briefing schedule at the most recent hearing regarding this matter. (lom) (Entered: 10/16/2015)
44 NOTICE OF MOTION AND MOTION to Disqualify Counsel Munger, Tolles & Olson, LLP filed by Defendants County of Los Angeles, Jim McDonnell. Motion set for hearing on 11/16/2015 at 10:00 AM before Judge Dean D. Pregerson. (Attachments: # 1 Memorandum of Points & Authorities in Support of Motion to Disqualify Counsel, # 2 Declaration of Castro−Silva in Support of Motion to Disqualify Counsel, # 3 Exhibit A to Declaration of Castro−Silva, # 4 Exhibit B to Declaration of Castro−Silva, # 5 Exhibit C to Declaration of Castro−Silva, # 6 Exhibit D to Declaration of Castro−Silva, # 7 Exhibit E to Declaration of Castro−Silva, # 8

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 14 of 22

10/19/2015 10/20/2015
10/20/2015 10/21/2015 10/21/2015
10/21/2015
10/21/2015 10/21/2015 10/21/2015 10/21/2015 10/22/2015 10/22/2015

Exhibit F to Declaration of Castro−Silva, # 9 Proposed Order Granting Defendants' Motion to Disqualify Counsel) (Hurley, Gregory) (Entered: 10/16/2015)
45 REQUEST TO WITHDRAW ATTORNEY Paul B. Beach and Justin W. Clark as counsel of record filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 (Proposed) Order on Request for Approval of Substitution of Attorney) (Beach, Paul) Modified on 10/20/2015 (lc). (STRICKEN PER 1020/15 MINUTES). (Entered: 10/19/2015)
46 MINUTE ORDER IN CHAMBERS by Judge Dean D. Pregerson: COUNSEL ARE NOTIFIED that the document entitled REQUEST TO WITHDRAW, filed on October 19, 2015, docket number 45 was filed incorrectly by not sending a PDF of the document and a Word or WordPerfect copy of the [proposed] order to the chambers email address and therefore ordered STRICKEN from the docket. Counsel shall review the electronic filing procedures and re−file the document forthwith. (lc) (Entered: 10/20/2015)
47 REQUEST TO WITHDRAW ATTORNEY Paul B. Beach and Justin W. Clark as counsel of record filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Proposed Order) (Beach, Paul) (Entered: 10/20/2015)
48 ORDER by Judge Dean D. Pregerson: granting 47 Request to Substitute Attorney Gregory F. Hurley in place and instead of Paul B. Beach and Justin W. Clark, Lawrence Beach Allen & Choi, PC, on behalf of defendants LA County and LA County Sheriff. (lc) (Entered: 10/21/2015)
49 TRANSCRIPT ORDER as to Plaintiff−Intervenors David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield Court Reporter. Court will contact Mary Pantoja at mary.pantoja@mto.com with any questions regarding this order. Transcript portion requested: Other: 10/09/15. Transcript preparation will not begin until payment has been satisfied with the court reporter/recorder. (Phillips, Bradley) (Entered: 10/21/2015)
50 TRANSCRIPT ORDER as to Plaintiff−Intervenors David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield Court Reporter. Court will contact Mary Pantoja at mary.pantoja@mto.com with any questions regarding this order. Transcript portion requested: Other: 10/01/15. Transcript preparation will not begin until payment has been satisfied with the court reporter/recorder. (Phillips, Bradley) (Entered: 10/21/2015)
51 MEMORANDUM in Opposition to NOTICE OF MOTION AND MOTION to Intervene 17 filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Declaration Michael J. Chilleen)(Hurley, Gregory) (Entered: 10/21/2015)
52 Objections to Evidence in opposition re: NOTICE OF MOTION AND MOTION to Intervene 17 filed by Defendants County of Los Angeles, Jim McDonnell. (Hurley, Gregory) (Entered: 10/21/2015)
53 OPPOSITION re: NOTICE OF MOTION AND MOTION to Intervene 17 filed by Plaintiff United States America. (Monteleone, Robyn−Marie) (Entered: 10/21/2015)
54 NOTICE OF ERRATA filed by Defendants County of Los Angeles, Jim McDonnell. correcting MEMORANDUM in Opposition to Motion 51 Exhibit A to Declaration of Chilleen (Attachments: # 1 Exhibit A to Notice of Errata (Exhibit A to Declaration of Michael J. Chilleen))(Hurley, Gregory) (Entered: 10/21/2015)
55 TRANSCRIPT ORDER as to Defendant County of Los Angeles, Jim McDonnell Court Reporter. Court will contact Carrie Strand at cstrand@sheppardmullin.com with any questions regarding this order. Transcript portion requested: Transcript preparation will not begin until payment has been satisfied with the court reporter/recorder. (Hurley, Gregory) (Entered: 10/22/2015)
56 TRANSCRIPT ORDER as to Defendant County of Los Angeles, Jim McDonnell Court Reporter. Court will contact Carrie Strand at cstrand@sheppardmullin.com with any questions regarding this order. Transcript portion requested: Other: 10/9/2015. Transcript preparation will not begin until payment has been satisfied with the court reporter/recorder. (Hurley, Gregory) (Entered: 10/22/2015)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 15 of 22

10/26/2015 10/26/2015 10/28/2015 10/28/2015
10/29/2015 11/02/2015 11/05/2015
11/05/2015 11/05/2015
11/06/2015 11/06/2015 11/09/2015

57 OPPOSITION TO re: NOTICE OF MOTION AND MOTION to Disqualify Counsel Munger, Tolles & Olson, LLP 44 filed by Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration)(Phillips, Bradley) (Entered: 10/26/2015)
58 EX PARTE APPLICATION to Exceed Page Limitation filed by Intervenors David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration Alisa Hartz, # 2 Proposed Order) (Clancy, Thomas) (Entered: 10/26/2015)
59 ORDER GRANTING PLAINTIFF−INTERVENORS REQUEST TO FILE ENLARGED REPLY BRIEF NOT TO EXCEED 35 PAGES 58 by Judge Dean D. Pregerson (lc) (Entered: 10/28/2015)
60 REPLY IN SUPPORT OF NOTICE OF MOTION AND MOTION to Intervene 17 filed by Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration of Susan Burton, # 2 RESPONSE TO DEFENDANTS OBJECTIONS TO EVIDENCE IN SUPPORT OF THEIR OPPOSITION TO MOTION TO INTERVENE)(Clancy, Thomas) (Entered: 10/28/2015)
61 MINUTE ORDER IN CHAMBERS by Judge Dean D. Pregerson: COUNSEL ARE NOTIFIED, on the Court's own motion, the MOTION TO INTERVENE 17 is hereby continued from November 3, 2015 to November 23, 2015 at 10:00 a.m. (lc) (Entered: 10/29/2015)
62 REPLY in Support of Motion to NOTICE OF MOTION AND MOTION to Disqualify Counsel Munger, Tolles & Olson, LLP 44 filed by Defendants County of Los Angeles, Jim McDonnell. (Hurley, Gregory) (Entered: 11/02/2015)
63 TRANSCRIPT for proceedings held on 100915, 10:12 a.m.. Court Reporter/Electronic Court Recorder: Lisa M. Gonzalez, phone number 213−894−2979; CSRLISAG@AOL.COM. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Electronic Court Recorder before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Notice of Intent to Redact due within 7 days of this date. Redaction Request due 11/27/2015. Redacted Transcript Deadline set for 12/7/2015. Release of Transcript Restriction set for 2/3/2016. (Gonzalez, Lisa) (Entered: 11/05/2015)
64 NOTICE OF FILING TRANSCRIPT filed for proceedings 100915, 10:12 a.m. re Transcript 63 THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (Gonzalez, Lisa) TEXT ONLY ENTRY (Entered: 11/05/2015)
65 EX PARTE APPLICATION to Supplement Brief re MEMORANDUM in Opposition to Motion 51 filed by Defendant County of Los Angeles, Jim McDonnell. (Attachments: # 1 Memorandum of Point and Authorities in Support of Ex Parte Application to File Supplemental Brief, # 2 Declaration of Hurley in Support of Ex Parte Application to File Supplemental Brief, # 3 Exhibit A to Declaration of Hurley in Support of Ex Parte Application, # 4 Exhibit B to Declaration of Hurley in Support of Ex Parte Application, # 5 Proposed Order Granting Ex Parte Application to File Supplemental Brief) (Hurley, Gregory) (Entered: 11/05/2015)
66 ORDER GRANTING EX PARTE APPLICATION TO FILE SUPPLEMENTAL BRIEF 65 by Judge Dean D. Pregerson: Defendants may file a supplemental brief in opposition to ProposedIntervenors Motion to Intervene. (lc) (Entered: 11/06/2015)
67 SUPPLEMENT Supplemental Brief in Opposition to Proposed Intervenors' Motion to Intervene filed by Defendants County of Los Angeles, Jim McDonnell. (Hurley, Gregory) (Entered: 11/06/2015)
68 EX PARTE APPLICATION for Leave to file RESPONSE TO DEFENDANTS' SUPPLEMENTAL BRIEF IN OPPOSITION TO PLAINTIFF−INTERVENORS' MOTION TO INTERVENE filed by PLAINTIFF−INTERVENORS David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration Alisa Hartz, # 2 Exhibit A, # 3 Exhibit B, # 4 Proposed Order) (Clancy, Thomas) (Entered: 11/09/2015)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 16 of 22

11/10/2015 11/10/2015 11/10/2015 11/20/2015 11/25/2015
11/30/2015
12/15/2015 01/14/2016 01/15/2016 01/19/2016
01/27/2016 02/01/2016 03/01/2016

69 MINUTE ORDER IN CHAMBERS by Judge Dean D. Pregerson:COUNSEL ARE NOTIFIED, on the Court's own motion, the MOTION TO DISQUALIFY COUNSEL MUNGER, TOLLES & OLSON, LLP FILED BY DEFENDANTS COUNTY OF LOS ANGELES, JIM MCDONNELL 44 is hereby continued from November 16, 2015 to November 23, 2015 at 10:00 a.m. (lc) (Entered: 11/10/2015)
70 ORDER GRANTING PLAINTIFF−INTERVENORS REQUEST TO FILE RESPONSE TODEFENDANTS SUPPLEMENTAL BRIEF 68 by Judge Dean D. Pregerson (lc) (Entered: 11/10/2015)
71 RESPONSE IN SUPPORT of NOTICE OF MOTION AND MOTION to Intervene 17 filed by Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Murphy, Emily) (Entered: 11/10/2015)
72 DECLARATION of Timothy Polk in support of motion to intervene NOTICE OF MOTION AND MOTION to Intervene 17 (Supplemental Declaration) filed by Movants David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Murphy, Emily) (Entered: 11/20/2015)
73 MINUTES OF Motion Hearing held before Judge Dean D. Pregerson: RE MOTION TO INTERVENE MOTION TO DISQUALIFY COUNSEL MUNGER, TOLLES AND OLSON, LLP FILED BY DEFENDANTS COUNTY OF LOS ANGELES, JIM MCDONNELL. Court hears oral argument and rules as follows: Motion to Intervene 17 is taken under submission with an order to be issued hereafter. The Motion to Disqualify 44 is DENIED.Court Reporter: Maria Bustillos. (lc) (Entered: 11/25/2015)
74 TRANSCRIPT ORDER as to Plaintiff−Intervenors David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams for Court Reporter. Court will contact Mary Pantoja at mary.pantoja@mto.com with any questions regarding this order. Transcript preparation will not begin until payment has been satisfied with the court reporter. (Phillips, Bradley) (Entered: 11/30/2015)
75 ORDER GRANTING MOTION TO INTERVENE filed by Teresa Powers, David Penn, Timothy Polk, Mark Sarni, Derrick Thomas, Darsel Whitfield, Royal Williams, and Lepriest Valentine 17 by Judge Dean D. Pregerson (lc). Modified on 12/15/2015 .(lc). (Entered: 12/15/2015)
76 FIRST AMENDED COMPLAINT against Defendants County of Los Angeles, Jim McDonnell amending Complaint (Attorney Civil Case Opening) 1 , filed by Intervenors Darsel Whitfield, Mark Sarni, Teresa Powers, Timothy Polk, Lepriest Valentine, Derrick Thomas, David Penn, Royal Williams(Murphy, Emily) (Entered: 01/14/2016)
77 STATUS REPORT AND REQUEST FOR STATUS CONFERENCE filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D)(Murphy, Emily) (Entered: 01/15/2016)
78 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: Status Report, 77 includes request for status conference. The following error(s) was found: missing Proposed order which was not submitted as separate attachment. In response to this notice the court may order (1) an amended or correct document to be filed (2) the document stricken or (3) take other action as the court deems appropriate. You need not take any action in response to this notice unless and until the court directs you to do so. (lc) (Entered: 01/19/2016)
79 RESPONSE filed by Defendants County of Los Angeles, Jim McDonnellto Status Report, 77 (Hurley, Gregory) (Entered: 01/27/2016)
80 ANSWER to Amended Complaint/Petition, 76 filed by defendants County of Los Angeles, Jim McDonnell.(Hurley, Gregory) (Entered: 02/01/2016)
81 MONITOR'S FIRST REPORT filed by Defendant County of Los Angeles. (Drooyan, Richard) (Entered: 03/01/2016)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 17 of 22

03/08/2016 03/09/2016
03/14/2016 03/17/2016 03/17/2016
03/17/2016 03/21/2016
03/28/2016 03/28/2016 04/04/2016 04/06/2016

82 JOINT REPORT REPORT of RULE 26(F) PLAN filed by Intervenor Plaintiff Teresa Powers. (Clancy, Thomas) (Entered: 03/08/2016)
83 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: Report 82 . The following error(s) was found: Incorrect event selected. The correct event is: Joint Rule 26(f) Discovery Plan. In response to this notice the court may order (1) an amended or correct document to be filed (2) the document stricken or (3) take other action as the court deems appropriate. You need not take any action in response to this notice unless and until the court directs you to do so. (lc) (Entered: 03/09/2016)
84 NOTICE OF MOTION AND MOTION for Judgment on the Pleadings as to Intervenors' First Amended Complaint in Intervention filed by defendants County of Los Angeles, Jim McDonnell. Motion set for hearing on 4/11/2016 at 10:00 AM before Judge Dean D. Pregerson. (Attachments: # 1 Memorandum in Support of Motion for Judgment on the Pleadings, # 2 Proposed Judgment) (Hurley, Gregory) (Entered: 03/14/2016)
85 EX PARTE APPLICATION to Continue Motion for Judgment on the Pleadings from April 11, 2016 to a date selected by the Court Re: NOTICE OF MOTION AND MOTION for Judgment on the Pleadings as to Intervenors' First Amended Complaint in Intervention 84 filed by Plaintiff−Intervenor David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Proposed Order) (Hartz, Alisa) (Entered: 03/17/2016)
86 OPPOSITION to EX PARTE APPLICATION to Continue Motion for Judgment on the Pleadings from April 11, 2016 to a date selected by the Court Re: NOTICE OF MOTION AND MOTION for Judgment on the Pleadings as to Intervenors' First Amended Complaint in Interventi 85 filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Exhibit A to Defendants' Response to Plaintiff−Intervenors Ex Parte Application to Continue Hearing)(Hurley, Gregory) (Entered: 03/17/2016)
87 RESPONSE IN SUPPORT of EX PARTE APPLICATION to Continue Motion for Judgment on the Pleadings from April 11, 2016 to a date selected by the Court Re: NOTICE OF MOTION AND MOTION for Judgment on the Pleadings as to Intervenors' First Amended Complaint in Interventi 85 filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Hartz, Alisa) (Entered: 03/17/2016)
88 MEMORANDUM in Opposition to NOTICE OF MOTION AND MOTION for Judgment on the Pleadings as to Intervenors' First Amended Complaint in Intervention 84 filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration Declaration Of L. Adelaide Anderson In Support Of Opposition To Motion For Judgment On The Pleadings)(Clancy, Thomas) (Entered: 03/21/2016)
89 REPLY support NOTICE OF MOTION AND MOTION for Judgment on the Pleadings as to Intervenors' First Amended Complaint in Intervention 84 filed by Defendants County of Los Angeles, Jim McDonnell. (Hurley, Gregory) (Entered: 03/28/2016)
90 Objection Support re: NOTICE OF MOTION AND MOTION for Judgment on the Pleadings as to Intervenors' First Amended Complaint in Intervention 84 Objections to Declaration of L. Adelaide Anderson filed by Defendants County of Los Angeles, Jim McDonnell. (Hurley, Gregory) (Entered: 03/28/2016)
91 RESPONSE filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williamsto Objection/Opposition (Motion related), 90 to Objections to Declaration of L. Adelaide Anderson (Hartz, Alisa) (Entered: 04/04/2016)
92 MINUTES (IN CHAMBERS) by Judge Dean D. Pregerson: COUNSEL ARE NOTIFIED Intervenors' Ex Parte Application to Continue Motion is GRANTED 85 . Defendants' Motion for Judgment on the Pleadings 84 is continued to Monday, April 18, 2016 at 2:30 p.m. (lc) (Entered: 04/06/2016)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 18 of 22

04/12/2016
04/18/2016 04/18/2016 04/19/2016 04/21/2016 04/25/2016 04/27/2016 05/11/2016 05/16/2016
05/16/2016 05/17/2016

93 NOTICE OF MOTION AND MOTION to Compel Deposition of Dr. Mitchell Katz filed by Plaintiff−Intervenors David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. Motion set for hearing on 5/3/2016 at 10:00 AM before Magistrate Judge John E. McDermott. (Attachments: # 1 Memorandum Joint Stipulation Regarding Disputed Issues Concerning Deposition of Mitchell Katz, MD, # 2 Declaration Alisa Hartz in Support of Motion to Compel, # 3 Declaration Mark Rosenbaum in Support of Joint Stipulation, # 4 Declaration Michael Chilleen in support of Defendants' Opposition to Intervenors' Motion to Compel, # 5 Declaration Dr. Mitchell Katz in Support of Defendants Opposition to Intervenors' Motion, # 6 Proposed Order)(Clancy, Thomas) (Entered: 04/12/2016)
94 MINUTES OF Motion Hearing held before Judge Dean D. Pregerson: RE MOTION FOR JUDGMENT ON THE PLEADINGS AS TO INTERVENORS' FIRST AMENDED COMPLAINT ININTERVENTION FILED BY DEFENDANTS 84 . Court hears oral argument and takes the matter under submission.Court Reporter: Maria Bustillos. (lc) (Entered: 04/19/2016)
96 AMENDED MINUTES 94 OF Motion Hearing held before Judge Dean D. Pregerson: RE MOTION FOR JUDGMENT ON THE PLEADINGS AS TO INTERVENORS' FIRST AMENDED COMPLAIN IN INTERVENTION FILED BY DEFENDANTS 84 . Court hears oral argument and takes the matter under submission. Court Reporter: Maria Bustillos (lc) (Entered: 04/20/2016)
95 SUPPLEMENT to MOTION to Compel Deposition of Dr. Mitchell Katz 93 as permitted by L.R. 37−2.3 filed by Intervenor Plaintiffs Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Hartz, Alisa) (Entered: 04/19/2016)
97 SCHEDULING NOTICE by Magistrate Judge John E. McDermott re: MOTION to Compel Deposition of Dr. Mitchell Katz 93 . Hearing set for May 3, 3016 is hereby VACATED. A ruling will follow. THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (san) TEXT ONLY ENTRY (Entered: 04/21/2016)
98 TRANSCRIPT ORDER as to Defendants County of Los Angeles, Jim McDonnell for Court Reporter. Court will contact Carrie Strand at cstrand@sheppardmullin.com with any questions regarding this order. Transcript preparation will not begin until payment has been satisfied with the court reporter. (Hurley, Gregory) (Entered: 04/25/2016)
99 MINUTES (IN CHAMBERS) ORDER RE PLAINTIFF−INTERVENORS' MOTION TO COMPEL DEPOSITION OF DR. MITCHELL KATZ by Magistrate Judge John E. McDermott 93 Motion to Compel Deposition. The Motion is GRANTED in part and DENIED in part. [See Order for details.] (san) (Entered: 04/27/2016)
100 OBJECTIONS to Order on Motion to Compel Deposition, 99 filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Declaration of Dr. Mitchell Katz (Supplemental))(Hurley, Gregory) (Entered: 05/11/2016)
101 NOTICE OF MOTION AND MOTION for Review of U.S. Magistrate's Order re Plantiff−Intervenors' Motion to Compel Deposition of Dr. Katz re Order on Motion to Compel Deposition, 99 filed by defendants County of Los Angeles, Jim McDonnell. Motion set for hearing on 6/13/2016 at 10:00 AM before Judge Dean D. Pregerson. (Attachments: # 1 Declaration of Dr. Mitchell Katz, # 2 Memorandum of Points and Authorities in Support of Motion for Review, # 3 Proposed Order) (Hurley, Gregory) (Entered: 05/16/2016)
102 NOTICE OF MOTION AND MOTION to Disqualify Counsel Mark Rosenbaum filed by defendants County of Los Angeles, Jim McDonnell. Motion set for hearing on 6/13/2016 at 10:00 AM before Judge Dean D. Pregerson. (Attachments: # 1 Memorandum of Points & Authorities in Support of Motion to Disqualify, # 2 Declaration of Dr. Mitchell Katz, # 3 Declaration of Michael J. Chilleen, # 4 Proposed Order) (Hurley, Gregory) (Entered: 05/16/2016)
103 ORDER DENYING DEFENDANTS MOTION FOR JUDGMENT ON THE PLEADINGS 84 by Judge Dean D. Pregerson. (SEE DOCUMENT FOR FURTHER DETAILS) (vv) (Entered: 05/17/2016)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 19 of 22

05/18/2016 05/19/2016
05/20/2016 05/23/2016 05/23/2016
05/24/2016 05/25/2016 05/27/2016 05/27/2016

104 EX PARTE APPLICATION for Order for Stay of Magistrate's Ruling Compelling Deposition of Dr. Katz [Dkt. 99] filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Memorandum of Points and Authorities, # 2 Declaration of Michael J. Chilleen, # 3 Proposed Order)(Hurley, Gregory) (Entered: 05/18/2016)
105 INTERVENOR'S OPPOSITION TO DEFENDANTS' EX PARTE APPLICATION TO STAY MAGISTRATE JUDGE'S ORDER RE: MOTION TO COMPEL DEPOSITION OF DR. MITCHELL KATZ Opposition re: EX PARTE APPLICATION for Order for Stay of Magistrate's Ruling Compelling Deposition of Dr. Katz [Dkt. 99] 104 filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Exhibit Exhibit A, # 2 Exhibit Exhibit B, # 3 Exhibit Exhibit C)(Murphy, Emily) (Entered: 05/19/2016)
106 ORDER DENYING DEFENDANTS' EX PARTE APPLICATION TO STAY 104 by Magistrate Judge John E. McDermott. NOTE CHANGES MADE BY THE COURT. (kl) (Entered: 05/20/2016)
107 OPPOSITION to NOTICE OF MOTION AND MOTION to Disqualify Counsel Mark Rosenbaum 102 filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration of Mark Rosenbaum, # 2 Exhibit "A" to Rosenbaum Declaration, # 3 Exhibit "B" to Rosenbaum Declaration, # 4 Exhibit "C" to Rosenbaum Declaration)(Clancy, Thomas) (Entered: 05/23/2016)
108 OPPOSITION to NOTICE OF MOTION AND MOTION for Review of U.S. Magistrate's Order re Plantiff−Intervenors' Motion to Compel Deposition of Dr. Katz re Order on Motion to Compel Deposition, 99 101 filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration of Alisa Hartz, # 2 Exhibit "A" to Hartz Declaration, # 3 Exhibit "B" to Hartz Declaration, # 4 Exhibit "C" to Hartz Declaration, # 5 Exhibit "D" to Hartz Declaration, # 6 Exhibit "E" to Hartz Declaration)(Clancy, Thomas) (Entered: 05/23/2016)
109 EX PARTE APPLICATION to Stay pending Court's Ruling on Defendants' Motion for Review (Dkt. 101) and Motion to Disqualify (Dkt. 102) Order on Motion to Compel Deposition, 99 filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Memorandum in Support of Ex Parte Application to Stay Magistrate Judge's Order, # 2 Declaration of Chilleen in Support of Ex Parte Application to Stay Magistrate Judge's Order, # 3 Proposed Order Granting Ex Parte Application to Stay Magistrate Judge's Order) (Hurley, Gregory) (Entered: 05/24/2016)
110 OPPOSITION to EX PARTE APPLICATION to Stay pending Court's Ruling on Defendants' Motion for Review (Dkt. 101) and Motion to Disqualify (Dkt. 102) Order on Motion to Compel Deposition, 99 109 With Supporting Declaration of Alisa Hartz filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Mark Sarni, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Exhibit A to Opposition, # 2 Exhibit B to Opposition, # 3 Exhibit C to Opposition)(Murphy, Emily) (Entered: 05/25/2016)
111 REPLY in support NOTICE OF MOTION AND MOTION for Review of U.S. Magistrate's Order re Plantiff−Intervenors' Motion to Compel Deposition of Dr. Katz re Order on Motion to Compel Deposition, 99 101 filed by Defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Declaration of Michael J. Chilleen, # 2 Exhibit A to Declaration of Michael J. Chilleen)(Hurley, Gregory) (Entered: 05/27/2016)
112 MINUTES (IN CHAMBERS) by Judge Dean D. Pregerson: Defendants Ex Parte Application for a Stay is DENIED (Dkt. No. 109).Defendants presented a nearly identical ex parte application to Magistrate JudgeMcDermott, who denied the application for a stay. The court construes the instant application as an ex parte application for review of Magistrate Judge McDermotts denial of a stay. Defendants do not argue that Magistrate Judge McDermotts denial of a stay was clearly erroneous or an abuse of discretion. Nor does it appear that the denial of a stay, or a two−hour deposition subject to the limitations imposed by Magistrate Judge McDermott, will irreparably harm Defendants. (lc) (Entered: 05/27/2016)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 20 of 22

05/27/2016 06/07/2016 06/09/2016
07/11/2016
07/22/2016 07/22/2016 07/22/2016 07/27/2016
09/01/2016 09/02/2016 03/01/2017 04/24/2017

113 REPLY in support NOTICE OF MOTION AND MOTION to Disqualify Counsel Mark Rosenbaum 102 filed by Defendants County of Los Angeles, Jim McDonnell. (Hurley, Gregory) (Entered: 05/27/2016)
114 Joint STIPULATION to Continue Motion for Review of US Magistrate Judge's Order re: Plaintiff Intervenors' Motion to Compel Deposition of Dr. Mitchell Katz from 06/13/2016 to 07/11/2016 filed by defendants County of Los Angeles, Jim McDonnell. (Attachments: # 1 Proposed Order)(Hurley, Gregory) (Entered: 06/07/2016)
115 ORDER GRANTING 114 JOINT STIPULATION TO CONTINUE HEARING DATE OF DEFENDANTS MOTION FOR REVIEW OF U.S. MAGISTRATE JUDGES ORDER RE: PLAINTIFF−INTERVENORS MOTION TO COMPEL DEPOSITION OF DR. MITCHELL KATZ AND DEFENDANTS MOTION TO DISQUALIFY JULY 11, 2016 10:00 AM 101 , 102 by Judge Dean D. Pregerson, (lc) (Entered: 06/09/2016)
116 MINUTES OF Motion Hearing held before Judge Dean D. Pregerson: RE MOTION FOR REVIEW OF U.S. MAGISTRATE'S ORDER RE PLANTIFF−INTERVENORS' MOTION TO COMPELDEPOSITION OF DR. KATZ RE ORDER ON MOTION TO COMPEL DEPOSITION, FILED BYDEFENDANTS[101 MOTION TO DISQUALIFY COUNSEL MARK ROSENBAUM FILED BY DEFENDANTS 102 . Court and counsel confer as reflected on the record. The matter is taken under submission. Court Reporter: Maria Bustillos. (lc) (Entered: 07/11/2016)
117 Notice of Appearance or Withdrawal of Counsel: for attorney Joanna Berney Hull counsel for Plaintiff United States America. Adding Joanna B. Hull as counsel of record for United States of America for the reason indicated in the G−123 Notice. Filed by Plaintiff Joanna B. Hull. (Attorney Joanna Berney Hull added to party United States America(pty:pla))(Hull, Joanna) (Entered: 07/22/2016)
118 Notice of Appearance or Withdrawal of Counsel: for attorney Geoffrey Daniel Wilson counsel for Plaintiff United States America. Geoffrey Daniel Wilson is no longer counsel of record for the aforementioned party in this case for the reason indicated in the G−123 Notice. Filed by Plaintiff United States of America. (Wilson, Geoffrey) (Entered: 07/22/2016)
119 Notice of Appearance or Withdrawal of Counsel: for attorney Robyn−Marie L Monteleone counsel for Plaintiff United States America. Robyn−Marie Lyon Monteleone is no longer counsel of record for the aforementioned party in this case for the reason indicated in the G−123 Notice. Filed by Plaintiff United States of America. (Monteleone, Robyn−Marie) (Entered: 07/22/2016)
120 ORDER DENYING DEFENDANT'S MOTIONS FOR (1) REVIEW OF MAGISTRATE JUDGE'S ORDER AND (2) DISQUALIFICATION [Dkt. Nos. 101 , 102 ] by Judge Dean D. Pregerson: Defendant's Motion to Disqualify and Motion for Review are DENIED. In light of the waiver of the apex doctrine objection, this Court declines to adopt the portion of the Magistrate Judge's decision limiting the scope and duration of the deposition. The court expects, however, that the parties will work collaboratively to ensure that the deposition is as brief and efficient as possible. IT IS SO ORDERED. See order for details. (jy) (Entered: 07/27/2016)
121 MONITOR'S SECOND REPORT filed by Defendant County of Los Angeles. (Drooyan, Richard) (Entered: 09/01/2016)
122 Notice of Appearance or Withdrawal of Counsel: for attorney Karen C Joynt counsel for Defendant County of Los Angeles. Tiana Murillo is no longer counsel of record for the aforementioned party in this case for the reason indicated in the G−123 Notice. Filed by Defendant County of Los Angeles. (Joynt, Karen) (Entered: 09/02/2016)
123 Monitor's Third REPORT filed by Defendant County of Los Angeles. (Drooyan, Richard) (Entered: 03/01/2017)
124 Notice of Appearance or Withdrawal of Counsel: for attorney Matthew Edward Nickell counsel for Plaintiff United States America. Adding Matthew Nickell as counsel of record for United States of America for the reason indicated in the G−123 Notice. Filed by Plaintiff Matthew Nickell. (Attorney Matthew Edward Nickell added to party United States America(pty:pla))(Nickell, Matthew) (Entered: 04/24/2017)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 21 of 22

08/11/2017
08/14/2017 08/21/2017 08/21/2017 08/21/2017 08/28/2017
09/01/2017 09/06/2017 09/07/2017
09/07/2017 09/07/2017 09/19/2017

125 NOTICE OF MOTION AND MOTION of MUNGER, TOLLES & OLSON LLP, PUBLIC COUNSEL & EMILY MURPHY to Withdraw as Attorney for Plaintiff−Intervenor MARK SARNI filed by Plaintiff−Intervenors David Penn, Timothy Polk, Teresa Powers, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. Motion set for hearing on 9/11/2017 at 10:00 AM before Judge Dean D. Pregerson. (Attachments: # 1 Memorandum, # 2 Declaration of Adelaide Andeson, # 3 Declaration of Jessica M. Gomez, # 4 Declaration of Thomas P. Clancy, # 5 Proposed Order) (Clancy, Thomas) (Entered: 08/11/2017)
126 First NOTICE OF MOTION AND MOTION to Dismiss for Lack of Prosecution Mark Sarni's Claims in Intervention filed by Defendants County of Los Angeles, Jim McDonnell. Motion set for hearing on 9/11/2017 at 10:00 AM before Judge Dean D. Pregerson. (Attachments: # 1 Proposed Order) (Joynt, Karen) (Entered: 08/14/2017)
127 NOTICE OF NON−OPPOSITION to NOTICE OF MOTION AND MOTION of MUNGER, TOLLES & OLSON LLP, PUBLIC COUNSEL & EMILY MURPHY to Withdraw as Attorney for Plaintiff−Intervenor MARK SARNI 125 filed by Plaintiff United States America. (Hull, Joanna) (Entered: 08/21/2017)
128 NOTICE OF NON−OPPOSITION to First NOTICE OF MOTION AND MOTION to Dismiss for Lack of Prosecution Mark Sarni's Claims in Intervention 126 filed by Plaintiff United States America. (Hull, Joanna) (Entered: 08/21/2017)
129 NOTICE OF NON−OPPOSITION to First NOTICE OF MOTION AND MOTION to Dismiss for Lack of Prosecution Mark Sarni's Claims in Intervention 126 filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Clancy, Thomas) (Entered: 08/21/2017)
130 REPLY In Support Of NOTICE OF MOTION AND MOTION of MUNGER, TOLLES & OLSON LLP, PUBLIC COUNSEL & EMILY MURPHY to Withdraw as Attorney for Plaintiff−Intervenor MARK SARNI 125 filed by Intervenor Plaintiffs David Penn, Timothy Polk, Teresa Powers, Derrick Thomas, Lepriest Valentine, Darsel Whitfield, Royal Williams. (Attachments: # 1 Declaration Jessica Gomez)(Clancy, Thomas) (Entered: 08/28/2017)
131 Monitor's Fourth REPORT filed by Defendant County of Los Angeles. (Drooyan, Richard) (Entered: 09/01/2017)
132 MINUTE ORDER IN CHAMBERS by Judge Dean D. Pregerson: the Motion to Withdraw as Attorney 125 , and Motion To Dismiss For Lack of Prosecution 126 set for September 11, 2017 at 10:00 a.m., are hereby taken off calendar, the hearing dates are vacated and will be decided without oral argument. (pg) (Entered: 09/06/2017)
133 MINUTES (IN CHAMBERS) by Judge Dean D. Pregerson. Good cause being shown, counsel's unopposed Motion to Withdraw as Attorney for Plaintiff−Intervenor Mark Sarni is GRANTED 125 . Attorney Thomas P Clancy; Grant A Davis−Denny; Alisa Louise Hartz; Emily Rose DiMento Murphy; Bradley S Phillips; Anne K Richardson; Mark D Rosenbaum; L Adelaide Anderson and Gary Lee Blasi terminated. (smo) (Entered: 09/07/2017)
134 MINUTE ORDER (IN CHAMBERS) by Judge Dean D. Pregerson: Good cause being shown, counsel's unopposed Motion to Withdraw as Attorney for Plaintiff−Intervenor Mark Sarni is GRANTED 125 . (yl) (Entered: 09/08/2017)
135 MINUTES (IN CHAMBERS) by Judge Dean D. Pregerson: Defendants' unopposed Motion To Dismiss for Lack of Prosecution Mark Sarni's Claims in Intervention is GRANTED.granting 126 MOTION to Dismiss for Lack of Prosecution (yl) (Entered: 09/08/2017)
136 Notice of Appearance or Withdrawal of Counsel: for attorney Amie S Park counsel for Defendants County of Los Angeles, Jim McDonnell. Adding Amie S. Park as counsel of record for County of Los Angeles and Los Angeles County Sheriff, Jim McDonnell for the reason indicated in the G−123 Notice. Filed by Defendants County of Los Angeles and Los Angeles County Sheriff Jim McDonnell. (Attorney Amie S Park added to party County of Los Angeles(pty:dft), Attorney Amie S Park added to party Jim McDonnell(pty:dft))(Park, Amie) (Entered: 09/19/2017)

Case: 2:15-cv-5903 As of: 10/25/2018 10:53 PM PDT 22 of 22

10/02/2017 10/02/2017 03/01/2018 08/01/2018
08/31/2018

137 Request for Approval of Substitution or Withdrawal of Counsel (Park, Amie) Modified on 10/4/2017 (shb). (Entered: 10/02/2017)
138 ORDER by Judge Dean D. Pregerson: GRANTING 137 Request to Substitute Attorney Amie S. Park for Defendants Los Angeles County; Sheriff Jim McDonnell. Attorney Paul B Beach and Justin W Clark terminated. (shb) (Entered: 10/04/2017)
139 MONITOR'S FIFTH REPORT filed by Defendant County of Los Angeles. (Drooyan, Richard) (Entered: 03/01/2018)
140 Notice of Appearance or Withdrawal of Counsel: for attorney Joanna Berney Hull counsel for Plaintiff United States America. Joanna Hull is no longer counsel of record for the aforementioned party in this case for the reason indicated in the G−123 Notice. Filed by Plaintiff United States of America. (Hull, Joanna) (Entered: 08/01/2018)
141 MONITOR'S SIXTH REPORT filed by Defendant County of Los Angeles. (Drooyan, Richard) (Entered: 08/31/2018)