Case 3:07-cv-01559-N Document 1 Filed 09/12/2007 Page 1 of 7

I' - ::-\"-..-, I-lH"E-S.~-.R-DN-;SD-Ti·SRrIUC::C;-O;TUr;R.T:;::~---

d IN THE UNITED STATES DISTRICT 'OURT
FOR THE NORTHERN DISTRICT OF T~XAS

RICT OF TEXAS
FILED

f

SEP , 2 aJj'

UNITED STATES OF AMERICA, PLAINTIFF,

I
~-_ _ _ _ _ _ _ _ _ _~Dt~p~ul'Y~-------

v.
DALLAS COUNTY, TEXAS; LUPE VALDEZ, SHERIFF OF DALLAS COUNTY, TEXAS (in her official capacity),

Civil No.
S O'1C V 1 5 5 9 - N

DEFENDANTS.

COMPLAINT THE UNITED STATES OF AMERICA alleges:
1. The Attorney General files this complaint on behalf of the United States of America pursuant to the Civil Rights of Institutionalized Persons Act of 1980, 42 U.S.C. § 1997, to enjoin the named Defendants from depriving persons incarcerated at the Dallas County Jail, located in Dallas, Texas, of rights, privileges, or immunities secured and protected by the Constitution of the United States.
JURISDICTION AND VENUE 2. This Court has jurisdiction over this action under 28 U.S.C. § 1345. 3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 1997a.

Case 3:07-cv-01559-N Document 1 Filed 09/12/2007 Page 2 of 7
4. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein.
5. Venue in the Northern District of Texas is proper pursuant to 28 U.S.C. § 1391.
DEFENDANTS 6. Defendant DALLAS COUNTY is a governmental subdivision created under the laws of the State of Texas. The Dallas County Sheriff's Office is a division of the Dallas County government. The County owns and operates the Dallas County Jail ("DCJ"), located in Dallas, Texas. 7. Defendant DALLAS COUNTY is the entity charged by the laws of the State of Texas with authority to maintain DCJ and is responsible for the conditions of confinement and health and safety of persons incarcerated at DCJ. 8. Defendant LUPE VALDEZ is the Sheriff of the Dallas County Jail and is responsible for the day-to-day operations of DCJ. In her official capacity as Sheriff, she has the custody, control, and charge of the jail and inmates. Sheriff VALDEZ is sued in her official capacity.
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Case 3:07-cv-01559-N Document 1 Filed 09/12/2007 Page 3 of 7
9. Defendants are legally responsible, in whole or in part, for the operation and conditions of DCJ, and for the health and safety of persons incarcerated in DCJ.
10. At all relevant times, the Defendants or their predecessors in office have acted or failed to act, as alleged herein, under color of state law.
FACTUAL ALLEGATIONS 11. The Dallas County Jail is an institution within the meaning of 42 U.S.C. § 1997(1). 12. Persons confined to the Dallas County Jail include both pre-trial detainees and sentenced inmates. 13. Defendants have engaged in and continue to engage in a pattern or practice of failing to protect inmates at the Dallas County Jail from serious harm and undue risk of serious harm by, inter alia, failing to provide adequate medical and mental health care, and failing to provide safe and sanitary living conditions. 14. The factual allegations set forth in paragraph 13 have been obvious and known to Defendants for a substantial period of time; yet Defendants have failed to address adequately the conditions described.
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Case 3:07-cv-01559-N Document 1 Filed 09/12/2007 Page 4 of 7
VIOLATIONS ALLEGED 15. Through the acts and omissions alleged in paragraphs 13 and 14, Defendants have exhibited deliberate indifference to the health and safety of Dallas County Jail inmates, in violation of the rights, privileges, or immunities of those inmates as secured or protected by the Constitution of the United States. U.S. Const. amend. VIII, XIV. 16. Unless restrained by this Court, Defendants will continue to engage in the acts and omissions set forth in paragraph 13 that deprive persons confined in the Dallas County Jail of rights, privileges, or immunities secured or protected by the Constitution of the United States.
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Case 3:07-cv-01559-N Document 1 Filed 09/12/2007 Page 5 of 7
PRAYER FOR RELIEF 19. The Attorney General is authorized under 42 U.S.C. § 1997 to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Court enter an order permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practices set forth in paragraph 15 above, and that this Court require Defendants to take such actions as will ensure lawful conditions of confinement are afforded to inmates at the Dallas County Jail. The United States further prays that this Court grant such other and further equitable relief as it may deem just and proper.
Respectfully submitted,
AL At orney General of the United States
5

Case 3:07-cv-01559-N Document 1 Filed 09/12/2007 Page 6 of 7

United States Attorney Northern District of Texas 1100 Commerce Street Suite 300 Dallas, Texas 75242-1699

Acting Assistant Attorney General
Civil Rights Division

JOHN R. PARKER Chief, Civil Division United States Attorney's Office Northern District of Texas 1100 Commerce Street Suite 300 Dallas, Texas 75242-1699

ETTA Y. CUTLAR pecial Litigation Section

DANIEL H. WEISS Deputy Chief Special Litigation Section

DAVID DEUTSCH WILLIAM E. NOLAN Attorneys Civil Rights Division Special Litigation Section U.S. Department of Justice 950 Pennsylvania Avenue, NW Washington, DC 20530 (202)514-6270

~JS 44 (Rev. 3/99) Case 3:07-cv-01559-NCIVDIoLcuCmOenVt E1 R SFHileEdE0T9/12/2007 Page 7 of 7

The JS-44 civil cover sHeet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required
by law, except as Provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the
use of the Clerk of Court for the purpose of initiating the civil docket sheet. (SEE INSTRUCTIONS ON THE REVERSE OF THE FORM.)

I. (a) PLAINTIFFS
UNITED STATES OF AMERICA

DEFENDANTS
DALLAS COUNTY, TEXAS; LUPE VALDEZ, SHERIFF OF
DALLAS COUNTY, TEXAS (in her official capacity)

(b) County of Residence of First Listed

County of Residence of First Listed Dallas Counn::

(EXCEPT IN U.S. PLAINTIFF CASES)

(IN U.S. PLAINTIFF CASES ONLY)

NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE

-"I
_-~" n::n

LAND INVOLVED.

CV 1 5 : J 9 - N (c) Attorney's (Finn Name, Address, and Telephon~ Numb~ t.\.JL.1 V ~

, u.s·l John R. Parker, Assistant United States Attome

Attorney's Office,

A ~me~fO'

SE\l Third Floor, 1100 Commerce Street, Dallas, Tex s 75 42-I
, \ 2 2001 ~Q-r ."

II. BASIS OF JURISDICTION (place an "X" ., OIC~~·S:,~ ~~II' lz:.~ IP OF PRINCIPAL P ARTIES(place an "X" in One Box for Plaintiff

---NORTH N 01

(For Diversity Cases Only) PTF DEF

and One Box for Defendant) PTF DEF

Xl U.S. Government

o 3 Federal Question

Citizen of This State o 1 01 Incorporated or Principal Place o 4 04

Plaintiff

(U.S. Government Not a Party)

of Business In This State

2 U.S. Government Defendant

04 Diversity (Indicate Citizenship of Parties in Item Ill)

Citizen of Another State 0 2 02 Incorporated and Principal Place 0 5 05
of Business In Another State

Citizen or Subject ofa o 3 03 Foreign Nation
Foreign Country

o 6 06

IV. NATURE OF SUIT (Place an "X" in One Box Only)

CONTRACT

TORTS

FORFEITUREIPENALTY

BANKRUPTCY

OTHER STATUTES

0 110 Insurance

PERSONAL INJURY

0 120 Marine

0 310 Airplane

0 130 Miller Act

0 315 Airplane Product

0 140 Negotiable Instrument

Liability

0 150 Recovery of Overpayment 0 320 Assault, Libel &

& Enforcement ofJudgment

Slander

0 151 Medicare Act

0 330 Federal Employers'

0 152 Recovery of Defaulted

Liability

Student Loans

0 340 Marine

(Excl. Veterans)

0 345 Marine Product

0 153 Recovery ofOverpayment

Liability

of Veteran's Benefits 0 350 Motor Vehicle

PERSONAL INJURY 0

0 362 Personal Injury- 0

Med. Malpractice 0

0 365 Personal Injury-

Product Liability

0

0 368 Asbestos Personal 0

hUury Product

0

Liability

0

PERSONAL PROPERTY

o 370 Oilier Fraud

0

o 371 Truth in Lending

o 380 Oilier Personal

610 Agriculture 620 Other Food & Drug 625 Drug Related Seizure
of Property 21 USC 630 Liqnor Laws 640 R.R. & Truck 650 Airline Regs. 660 Occupational
SafetylHealili 690 Other
LABOR

0422 Appea128 USC 158
0423 Withdrawal 28 USC 157
PROPERTY RIGHTS 0820 Copyrights 0830 Patent 0840 Trademark
SOCIAL SECURITY

o 400 State Reapportiomnent o 410 Antitrust o 430 Banks and Banking o 450 CornmercelJCC Rates/etc. o 460 Deportation o 470 Racketeer Influenced and
ConruptOrga~tions
o 810 Selective Service o 850 Secwities/Commodities/
Exchange
o 875 Customer Challenge
12 USC 3410

0 160 Stockbolders' Suits 0 190 Oilier Contract

0 355 Motor Vehicle Product Liability

Property Damage 0 385 Property Damage

0

0 195 Contract Product Liability 0 360 Oilier Personal Injury

Product Liability

0

REAL PROPERTY

CIVIL RIGHTS

0 210 Land Condenmation

0 441 Voting

0 220 Foreclosnre

0 442 Employment

0 230 Rent Lease & Ejectment 0 443 Housing!

0 240 Torts to Land

Acconuoodations

0 245 Tort Product Liability 0 444 Welfare

0 290 All Oilier Real Property X 440 Oilier Civil Rights

PRISONER PETITIONS 0

0 510 Motions to Vacate

Sentence

0

Habeas Corpus:

0 530 General

0

0 535 Deaili Penalty

0 540 Mandamus & Oilier 0

0 550 Civil Rights

0 555 Prison Condition

710 Fair Labor Standards 0861 InA (1395ft)

Act

0862 Black Lung (923)

720 LaborlMgmt. Relations 0863 DIWCIDIWW (405(g»

0864 SSID Title XVI

730 LaborlMgmtReporting 0865 RSI (405(g»

& Disclosnre Act 740 Railway Labor Act

FEDERAL TAX SUITS

790 Oilier Labor Litigation

0170 Taxes (U.S. Plaintiff or Defendant)

791 EmpJ. Ret Inc. Secwity Act

0171 IRS-Third Party 26 USC 7609

o 891 Agricultnral Acts o 892 Economic Stabilization Act o 893 Enviromnental Matters o 894 Energy Allocation Act o 895 Freedom of
Infonnation Act
o 900 Appeal of Fee
Detennination Under Equal
Access to Justice
o 950 Constitntionality of
State Statutes
o 890 Oilier Statntory Actions

V. ORIGIN
X 1 Original Proceeding

(PLACE AN "X" IN ONE BOX ONLY)

2 Removed from State Court

0 3 Remanded from Appellate Court

Transferred from
another district 0 4 Reinstated or 0 5 (specify)
Reopened

VI CAUSE OF ACTION (Cite the l!'s: C~vi~ S~tnte under which yo~ are.filing aud write brief statement of cause.

•

Do not CIte JW1SdictlOnal statntes unless diversIty.)

42 U.S.C. § 1997 Violations ofilie Civil Rights ofinstitntionalized Persons Act of 1980 at ilie Dallas County Jail

o 6 Multidistrict
Litigation

Appeal to District
Judge from
o 7 Magistrate Judgment

VII. REQUESTED IN
COMPLAINT:

o CHECK IF THIS IS A CLASS ACTION
UNDER F.R.C.P. 23

VIII. RELATED CASE(S)

(See instructions):

IF

DATE

o.

DEMANDS

CHECK YES only if demanded in complaint:

JURy DEMAND:

0 Yes X No

DOCKET NUMBER

 
 Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 1 of 24

IN THE UNITED STATES DISTRICT CO RT FOR THE NORTHERN DISTRICT OF TE S

NOV - 6 2007

UNITED STATES OF AMERICA,
PLAINTIFF,
v.
DALLAS COUNTY, TEXAS; LUPE VALDEZ, SHERIFF OF DALLAS COUNTY, TEXAS (in her official capacity),
DEFENDANTS.

Civil No. 307 CV 1559-N

AGREED ORDER
I. INTRODUCTION
A. On November 28, 2005, the United States notified Dallas County officials of its intention to investigate conditions of confinement at the Dallas County Jail (~DCJ" or ~the Jail"), pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997.
B. On February 20-24, 2006 and March 20-23, 2006, the United States toured DCJ with consultants in the fields of correctional health care, correctional mental health care, and environmental health.
C. Throughout the course of the investigation, the United States received complete cooperation and access to all facilities and documents from the Dallas County Commissioners Court, Dallas County Sheriff's Office, University of Texas Medical Branch at Galveston, and Parkland Hospital.
D. On December 8, 2006, the United States issued a findings letter pursuant to 42 U.S.C. § 1997 that concluded that certain conditions at DCJ violate the constitutional or statutory rights of individuals confined at the Jail.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 2 of 24

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E. Defendants in this action are Dallas County, Texas; the Dallas County Sheriff; and their successors, contractors, and agents (collectively, the "County"). The County shall ensure that all County agencies take any actions necessary to comply with the provisions of this Agreed Order.

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

G. For the purposes of this lawsuit only and in order to settle this matter, the Defendants consent to the entry of a finding that the conditions at DCJ necessitate the remedial measures contained in this Agreed Order. As indicated in Section VII of this Agreed Order, the parties consent to a finding that this Agreed Order complies in all respects with the provisions of the Prison Litigation Reform Act, 18 U.S.C. § 3626(a).

H. No person or entity is intended to be a third-party beneficiary of the provisions of this Agreed Order for purposes of any civil, criminal, or administrative action, and accordingly, no person or entity may assert any claim or right as a beneficiary or protected class under this Agreed Order. This Agreed Order is not intended to impair or expand the right of any person or organization to seek relief against the Defendants or their officials, employees, or agents for their conduct. This Agreed Order does not alter legal standards governing any such claims, including those standards established by Texas law.

II.

DEFINITIONS

A. "DCJ" or "the Jail" shall refer to the Dallas County Jail and shall include the Suzanne Kays Detention Facility; the Decker Detention Facility; the George Allen Courts Building; and the adjoining Lew Sterrett Center Tower Facilities ("Lew Sterrett"); as well as any facility that is built, leased, or otherwise used, to replace or supplement the Jail.

B. "DOJ" shall refer to the United States Department of Justice, which represents the United States in this matter.

C. "Effective date" shall mean the date the Agreed Order is signed and entered by the Court.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 3 of 24
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D. "Include" or "including" shall mean "include, but not be limited to" or "including, but not limited to."
E. "Inmate" or "inmates" shall be construed broadly to refer to one or more individuals detained at, or otherwise housed, held, in the custody of, or confined at either the existing Jailor any institution that is built or used to replace the Jailor any part of the Jail.
F. Consistent with, or in accordance with, the term "generally accepted professional standards of care" shall mean a decision by a qualified professional that is substantially aligned with contemporary, accepted professional judgment, practice, or standards as to demonstrate that the person responsible based the decision on such accepted professional judgment.
G. "Quality Assurance" means a system of self-audit and improvement to assess the implementation and effectiveness of all remedies instituted pursuant to this Agreed Order, to identify deficits that may exist, and to effectuate new measures to cure deficits identified.
H. "Qualified Medical Professional" shall mean a licensed physician, licensed physician assistant, or a licensed nurse practitioner, who is currently licensed by the State of Texas to deliver those health care services they have undertaken to provide.
I. "Qualified Medical Staff" shall refer to qualified medical professionals and qualified nursing staff.
J. "Qualified Mental Health Professional" shall refer to: a) an individual with a minimum of masters-level education and training in psychiatry, psychology, counseling, social work or psychiatric nursing, who is currently licensed by the State of Texas to deliver those mental health services they have undertaken to provide.
K. "Qualified Mental Health Workers" and "Qualified Mental Health Staff" shall refer to individuals with a minimum of a bachelor's degree and two years of experience providing mental health services.
L. "Qualified Nursing Staff" means registered nurses and licensed practical nurses currently licensed by the State of Texas to deliver those health services they have undertaken to provide.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 4 of 24
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M. "Suicide Precautions" means any level of watch, observation, or measures to prevent self-harm.
N. "Train," means to instruct in the skills addressed to a level that the trainee has the demonstrated proficiency to implement those skills as and when called for in the training. "Trained" means to have achieved such proficiency.
O. Throughout this Agreed Order, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance: "Substantial compliance" indicates that the Jail has achieved compliance with most or all components of the relevant provision of the agreed Order. "Partial compliance" indicates that compliance has been achieved on some of the components of the relevant provision of the Agreed Order, but significant work remains. "Non-compliance" indicates that most or all of the components of the Agreed Order provision have not yet been met.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 5 of 24
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III. SUBSTANTIVE PROVISIONS
A. MEDICAL CARE
1. Intake screening:
a. Defendants shall implement and comply with policies to provide adequate medical and mental health intake screening to all inmates; shall provide a 14-day health assessment and examination; shall ensure continuation of prescription medications within 24 hours of intake; shall comply with stated policies to screen inmates for infectious disease; shall continue to provide mental health evaluations for all inmates whose histories or whose responses to initial screening questions indicate a need for such an evaluation; shall provide accurate diagnoses for inmates in need of mental health services; and shall continue to provide timely and appropriate referrals for specialty care.
b. Records documenting the assessment and results shall become part of each inmate's medical record. A re-admitted inmate or an inmate transferred from another facility who has received a documented full health assessment within the previous three months and whose receiving screening shows no change in the inmate's health status need not receive a new full physical health assessment. For such inmates, qualified personnel shall review prior records and update tests and examinations as needed.
c. When the initial clinical health screening indicates that an inmate has acute health or mental health needs, Defendants shall provide timely care by trained and licensed medical staff, registered nurses, or mental health professionals as soon as medically necessary, but no later than twenty-four (24) hours after the initial health screening. Defendants shall schedule individuals with chronic health or mental health needs, and those who are pregnant but who present in a stable condition, to be seen by medical staff or mental health professionals as soon as medically necessary. Incoming inmates who present with current risk of suicide or other acute mental

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 6 of 24
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health needs will be immediately referred for a mental health evaluation by a mental health professional. Staff will observe such inmates until they are seen by mental health professionals. Incoming inmates reporting these conditions will be housed under appropriate conditions unless and until a mental health care professional clears them for housing in segregation or with the general population.
2. Acute care:
a. Defendants shall provide adequate and timely acute care for inmates with serious and life-threatening conditions, and ensure that such care adequately addresses the serious medical needs of inmates. Adequate care will include timely medical appointments and follow-up medical treatment.
b. Defendants shall train correctional officers to recognize and respond to medical and mental health emergencies, and shall ensure that inmates with emergency medical or mental health needs are promptly referred and transported for outside care when the facility is unable to provide appropriate care.
3. Chronic care:
a. Defendants shall adopt and implement a system to track inmates with serious and/or chronic illnesses, including mental illnesses, to ensure that these inmates receive necessary diagnosis, monitoring and treatment.
b. Defendants shall implement a medication continuity system so that incoming inmates' medication for serious medical needs can be obtained in a timely manner, as medically appropriate when medically necessary. Within twenty-four hours of an inmate's arrival at the facility, or sooner if medically necessary, the County shall decide whether to continue the same or comparable medication for serious medical needs as an inmate reports on arrival that she or he has been prescribed. If the inmate's reported medication is discontinued or changed by medical staff,

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 7 of 24
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medical staff shall evaluate the inmate face-toface as soon as medically appropriate. The County shall develop and implement a protocol and screening tool to guide staff in gathering necessary information and present such information to medical staff for medication continuity decisions.
c. Defendants shall ensure that inmates who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care.
d. Defendants shall maintain an updated log of inmates with chronic illness. Defendants shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmate's individual medical record.
4. Treatment and Management of Communicable Disease:
a. Defendants shall implement and refine their communicable disease testing, monitoring, and treatment programs. Defendants shall continue to test for tuberculosis ("TBII) all inmates arriving at the jail upon booking and will follow-up on test results as medically indicated.
b. Defendants shall develop and implement infection control policies and procedures to prevent the spread of infections or communicable diseases, including TB and Methicillin Resistant Staphylococcus aureus ("MRSAII ), consistent with generally accepted professional standards of care.
c. Defendants shall establish effective infection control programs, including programs for TB and skin infections, that:
i. actively collect data regarding infections and communicable diseases;
ii. assess this data for trends; iii. initiate inquiries regarding
problematic trends; iv. identify necessary corrective action; v. monitor to ensure that appropriate
remedies are achieved; and

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 8 of 24
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vi. integrate this information into the Jail's quality assurance review.
d. Defendants shall develop and implement adequate guidelines to ensure that inmates receive appropriate wound care. Such guidelines will include precautions to limit the possible spread of communicable diseases.
e. Defendants shall ensure that the specialized respiratory isolation ("negative pressure") and HVAC (heating, ventilating and airconditioning) systems function properly.
5. Access to Health Care:
a. Defendants shall ensure that inmates have adequate access to appropriate health care.
b. Defendants shall ensure that the medical request ("sick call") process for inmates is adequate and facilitates adequate access to medical care.
c. The sick call process shall include procedures for logging, tracking, and timely responses by medical staff.
d. Defendants shall develop and implement an effective system for triaging sick call requests based upon the urgency of the medical issue.
6. Follow-Up Care:
a. Defendants shall provide adequate follow up care and maintain appropriate records for inmates who return to the Jail following hospitalization.
b. Defendants shall ensure that inmates who receive specialty or hospital care are evaluated upon their return to the Jail and that, at a minimum, discharge instructions are recorded in the inmate's medical records and appropriately followed.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 9 of 24
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7. Record Keeping:
a. Defendants shall ensure that medical records are maintained consistent with generally accepted professional standards of care.
b. Defendants shall ensure that DCJ medical and mental health records are centralized, complete, and accurate. To ensure continuity of care, medical record information shall be submitted to outside medical providers when inmates are sent out of the Jail for medical care, and reports and records from those providers will be returned with the inmates to the Jail.
c. Defendants shall maintain unified medical and mental health records including documentation of inmates' psychiatric histories and individual mental health assessments.
8. Medication Administration:
a. Defendants shall ensure that treatment and administration of medication to inmates is implemented in accordance with generally accepted professional standards of care. Defendants shall develop policies and procedures for the accurate administration of medication and maintenance of medication records. Defendants shall provide a systematic physician review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition.
b. Defendants shall ensure that medication administration is hygienic and recorded concurrently with administration.
9. Medical Facilities:
a. Defendants shall ensure that sufficient clinical space is available to provide inmates with adequate medical care services including: intake screening; sick call; physical assessment; and acute, chronic,

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 10 of 24
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emergency, and speciality medical care (such as for geriatric or pregnant inmates).
b. Defendants shall ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in medical exam rooms. All hand washing stations in medical areas shall be fully equipped, operational, and accessible.
10. Specialty Care:
a. Defendants shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at the Jail shall receive timely referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs, in accordance with generally accepted professional standards of care.
b. Defendants shall ensure that inmates who have been referred for outside specialty care by the medical staff or another specialty care provider are scheduled for timely outside care appointments and transported to their appointments. Inmates awaiting outside care shall be seen by medical staff as medically necessary to evaluate the current urgency of the problem and respond as medically appropriate.
c. Defendants shall obtain records of care and diagnostic tests received during outside appointments in a timely fashion and include such records in the inmate's medical record or document the inmate's refusal to cooperate and release medical records. Following a visit to an outside specialist, medical staff, mental health staff, or a dentist shall review information and documentation available from the visit and provide reasonable follow-up care.
d. Defendants shall maintain a current log of all inmates who have been referred for outside specialty care, including the date of the referral, the date the appointment was

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 11 of 24
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scheduled, the date the appointment occurred and the reason for any missed or delayed appointments, and information on follow up care, including the dates of any future appointments.
e. Defendants shall ensure that pregnant inmates are provided adequate pre-natal care in accordance with generally accepted professional standards of care.
11. Staffing, Training, and Supervision:
a. Defendants shall provide adequate staffing and training of medical, mental health, and correctional staff necessary to ensure that adequate medical and mental health care is provided.
b. Defendants shall ensure that medical staff receive adequate physician oversight and supervision.
c. Defendants shall ensure that services and procedures, such as medication administration and use of cut-down tools, are performed by nurses or other properly trained staff.
d. Defendants shall provide adequate numbers of correctional staff to ensure inmates have access to appropriate medical care.
e. Defendants shall conduct initial and periodic training for all correctional staff on how to recognize symptoms of mental illness and respond appropriately. Such training shall be conducted by qualified mental health professionals and shall include instruction on how to recognize and respond to mental health emergencies.
12. Quality Assurance Review:
a. The Defendants shall develop and implement quality assurance programs adequate to identify and correct serious deficiencies in medical care, mental health care, suicide prevention, sanitation, and fire safety.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 12 of 24
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13. Dental Care:
a. Defendants shall ensure that inmates receive adequate dental care consistent with generally accepted professional standards of care and that such care be provided in a timely manner.
b. Defendants shall ensure that inmates with emergency dental needs shall receive such care immediately. Adequate dentist hours will be provided to avoid unreasonable delays in dental care.
B. MENTAL HEALTH CARE
Defendants shall provide adequate mental health care to address inmates' serious mental health needs.
1. Timely and Appropriate Evaluation:
a. Defendants shall provide develop and implement policies and procedures to appropriately assess inmates with mental illness, and evaluate inmates' mental health needs.
b. Defendants shall ensure that the intake evaluation process includes a mental health screening, which shall be incorporated into the corresponding inmate's medical records. Defendants shall ensure timely access to a qualified mental health professional when presenting symptoms of mental illness require such care.
c. Defendants shall ensure that the mental health screening process includes inquiry regarding:
(1) past suicidal ideation and/or attempts, (2) current ideation, threat, or plan, (3) prior mental health treatment or
hospitalization, (4) recent significant loss, such as the
death of a family member or close friend, (5) history of suicidal behavior by family
members and close friends, (6) suicide risk during any prior
confinement, and

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 13 of 24
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(7) any observations of the transporting officer, court, transferring agency, or similar individuals regarding the inmate's potential suicide risk.
d. Defendants shall ensure adequate and timely treatment for inmates whose assessments reveal serious mental illness, including timely and appropriate referrals for specialty care and regularly scheduled visits with qualified mental health professionals.
e. Defendants shall ensure an adequate array of crisis services to appropriately manage the psychiatric emergencies that occur among inmates. Crisis services shall not be limited to administrative segregation or observation status. Inmates shall have access to appropriate licensed in-patient psychiatric care when clinically appropriate.
2. Assessment and Treatment:
a. Defendants shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the inmates' diagnoses.
b. Defendants shall provide for an inmate's reasonable privacy in medical and mental health care, and maintain confidentiality of inmates' medical and mental health status, subject to legitimate security concerns and emergency situations.
c. Defendants shall provide adequate on-site psychiatric coverage for inmates' serious mental health needs and ensure that psychiatrists see inmates in a timely manner.
d. Defendants shall ensure that disciplinary charges against inmates are reviewed by a qualified mental health professional to determine the extent to which the charge was related to serious mental illness, to ensure that inmates who commit infractions resulting from a serious mental illness are not punished

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 14 of 24
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for behavior caused by mental illness, and to ensure that an inmate's serious mental illness is used as a mitigating factor, as appropriate, when punishment is imposed on inmates with a serious mental illness.
e. Defendants shall ensure that mentally ill inmates in segregation receive timely and appropriate treatment, including completion and documentation of regular rounds in the segregation units at least once per week by adequately trained qualified mental health professionals in order to assess the serious mental health needs of inmates in segregation. Inmates with serious mental illness who are placed in segregation shall be immediately and regularly evaluated by a qualified mental health professional to determine the inmate's mental health status, which shall include an assessment of the potential effect of segregation on the inmate's mental health. During these regular evaluations, Defendants shall evaluate whether continued segregation is appropriate for that inmate, considering the assessment of the qualified mental health professional, or whether the inmate would be appropriate for graduated alternatives.
3. Psychotherapeutic Medication Administration:
a. Defendants shall ensure that psychotherapeutic medication administration is provided in accordance with generally accepted professional mental health care standards.
b. Defendants shall ensure that pyschotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment.
c. Defendants shall ensure timely implementation of physician orders for medication and laboratory tests. Defendants shall ensure that inmates who are being treated with psychotropic medications are seen regularly by a physician to monitor responses and potential reactions to

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 15 of 24
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those medications, in accordance with generally accepted correctional mental health care standards.
4. Suicide Prevention:
a. Defendants shall develop policies and procedures to ensure the appropriate management of suicidal inmates, and shall establish a suicide prevention program in accordance with generally accepted professional standards of care.
b. Defendants shall ensure that suicide prevention procedures include provisions for constant direct supervision of actively suicidal inmates and close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks). Officers shall document their checks. Suicide prevention policies shall include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs. Cells for suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, exposed bars, unshielded lighting or electrical sockets).
c. Defendants shall ensure that all staff are trained on suicide response, prevention, and detection. Staff posts will be equipped with 911 rescue tools.
d. Defendants shall ensure adequate administrative mortality and morbidity review of custodial suicides and serious suicide attempts review following a custodial suicide or suicide attempt. At a minimum, the review shall include:
(1) critical review of the circumstances surrounding the incident;
(2) critical review of procedures relevant to the incident;
(3) synopsis of all relevant training received by involved staff;
(4) pertinent medical and mental health services/reports involving the victim;

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 16 of 24
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(5) possible precipitating factors leading to the suicide or attempt; and
(6) recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures.
C. SANITATION AND ENVIRONMENTAL CONDITIONS
1. Sanitation of Laundry:
a. Defendants shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to contagious disease, bodily fluids, and pathogens. Defendants shall ensure that inmates are provided clean clothing, underclothing and bedding in compliance with policy, and that the laundry exchange schedule provides equitable distribution and pickup service to all housing areas.
b. Defendants shall train staff and educate inmates regarding laundry sanitation policies.
2. Protection from Biohazards:
a. Defendants shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials. Defendants shall ensure that any inmate or staff utilized to clean a biohazardous area are properly trained in universal precautions, are outfitted with protective materials, and receive proper supervision when cleaning a biohazardous area.
b. Defendants shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
c. Defendants shall ensure biohazard disposal containers in medical areas are properly installed and positioned so as to limit unnecessary risk to staff.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 17 of 24

- 17 -

d. Defendants shall secure all sharp medical tools.

e. Defendants shall destroy any mattress that cannot be sufficiently sanitized to kill bacteria.

3. Environmental Control:

a. Defendants shall ensure adequate control and observation of jail cell environs, including razors and cleaning supplies. All cleaning tools and hazardous chemicals shall be removed from housing areas after use.

b. Chemical cleaning agents shall be safely stored, used, and mixed. Inmates provided cleaning agents shall receive training on the safe storage, use, and mixture of chemical cleaners.

4. Maintenance and Sanitation of Facilities:

a. Defendants shall immediately revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing and shower areas, and medical areas.

b. Defendants shall implement a preventive maintenance plan to respond to routine and emergency maintenance needs, including maintenance of shower, toilet, and sink units.

5. Fire and Life Safety:

a. Defendants shall ensure that the Jail has adequate fire and life safety equipment, including installation and maintenance of fire alarms in all housing areas. Defendants shall ensure that all fire and life safety equipment is properly maintained and inspected, with adequate documentation thereof.

b. Defendants shall implement competency-based

testing for staff regarding fire/emergency

procedures.

.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 18 of 24
- 18 -
c. Defendants shall ensure that emergency keys are appropriately marked and identifiable by touch and consistently stored in a quickly accessible location, and that staff are adequately trained in use of the emergency keys.
d. Defendants shall control combustibles and eliminate highly flammable materials throughout inmate living areas.
IV. REPORTING REQUIREMENTS AND RIGHT OF ACCESS
A. Defendants shall submit quarterly compliance reports to the United States, the first of which shall be filed within 90 days of the date of this Agreed Order. Thereafter, the quarterly reports shall be filed fifteen (15) days after the termination of each four-month period thereafter until the Agreed Order is terminated.
B. Each compliance report shall describe the actions the Defendants have taken during the reporting period to implement this Agreed Order and shall make specific reference to the Agreed Order provisions being implemented.
C. Defendants shall maintain sufficient records to document that the requirements of this Agreed Order are being properly implemented and shall make such records available to the DCJ at all reasonable times for inspection and copying by the United States. In addition, Defendants shall maintain and submit upon request records or other documents to verify that they have taken such actions as described in their compliance reports (e.g., census summaries, policies, procedures, protocols, training materials, and incident reports) and will also provide all documents reasonably requested by the United States.
D. The United States and its attorneys, consultants, and agents, and any other persons authorized by the parties, shall have unrestricted access to the Jail, Jail inmates, Jail staff (including staff at DCJ employed by Parkland or any other outside medical services provider), and documents as reasonably necessary to address issues affected by this Agreed Order.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 19 of 24
- 19 -
E. Within 30 days of receipt of written questions from the DOJ concerning Defendants' compliance with the requirements of this Agreed Order, Defendants shall provide the DOJ with written answers and any requested documents.
F. Defendants shall appoint a compliance coordinator to oversee compliance with this Agreed Order and to serve as a point of contact.
G. The parties have, by separate agreement, agreed upon an Independent Monitor to assist Defendants in achieving compliance with the provisions of this Agreed Order, to report those opinions to the parties, and to provide Defendants with technical assistance in attaining compliance with the Agreed Order. The parties agree to file these reports with the Court on a routine basis for the Court's information.
v. CONSTRUCTION, IMPLEMENTATION AND TERMINATION
A. Defendants shall implement all reforms necessary to effectuate this Agreed Order. The implementation of this Agreed Order will begin immediately upon the filing of this Agreed Order before the United States District Court for the Northern District of Texas. As needed, Defendants shall retain the services of third-party consultants to provide technical assistance regarding the implementation of the substantive provisions contained in Section III of this Agreed Order.
B. Except where otherwise specifically provided, Defendants shall complete implementation of all provisions of this Agreed Order within 180 days of the entry of this Agreed Order.
C. This Agreed Order shall terminate four years from the date the Agreed Order is ordered by the Court. The Agreed Order may terminate earlier if Defendants have substantially complied with each of the provisions of the Agreed Order and has maintained substantial compliance for at least two years. The burden ,shall be on Defendants to demonstrate this level of compliance. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained noncompliance

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 20 of 24
- 20 -
shall not constitute substantial compliance. If after four years Defendants have failed to comply with the requirements of this Agreed Order, the United States has the right to seek relief from the United States District Court of the Northern District of Texas.
D. Failure by either party to enforce this entire Agreed Order or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreed Order.
E. If any unforseen circumstance occurs that causes a failure to timely carry-out any requirements of this Agreed Order, Defendants shall notify the DOJ in writing within 20 calendar days after Defendants become aware of the unforseen circumstance and its impact on the Defendant's ability to perform under the Agreed Order. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. Defendants shall implement all reasonable measures to avoid or minimize any such failure.
F. This Agreed Order shall constitute the entire integrated Agreed Order of the parties. With the exception of DOJ's findings letter referenced in paragraph (I) (D) herein and any DOJ technical assistance recommendations, no prior or contemporaneous communications, oral or written, will be relevant or admissible for purposes of determining the meaning of any provisions herein in this litigation or in any other proceeding.
G. The Agreed Order shall be applicable to, and binding upon, all parties, their officers, agents, employees, assigns, and their successors in office.
H. Each party shall bear the cost of their fees and expenses incurred in connection with this cause.
I. In the event that any provision of this Agreed Order is declared invalid for any reason by a court of competent jurisdiction, said finding shall not affect the remaining provisions of this Agreed Order.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 21 of 24
- 21 -
VI. STIPULATION PURSUANT TO THE PRISON LITIGATION REFORM ACT, 18 U.S.C. § 3626
A. For the purposes of this Agreed Order only and in order to settle this matter, the Parties stipulate that this Agreed Order complies in all respects with the provisions of 18 U.S.C. § 3626(a). The Parties further stipulate and agree that the prospective relief in this Agreed Order is narrowly drawn, extends no further than necessary to correct the violations of federal rights alleged by the United States, is the least intrusive means necessary to correct these violations, and will not have an adverse impact on public safety or the operation of a criminal justice system. Accordingly, the Parties agree and represent that the Agreed Order complies in all respects with the provisions of 18 U.S.C. § 3626(a)
B. The issue of liability has not been litigated.
C. This Agreed Order is not intended to have any preclusive effect except between the Parties. Should the issue of the preclusive effect of this Agreed Order be raised, the Parties agree to certify that this Agreed Order was intended to have no such preclusive effect.

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 22 of 24

- 22 -

~ee~ RENAi.CIsAc

United States Attorney

Acting Assistant Attorney

Northern District of Texas

General

1100 Commerce Street, Suite 300

Civil Rights Division

Dallas, Texas 75242-1699

JOHN R. PARKER Chief, Civil Division United States Attorney's Office Northern District of Texas 1100 Commerce Street Suite 300 Dallas, Texas 75242-1699

ETTA Y. CUTLAR Chief Special Litigation Section
!tid11f!?-- D~L.H. WEISS
Deputy Chief

DAVID DEUTSCH Senior Trial Attorney

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 23 of 24

FOR DALLAS COUNTY, TEXAS:

- 23 -

allas County Judge Dallas County Commissioners Court
~-
LUPE VALDEZ Sheriff Dallas County
PETER HARLAN Assistant District Attorney for Dallas County Dallas County

Case 3:07-cv-01559-N Document 8 Filed 11/06/2007 Page 24 of 24

L Mv.evt\W, SO ORDERED this

- 24 -
day of

2007:

NORTHERN DISTRICT OF~~~~

 
 Case 3:07-cv-01559-N Document 20 Filed 11/04/11 Page 1 of 3 PageID 758

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS

UNITED STATES OF AMERICA,
PLAINTIFF,
v.
DALLAS COUNTY TEXAS ; LUPE VALDEZ , SHERIFF OF DALLAS COUNTY , TEXAS ( in her official capacity) ,
DEFENDENTS.

)

)

)

)

)

)

) )

Civil No. 3:07 CV 1559-N

)

)

)

)

)

)

JOINT NOTICE OF TERMINATION
THE UNITED STATES OF AMERICA AND DALLAS COUNTY, in accordance with Section V (C) of the Agreed Order, hereby gives notice of, and respectfully submits to this Court the following:
1. The United States and the Defendants entered into an Agreed Order that was approved and ordered by this Court on November 6, 2007;
2. The Agreed Order required the Defendants to take specified remedial measures in the areas of medical care, mental health care, sanitation, and environmental health in order to alleviate conditions at the Dallas County Jail that the United States found violated the constitutional rights of individuals confined to the Jail;
3. The Defendants have substantially complied with the provisions of the Agreed Order;
4. The Agreed Order contemplates that it shall terminate four years from the date the Agreed Order is ordered by the Court, which is November 6, 2011. Agreed Order, Section V (C).
Accordingly, the United States of America and Dallas County request that this Court terminate this action.

Case 3:07-cv-01559-N Document 20 Filed 11/04/11 Page 2 of 3 PageID 759 -2-

FOR THE UNITED STATES:

Respectfully submitted,

SARAH R. SALDAÑA United States Attorney
/s/ John R. Parker John R. Parker Chief, Civil Division United States Attorney’s Office Northern District of Texas 1100 Commerce Street, 3rd Floor Dallas, TX 75242-1699 (214) 659-8600

JONATHAN SMITH Chief Special Litigation Section
Shelley R. Jackson Deputy Chief Special Litigation Section
/s/ David Deutsch David Deutsch Senior Trial Attorney United States Department of Justice Civil Rights Division Special Litigation Section 601 D Street, NW Washington, DC 20004 (202) 514-6270

Case 3:07-cv-01559-N Document 20 Filed 11/04/11 Page 3 of 3 PageID 760 -3-
FOR DALLAS COUNTY, TEXAS:
CLAY JENKINS Dallas County Judge Dallas County Commissioners Court LUPE VALDEZ Sheriff Dallas County
/s/ Peter Harlan PETER HARLAN Assistant District Attorney Dallas County

 
 Case 3:07-cv-01559-N Document 10 Filed 10/15/08 Page 1 of 5 PageID 171

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·

i

I

 
 MEMORANDUM OF UNDERSTANDING
This Memorandum of Understanding (“MOU”) is between United States, by and through the United States Department of Justice, Civil Rights Division (“United States”), and Dallas County, Texas, and the Sheriff of the Dallas County Jail (collectively “Defendants”). This MOU resolves the United States’ outstanding claims against Defendants, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. ' 1997, regarding Defendants’ care and services for individuals at the Dallas County Jail (“DCJ”) in the areas of medication administration, access to health care, medical facilities, mental health assessment and treatment, that the United States and the Court Monitor maintain are still deficient. The MOU also requires the County to maintain and sustain the remedial measures made to date pursuant to the Agreed Order in United States v. Dallas County, Texas, et al., regarding DCJ.
I. INTRODUCTION
The United States began its investigation of DCJ in 2005. The Parties negotiated an Agreed Order entered by a federal court in November 2007. Agreed Order, United States v. Dallas County, et al., No. 3:07-CV-1559-N (N.D. Texas – Dallas Division, entered Nov. 6, 2007). The Agreed Order mandated comprehensive reforms at DCJ, including, inter alia, reforms in medical care, mental health care, and sanitation and environmental health. The Parties selected a monitor to assess, review, and report on the Defendants' implementation of, and compliance with, the provisions of the Agreed Order.
Following the entry of the Agreed Order, the United States along with the Independent Monitor and an expert compliance team worked with Dallas County and DCJ officials to assist in bringing DCJ into constitutional compliance. Compliance tours were conducted biannually, the most recent being the week of September 19-23, 2011. Reports were produced by the Independent Monitor following each tour, detailing the status of compliance and providing technical assistance. The most recent report of the Independent Monitor found that DCJ had achieved substantial compliance with virtually all of the 72 overall provisions of the Agreed Order. 9th Monitoring Report (September, 2011 visit) (incorporated by reference). The Independent Monitor found that there are three partially compliant areas in the medical program and one remaining partially compliant area in the mental health program.
The United States and the Defendants filed a Notice of Termination requesting the end of court supervision based on the County’s progress and compliance to that point in time with the Agreed Order. The District Court granted the request on October 27, 2011 thereby ending court supervision at DCJ.
The Parties, however, recognize that significant concerns remain in providing adequate medical and mental health care at DCJ. The Parties enter into this MOU to complete the necessary reforms and to ensure continued sustained compliance with all areas where substantial compliance had been achieved under the Agreed Order.

- 2 -

II. DEFINITIONS 

A. “DCJ” or “the Jail” shall refer to the Dallas County Jail and shall include the Suzanne Kays Detention Facility; the Decker Detention Facility; the George Allen Courts Building; and the adjoining Lew Sterrett Center Tower Facilities (“Lew Sterrett”); as well as any facility that is built, leased, or otherwise used, to replace or supplement the Jail.
B. “DOJ” shall refer to the United States Department of Justice, which represents the United States in this matter.
C. “Effective date” shall mean the date the MOU is signed and executed by the Parties.
D. Throughout this MOU and the previous Agreed Order, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance. “Substantial compliance” indicates that the Jail has achieved compliance with all components of the relevant provision of the MOU. “Partial compliance” indicates that compliance has been achieved on some of the components of the relevant provision of both the MOU and the Agreed Order, but significant work remains. “Non-compliance” indicates that most or all of the components of the MOU and the Agreed Order provision have not been met.
E. “Agreed Order” shall mean the Agreed Order entered by the federal court in November 2007. Agreed Order, United States v. Dallas County, et al., No. 3:07-CV-1559-N (N.D. Texas – Dallas Division, entered Nov. 6, 2007).
III. PURPOSE OF THE MOU AND EFFECT OF THE AGREED ORDER
The Parties acknowledge that the underlying purpose of this MOU is twofold: (1) to ensure that Defendants shall achieve substantial compliance with the areas in partial compliance when the Agreed Order was terminated; and, (2) to ensure that Defendants maintain compliance in those areas of the Agreed Order where substantial compliance has been achieved. The Parties acknowledge and recognize that this MOU shall remain in effect until the Defendants have achieved substantial compliance with all the provisions of this MOU. While the Agreed Order is no longer binding, in order to sustain substantial compliance, it is expressly incorporated as part of this MOU, and the Parties may reference the Agreed Order if disputes arise as to the meaning of the terms of this MOU. (See Attachment A).

- 3 -

IV. SUBSTANTIVE PROVISIONS
A. Achieve Substantial Compliance
The Defendants shall take all necessary measures to achieve substantial compliance in the areas of the Agreed Order found in partial compliance by the Monitor in his DCJ 9th Monitoring Report. More specifically, regarding medical care, the Defendants shall take all necessary measures to achieve substantial compliance in the areas of access to health care (Agreed Order, Section A (5) (a)-(d)); medication administration (Agreed Order, Section A (8) (a)-(b)); and medical facilities (Agreed Order, Section A (9) (a)-(b)). In addition, regarding mental health care, the Defendants shall take all necessary measures to achieve substantial compliance in the area of assessment and treatment, privacy, disciplinary charges, and segregation (Agreed Order, Section B (2) (b), (d), and (e)).
B. Maintaining Compliance
The Defendants shall maintain compliance in all areas where substantial compliance has been achieved under the Agreed Order. Specifically, the Defendants shall maintain compliance in the areas of (1) medical care (intake screening; acute care; chronic care; follow-up care; specialty care; staffing, training, and supervision; quality assurance review; and dental care); (2) mental health care (timely and appropriate evaluation; psychotherapeutic medication administration; and suicide prevention); and (3) sanitation and environmental conditions (sanitation of laundry; protection from biohazards; environmental control; maintenance and sanitation of facilities; and fire and life safety).
V. ENFORCEMENT
A. Selection of Monitor
The Parties jointly agree to continue to use Michael Puisis, D.O., as the expert to monitor the State’s implementation of this MOU (the “Monitor”). The Monitor shall have full authority to assess, review, and report on Defendants' implementation of and compliance with the provisions of the MOU. No Party, nor any employee or agent of any Party, shall have any supervisory authority over the Monitor’s activities, reports, findings, or recommendations. In the event that Dr. Puisis is unable to serve or continue serving as the Monitor, or in the event that the Parties for any reason agree to discontinue the use of Dr. Puisis, the Parties shall meet or otherwise confer within 30 days of being notified of the incapacity or the decision to discontinue use of Dr. Puisis to select a new Monitor. The Parties will endeavor to select a new Monitor in good faith. The procedure described in this paragraph shall apply to all successor Monitors.

- 4 -

The Parties agree that the Monitor may use consultants to assist the Monitor. Any such consultants shall be paid for time, services, and expenses pursuant to the Monitor’s existing budget. Neither the Monitor, nor any person or entity hired or retained by the Monitor to assist in furthering any provision of this MOU, shall be liable for any claim, lawsuit, or demand arising out of the monitoring of this MOU. This paragraph does not apply to any proceeding before a court for enforcement or payment of contracts or subcontracts for monitoring this MOU.
B. Reimbursement and Payment Provisions
1. The Parties and the Monitor have agreed upon the annual budget for the Monitor's work.
2. The cost of the Monitor, including the cost of any consultant(s) to assist the Monitor, shall be borne by Defendants. All reasonable expenses incurred by the Monitor or any consultant, in the course of the performance of the duties of the Monitor, pursuant to the budget of the Monitor, shall be reimbursed by the Defendants. The United States will bear its own expenses.
C. Responsibilities and Powers of the Monitor
1. The role of the monitor is to determine: (1) whether the Defendants have complied with the provisions of this MOU and (2) whether the implementation of the MOU has achieved the goals intended by both this MOU and the now terminated Agreed Order.
2. The overall duties of the Monitor shall be to observe, review, report findings, and make recommendations, where appropriate, with regard to the implementation of the foregoing substantive provisions by Defendants. The Monitor shall regularly review the services provided to DCJ inmates to determine Defendants' implementation of and compliance with this MOU and whether reforms have been successful in addressing deficiencies. During the Monitor’s review, the Monitor shall have full and complete access to all of DCJ’s buildings and facilities, staff, patients, patient records, documentation, and information relating to the issues addressed in this MOU. The Defendants shall direct all employees to cooperate fully with the Monitor. The Monitor shall be permitted to initiate and receive ex parte communications with the Parties. The Monitor shall devote such time as is necessary to fulfill the purposes of the duties and responsibilities of the Monitor pursuant to this MOU.
3. The Monitor shall consult with the Parties and shall continue to utilize the methodologies employed in assessing compliance with the now terminated Agreed Order to assess Defendants' compliance with and implementation of this MOU. The Monitor’s evaluation shall include: regular on-site inspection of DCJ’s facilities and programs for patients, interviews with administrators, professional and other staff, contractors, and patients, and detailed review of pertinent documents and patient records. The Parties envision that the Monitor may provide specific recommendations to Defendants with regard to steps to be taken to come into compliance with the MOU. Defendants, however, retain the discretion to achieve compliance by any legal means available to them, and may choose to utilize methods other than those that may

- 5 -

be proposed by the Monitor or the United States. The Monitor shall not be empowered to direct Defendants to take, or to refrain from taking, any specific action to achieve compliance with the MOU.
4. The Parties envision that the Monitor will use his last evaluations of DCJ during the Agreed Order as a “baseline” evaluation of Defendants' compliance with the terms of this MOU. This baseline evaluation is intended as an initial benchmark to inform the Parties and the Monitor of the status of compliance with this MOU.
5. The Monitor shall conduct an on-site tour of DCJ at least annually, upon reasonable notice, to fulfill his or her obligations pursuant to this MOU. The Monitor shall conduct the first tour of each unit of DCJ no later than 6 months from the Effective Date of this MOU.
The Monitor shall provide the Parties with a compliance report, transmitted electronically, as soon as possible, but at least within 60 days of each tour and shall detail with as much specificity as possible how the Defendants are or are not in compliance with particular provisions of the MOU. Drafts of the Monitor’s reports shall be provided to the Parties for comment at least 10 business days prior to issuance of the reports.
VI. REPORTING REQUIREMENTS AND RIGHT OF ACCESS
A. Defendants shall submit, at a minimum, annual compliance reports to both the United States and the Defendants.
B. Each compliance report shall describe the actions the Defendants have taken during the reporting period to implement both this MOU and the now terminated Agreed Order and shall make specific reference to the Agreed Order and MOU provisions being implemented.
C. Defendants shall maintain sufficient records to document that the requirements of this MOU are being properly implemented and shall make such records available at all reasonable times for inspection and copying by the United States. In addition, Defendants shall maintain and submit upon request records or other documents, at Defendant’s cost, to verify that they have taken such actions as described in their compliance reports (e.g., census summaries, policies, procedures, protocols, training materials, and incident reports) and will also provide all documents reasonably requested by the United States.
D. The United States and its attorneys, consultants, and agents, and any other persons authorized by the Parties, including the Monitor and any consultant(s), shall have unrestricted access to the Jail, Jail inmates, Jail staff (including staff at DCJ employed by Parkland or any other outside medical services provider), and documents as reasonably necessary to address issues affected by this MOU.
E. Within 30 days of receipt of written questions from the DOJ concerning Defendants’ compliance with the requirements of this MOU, Defendants shall provide the DOJ with written answers and any requested documents.

- 6 -

F. Defendants shall appoint a compliance coordinator to oversee compliance with this MOU and to serve as a point of contact.
VII. CONSTRUCTION, IMPLEMENTATION AND TERMINATION
A. Defendants shall implement all reforms necessary to effectuate this MOU. The implementation of this MOU will begin immediately upon execution by the Parties. As needed, Defendants shall retain the services of third-party consultants to provide technical assistance regarding the implementation of the substantive provisions contained in Section III of the Agreed Order.
B. This MOU shall not terminate until the Defendants have substantially complied with each of its provisions. The burden shall be on Defendants to demonstrate this level of compliance. After the IM has determined that the Defendants have substantially complied with each of the provisions of the MOU and has sustained such compliance for a period of at least one year, this MOU shall terminate. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained noncompliance shall not constitute substantial compliance.
C. Failure by either party to enforce this entire MOU or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this MOU.
D. If any unforeseen circumstance occurs that causes a failure to timely carry-out any requirements of this MOU, Defendants shall notify the DOJ in writing within 20 calendar days after Defendants become aware of the unforeseen circumstance and its impact on the Defendant’s ability to perform under the MOU. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. Defendants shall implement all reasonable measures to avoid or minimize any such failure.
E. This MOU and incorporated documents shall constitute the entire integrated MOU of the Parties.
F. The MOU shall be applicable to, and binding upon, all Parties, their officers, agents, employees, assigns, and their successors in office.
G. Each party shall bear the cost of their fees and expenses incurred in connection with this cause, except as specifically provided herein.
H. In the event that any provision of this MOU is declared invalid for any reason by a court of competent jurisdiction, said finding shall not affect the remaining provisions of this MOU.

-7­
FOR THE UNITED STATES:
THOMAS E. PEREZ Assistant Attorney General Civil....i.wy<q ¥'J

Chief Special Litigation Section Civil Rights Division
~ON 
 Deputy Chief Special Litigation Section Civil Rights Division
DAVID DEUTSCH Senior Trial Attorney Special Litigation Section Civil Rights Division

DATE 
 DATE 


-8­
FOR THE DEFENDANTS DALLAS COUNTY, TEXAS 
 AND LOPE VALDEZ, SHERIFF OF DALLAS COUNTY, TEXAS: 

I

LUPEVALDEZ SheriffofDallas County, Texas

RECOMMENDED FOR APPROVAL BY:
CRAIG WATKINS DISTRICT ATTORNEY

BY: PETERL. HARLAN ASSISTANT DISTRICT ATTORNEY CHmF OF FEDERAL LffiOATION FOR THE DEFENDANTS

DATE

 
 December 8, 2006
The Honorable Margaret Keliher Presiding Officer Dallas County Commissioners Court 411 Elm Street, 2nd Floor Dallas, TX 75202
Re: Investigation of the Dallas County Jail, Dallas, Texas
Dear Judge Keliher:
On November 28, 2005, we notified you of our intent to investigate conditions at the Dallas County Jail (“DCJ” or “the Jail”), in Dallas, Texas, pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997. Consistent with our statutory requirements, we write to report the findings of our investigation and to recommend remedial measures to ensure that DCJ meets federal constitutional requirements. See 42 U.S.C. § 1997b.
From February 20-24, 2006, and from March 20-23, 2006, we conducted on-site inspections of DCJ with consultants in the fields of correctional medical care, correctional mental health care, and environmental health and safety. While on-site, we interviewed administrative and security staff, medical and mental health care providers, and inmates. Before, during, and after our on-site inspections, we received and reviewed a large number of documents, including policies and procedures, incident reports, grievances, medical and mental health records, and other records. Consistent with our commitment to provide technical assistance and conduct a transparent investigation, we provided extensive debriefings at the conclusion of our inspections, during which our consultants expressed their initial impressions and concerns.
In July 2006, we received updated information regarding the efforts the Jail is undertaking to address many of the problems cited by our consultants during the two exit interviews and that are discussed herein. We are encouraged by the County’s prompt efforts to address deficient conditions at DCJ.

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We appreciate the full cooperation we received from County and DCJ officials throughout our investigation. We also wish to extend our appreciation to the Sheriff and the staff and administration at the Jail for their professional conduct and timely responses to our requests.
Having completed the fact-finding portion of our investigation of the Jail, we conclude that certain conditions at DCJ violate the constitutional rights of inmates confined there. As detailed below, we find that DCJ fails to provide inmates with: (1) adequate medical care; (2) adequate mental health care;1 and (3) safe and sanitary environmental conditions.
I. BACKGROUND
A. DESCRIPTION OF DCJ
The Dallas County Jail is operated by the Dallas County Sheriff’s Office (“Sheriff’s Office”) and is the seventh largest detention facility complex in the country. DCJ receives 90,000100,000 admissions per year, 57% of which are released within three days, and 68% within seven days. As of February 20, 2006, the Jail housed approximately 7,770 inmates, both pre-trial and sentenced, in five separate adult facilities: the Suzanne Kays Detention Facility; the Decker Detention Facility; the George Allen Courts Building; and the adjoining Lew Sterrett Center Tower Facilities (“Lew Sterrett”).
Most of the inmate population is housed in Lew Sterrett which includes: an intake area for all of DCJ; a medical infirmary; the majority of the Jail’s behavior observation cells for inmates with mental illnesses; housing for female inmates, including female observation cells; a male geriatric unit; a unit for juveniles; and a large general population. The George Allen facility has a female infirmary and houses both men and women of all classification levels. The Decker Detention facility is a minimum-security facility which houses both male and female inmates. Lastly, the Suzanne Kays facility is a minimum-security facility that houses both male and female inmates.
The Sheriff’s Office is responsible for all operations of the Jail, including classification, physical plant and services,

1

We note that in late 2004, the Dallas County

Commissioner’s Court commissioned a study of medical and mental

health care, the results of which became public in February 2005,

and are consistent with the findings contained herein.

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security, escort, and transportation for inmates. From October 2002 through February 2006, medical and mental health care services at the Jail were provided by the University of Texas Medical Branch at Galveston (“UTMB”) through a contract monitored by Parkland Health and Hospital System (“Parkland”). Parkland began providing medical and mental health care effective March 1, 2006.
II. LEGAL FRAMEWORK
CRIPA authorizes the Attorney General to investigate and take appropriate action to enforce the constitutional rights of jail detainees and inmates subject to a pattern or practice of unconstitutional conduct or conditions. 42 U.S.C. § 1997. Pre-trial detainees, individuals who have not been convicted of the criminal offenses with which they have been charged, comprise the majority of inmates at the DCJ. The rights of pre-trial detainees are protected under the Fourteenth Amendment which ensures that these inmates “retain at least those constitutional rights . . . enjoyed by convicted prisoners.” Bell v. Wolfish, 441 U.S. 520, 545 (1979) (applying the Fourteenth Amendment standard to a facility for adult pre-trial detainees); Scott v. Moore, 85 F.3d 230, 235 (5th Cir. 1996) (finding that a municipality assumed a Constitutional obligation under the Fourteenth Amendment to provide pre-trial detainees with minimal levels of safety and security); Hare v. City of Corinth, 74 F.3d 633, 639 (5th Cir. 1996) (en banc), rev’d on other grounds, 135 F.3d 320, 326 (5th Cir. 1998) (recognizing a “pretrial detainee’s constitutional right to be secure in his basic human needs, such as medical care and safety...”).
In Scott v. Moore, 85 F.3d 230, 235 (5th Cir. 1996), the Fifth Circuit has held that the protection of pre-trial detainees’ rights under the due process clause of the Fourteenth Amendment is “at least as great as the Eighth Amendment protections available to a convicted prisoner.” Id. (quoting City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983)). Under the Eighth Amendment, prison officials have an affirmative duty to ensure that inmates receive adequate food, clothing, shelter, and medical care. Farmer v. Brennan, 511 U.S. 825, 832 (1994); Bell, 441 U.S. at 535-36, 537 n.16; Scott, 85 F.3d at 235; Hare, 74 F.3d at 639. The Eighth Amendment protects prisoners not only from present and continuing harm, but also from future harm. Helling v. McKinney, 509 U.S. 25, 33 (1993).
Detainees have a constitutional right to adequate medical and mental health care, including psychological and psychiatric

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services. Farmer, 511 U.S. at 832; Gates v. Cook, 376 F.3d 323, 332 (5th Cir. 2004). Inmates’ Eighth Amendment rights are violated when prison officials exhibit deliberate indifference to their serious medical needs. See Estelle v. Gamble, 429 U.S. 97, 102 (1976). The standard for adequate medical and mental health care requires a showing of both the subjective and objective components of “deliberate indifference.” Gates, 376 F.3d at 333. Deliberate indifference may be inferred when a prison official “knows of and disregards an excessive risk of inmate health.” Farmer, 511 U.S. at 837. Prison personnel exhibit “deliberate indifference” to an inmate’s health when they refuse to treat him, ignore his complaints, intentionally treat him incorrectly or “engage in any similar conduct that would clearly evince a wanton disregard for any serious medical needs.” Domino v. Texas Dep’t Of Criminal Justice, 239 F.3d 752, 756 (5th Cir. 2001).
III. FINDINGS
A. MEDICAL CARE
DCJ fails to provide inmates with adequate medical care that complies with constitutional requirements. We found the following serious deficiencies: (1) inadequate intake screening; (2) inadequate acute care; (3) inadequate chronic care; (4) inadequate treatment and management of communicable disease; (5) inadequate access to health care; (6) inadequate follow-up care; (7) inadequate record keeping; (8) inadequate medication administration; (9) inadequate medical facilities; (10) inadequate speciality care; (11) inadequate staffing, training, and supervision; (12) inadequate quality assurance; and (13) inadequate dental care.
1. Inadequate Intake Screening
DCJ fails to adequately identify inmates’ health needs through appropriate intake screening, thereby preventing inmates from receiving adequate care for acute or chronic needs. Generally accepted correctional medical standards require that incoming inmates be screened by staff trained to identify and triage serious inmate medical needs, including drug and alcohol withdrawal, communicable diseases, acute or chronic needs, mental illness, and potential suicide risks. DCJ’s intake screening process fails to identify such needs and places inmates at risk of serious harm.
Prior to March 1, 2006, detention officers, who lacked adequate training and medical supervision, were responsible for conducting intake screenings. On March 1, 2006, DCJ began using

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paramedics to perform intake screenings. While this staffing change is an improvement, the intake screening process remains deficient because there are no medical policies governing the intake process and signs and symptoms of serious illness or contagious disease go unrecorded. Further, the screening form used by DCJ lacks sufficiently specific questions regarding acute and chronic illness, including drug and alcohol withdrawal. Moreover, screening interviews are conducted with a total lack of privacy, further compromising the quality of information received. These practices contravene generally accepted correctional medical standards and place inmates at significant risk of harm. The following examples illustrate the intake screening deficiencies.
! Inmate P.C.2 was booked into DCJ on February 21, 2006. Although he was diagnosed with alcohol withdrawal, the screening process failed to identify that he was suffering from delirium tremens, a potentially lifethreatening complication of alcohol withdrawal. As a result, P.C. did not receive appropriate medical care. Two days after intake, our medical consultant examined P.C. and found that he was acutely psychotic with tremors, delusions, and hallucinations. It was only after we brought his conditions to DCJ’s attention that P.C. was transferred to the hospital for necessary care.
! Inmate A.L. died in October 2005, two days after being booked into DCJ, of diabetic ketoacidosis, a lifethreatening complication of diabetes. At intake, A.L.’s blood sugar level was recorded at a dangerously high level yet he received no physician care while at DCJ. We note that while this incident occurred prior to the March 1, 2006 change, this type of deficiency can recur given that DCJ lacks policies and procedures to govern its intake process.
! Inmate A.N. suffered from HIV and died on October 5, 2005 of pneumocystis pneumonia, an opportunistic infection, which could have been prevented if he had continued to receive the antibiotic he was prescribed at the time he was admitted to DCJ.

2

Throughout this letter, when referring to a specific

inmate, we use pseudonymous initials to protect the identity of

the inmate. We are providing to the County a key to the identity

of inmates referenced in this letter under separate cover.

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The Jail failed to provide A.N. with this prescription for 11 days following intake.
! In December 2004, DCJ transferred inmate Q.S. to the hospital where he died of alcohol withdrawal. Q.S. had been admitted to DCJ a week prior with a history of alcoholism and seizures during alcohol withdrawal. Within four days of intake, he became disoriented, developed a fever, and had an elevated blood pressure. Q.S. was kept in the facility with no physician or nursing care, and no monitoring of his vital signs. Q.S. soon became lethargic and was later discovered lying in his feces. After finding him in this state, it took an additional five hours before Q.S. was transferred to the hospital where he subsequently died.
DCJ’s intake screening process also fails to identify the health needs of juveniles, notwithstanding this population’s particular vulnerabilities to mental illness and suicide. On February 20, 2006, DCJ had 11 juveniles in custody. Only six had a medical screening, and none had been screened for suicide risk. On March 21, 2006, there were also 11 juveniles in custody, but only two had a medical screening. There were no medical evaluations for those juveniles with asthma or for a youth with a history of being on pyschotropic medications.
Finally, DCJ inmates do not receive a full health assessment within a reasonable period after admission. The generally accepted correctional medical standard is to conduct health assessments within two weeks of admission. Appropriate and timely health assessments reduce the risk of harm should screening procedures fail to identify an inmate’s serious health needs and improves the facility’s ability to provide efficient, adequate care. Typically, this assessment includes a review of the intake information, a complete medical and mental health history, a physical examination, and screening for TB and sexually transmitted diseases. Approximately one in four inmates are still at DCJ two weeks after intake and many do not receive a health assessment. At DCJ, the need for a prompt assessment is compounded by the inadequacies in the intake screening process described above.
2. Inadequate Acute Care
DCJ fails to provide inmates adequate acute care, that is care for urgent and/or emergent medical conditions. Jail staff frequently mismanage inmates’ acute medical needs, thereby significantly delaying appropriate medical care. Most seriously,

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we found numerous instances where DCJ’s mismanagement contributed to preventable deaths, hospitalizations, and unnecessary harm.
Correctional facilities should provide adequate nursing and physician care for the treatment of serious and emergent conditions. Jail staff should be adequately trained and prepared to manage emergent situations in accordance with generally accepted correctional medical care standards. DCJ’s failure to provide such care has subjected inmates to serious harm. The following examples highlight DCJ’s deficiencies in providing acute care:
! On February 23, 2006, during our initial tour, we witnessed an emergent situation unfold involving inmate E.C. who had experienced a seizure. When medical staff evaluated him, E.C. was found to have a severely low blood sugar level. Contrary to generally accepted correctional medical standards which dictate that the inmate receive glucogon or an intravenous injection of glucose, the nurse failed to consult with a nearby physicians’ assistant, and inappropriately gave C.C. orange juice and peanut butter.
! In early 2006, inmate E.E. suffered a severe leg infection as a result of DCJ’s failure to provide adequate acute care both prior and subsequent to his hospitalization for a severe leg wound. Notably, even after E.E. was discharged from the hospital, DCJ failed to treat him in accordance with the directions provided in his hospital discharge instructions. E.E. received inadequate care for an additional five months. In fact, his care was so deficient that he was released by court order so that he could obtain medical care outside of DCJ.
! On April 28, 2004, inmate C.D. sustained trauma to his left eye. Although Jail staff were aware of the injury, C.D. was not seen by a physician for seven days, until he was hospitalized. By this time, C.D.’s injury was inoperable and he is now blind in that eye.
! Inmate A.F. died on February 1, 2004 after not receiving adequate care for an emergent and life threatening condition. A.F., who suffered from HIV, was admitted to DCJ in October 2003. In late December, Jail staff ordered an x-ray after A.F. complained of chest pain. Over two weeks passed before his x-ray was taken. During the interim, he developed pneumocystis

- 8 -
pneumonia, a life-threatening condition. The results of A.F.’s x-ray were not reviewed until late January 2004. On January 31, 2004, a physician who had reviewed A.F.’s chart ordered that A.F. be brought to him the next day. A.F. died prior to seeing the physician.
3. Inadequate Chronic Care
DCJ fails to provide constitutionally adequate care to meet the serious medical needs of inmates with chronic medical conditions. See, e.g., Lawson v. Dallas County, 112 F. Supp. 2d 616, 637 (D. Tex. 2000) aff’d 286 F.3d 257 (5th Cir. 2002) (finding deliberate indifference where prison officials, aware of an inmate’s deteriorating medical condition, failed to administer required medication and treatment). See also Domino v. Texas Dep’t of Criminal Justice, 239 F.3d 752, 756 (5th Cir. 2001) (finding deliberate indifference where jail staff had refused to treat, ignored complaints of, or intentionally mis-treated an inmate despite serious medical need). Jail staff may not effectively deny, substantially delay, or refuse care for an inmates’ serious medical needs. See Stewart v. Murphy, 174 F.3d 530, 537 (5th Cir. 1999) citing cf. Hudson v. McHugh, 148 F.3d 859, 863-64 (7th Cir. 1998) (noting deliberate indifference where jail officers and nurse refused to address an inmate’s repeated requests for epilepsy medicine despite knowing of his serious medical need).
Inmates who suffer from chronic medical conditions require ongoing coordinated care and treatment to prevent the progression of their illnesses. DCJ has no clinical practice guidelines for chronic and communicable diseases, such as diabetes, asthma, hypertension, HIV and sexually transmitted diseases. In particular, DCJ’s care for inmates with chronic medical conditions fails in two areas: (a) assessment of chronic conditions; and (b) timely and adequate follow-up medical treatment, including proper medication administration.
a. Failure to Assess for Chronic Conditions
Generally accepted standards of correctional medical care require that medical staff be able to identify inmates in need of chronic care and provide timely treatment or referrals for inmates’ chronic conditions. DCJ fails to ensure that inmates receive thorough assessments and monitoring of their chronic illnesses. The Jail has no established policies and procedures for identifying and caring for inmates with chronic illnesses or diseases. DCJ inmates with chronic conditions are not routinely

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identified and assessed at intake or shortly thereafter. As a result, no plan is made for their ongoing assessment and monitoring. Moreover, inmates with chronic conditions are not routinely seen by a physician to evaluate the status of their health and the effectiveness of the medication they are taking for their chronic conditions.
Additionally, DCJ intake nurses are not adequately trained to identify inmates with chronic conditions, and commonly fail to administer standard tests for treatment and prevention of medical complications, including blood tests for diabetics and peak air flow measurements for asthmatics. Without such routine tests, it is not possible to identify those who require urgent medical care and for medical staff to appropriately monitor inmates with these chronic illnesses.
b. Inadequate Follow Up Treatment and Medication Administration
Care for inmates with chronic conditions is plagued by delays in the treatment and administration of medication. Delays begin during the Jail’s intake routing process and are exacerbated by overall inadequacies in the medical care system. Our review of inmate medical records revealed consistent significant delays for inmates receiving care for chronic conditions. Such delays increase the risk of harm to inmates and the likelihood that their chronic conditions may worsen. This deficiency was acknowledged by DCJ’s medical director, who reported to us that inmates commonly wait two to three weeks before receiving medications following intake.
Inmates who are identified with chronic health conditions are often not scheduled for follow-up medical assessment. Rather, they are transferred to their housing unit, where they must avail themselves of the deficient processes described below, to seek further medical care. Consequently, inmates with chronic medical needs are routinely not seen timely by clinicians. During our investigation, we reviewed the medical charts of 18 inmates admitted to DCJ on February 13, 2006. Five of these inmates had a history of chronic disease yet, according to their medical records, one week later none had been seen by DCJ medical staff. Such delays are contrary to generally accepted standards of correctional medical care and expose inmates with chronic conditions3 to significant and unnecessary risk of harm. For

3

Inmates with chronic conditions require earlier

assessment and treatment sooner than the two week health

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example, Inmate Y.G. died of heart failure within 20 days of arriving at the Jail in October 2004, because he was unable to get care for his multiple chronic conditions and abdominal swelling (a symptom of heart failure). Despite efforts by both Y.G. and his sister to get the Jail to treat his diabetic and heart conditions, DCJ failed to administer Y.G.’s medication.
The lack of coordinated care for chronic conditions is particularly dangerous for diabetic inmates. As part of our review, we randomly selected 12 inmates from those designated as diabetics by DCJ. In a gross departure from generally accepted medical standards, none of the 12 inmates had been tested for two standard indicators of their diabetic condition and potential complications. Additionally, only nine of the 12 inmates had blood sugar measurements taken during intake; six did not receive their first dose of medication for a period ranging from six days to two months after intake; and two never received medication. These failings were typified by our interactions with inmate A.R. who had been in medical housing at the facility for three weeks as of our February 21, 2006 tour. A.R. had received no insulin and Jail staff had failed to measure his blood sugar level. At our request, DCJ checked A.R.’s blood sugar and discovered that it was extremely high. A.R. was unnecessarily exposed to potentially life-threatening harm due to DCJ’s failure to monitor his condition.
We found numerous additional instances of deficient chronic care that put inmates’ health and lives at serious risk:
! Inmate B.P. has HIV, asthma, and a drug-resistant skin infection. Although B.P. reported during our February 2006 tour that he has prescriptions for three HIV medications, his medical record reveals that Jail staff were administering only one of these medications. The failure to administer all three of the prescribed medications may cause B.P. to develop resistance to HIV medication. Moreover, without his HIV medications, B.P. becomes more susceptible to potentially fatal skin infections.
! Inmate N.T. has a seizure disorder. Although she suffered seizures on both October 10, and November 28, 2005, DCJ staff failed to order her
assessment, which is the generally accepted correctional medical standard for all inmates.

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seizure medication for several weeks, until February 16, 2006.
! Inmate B.Q. was admitted to the Jail in July 2005 but in February 2006 he reported to us that he was not receiving his HIV medication. A review of his medical record reveals that B.Q. had neither received his medication nor been evaluated by a physician during his seven months in custody.
! Inmate I.S. had five seizures at DCJ over a period of 12 days in December 2005. As of February 2006, she had not been seen by a physician for her condition. Our medical consultant reviewed her chart and found that I.S. had been prescribed a sub-therapeutic dosage of medication for her seizure disorders. I.S. remains at risk for repeated seizures.
! In July 2005, inmate L.E., who is bipolar and is HIV-positive, suffered repeated delays in receiving his medication each time he was transferred to a new cell. An examination of his medical record reveals that, with each of his four transfers, the Jail failed to administer his medication for periods ranging from four days to seven weeks.
4. Inadequate Treatment and Management of Communicable Disease
DCJ fails to adequately treat and manage communicable diseases. DCJ’s management of tuberculosis (“TB”), Methicillin Resistant Staphylococcus aureus (“MRSA”),4 and other infectious diseases deviates significantly from generally accepted correctional medical practices. Inmates with communicable diseases are not appropriately screened, treated, or isolated. Further, the crowded conditions at DCJ exacerbate the serious

4

MRSA (“methicillin-resistant staphylococcus aureus”) is

a bacteria resistant to certain antibiotics, including

methicillin, oxacillin, penicillin, and amoxicillin. Centers for

Disease Control and Prevention, at

http://www.cdc.gov/ncidod/hip/Aresist/ca_mrsa_public.htm. MRSA

manifests itself as a boil or sore on the skin and is spread

through contact with an infected person or a surface the person

has touched. Id. In some cases, MRSA can have serious medical

consequences, for example, by causing surgical wound infections,

bloodstream infections, and pneumonia. Id.

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risk of spreading communicable disease among inmates and staff. We note that DCJ’s inadequate practices pose a serious risk to DCJ inmates, staff, and even the Dallas community at large when the facility’s high turnover is taken into account. Similar to the deficiencies in chronic care, DCJ lacks practice guidelines, based on generally accepted correctional medical standards, for managing and treating communicable diseases in a correctional setting.
a. Tuberculosis
Pulmonary Tuberculosis (“TB”) is a potentially lifethreatening disease commonly found in correctional facilities. The transmittal of TB can be prevented or controlled with an appropriate TB control plan. A TB control plan provides guidelines for identification, treatment, and prevention of transmission of TB to staff and other inmates. The Jail has acknowledged the necessity of developing and implementing a TB control plan that is consistent with generally accepted correctional medical standards, however, such a plan is not currently in place.5 Consequently, we found deficiencies in: (1) screening; (2) containing; and (3) treating inmates for TB.
(1) Insufficient Screening
DCJ fails to adequately identify potential TB cases during intake screening, and fails to conduct timely and consistent clinical evaluations and diagnostic x-rays. These deficiencies expose inmates, staff, and the Dallas County community to an unnecessarily high risk of transmission.
Inmates who display symptoms of TB should be assessed and screened for exposure in a timely manner to facilitate the provision of any needed care. Screening tools include skintesting (for exposure) and chest x-rays, as needed. TB screening programs are intended to identify inmates who require treatment

5

On April 3, 2006, we notified the County of specific

instances of emergent medical concerns that required immediate

attention, including the creation and implementation of an

effective TB control plan. The County responded on

April 10, 2006, and stated that there was a TB screening team and

program in place at the Jail. However, our review of the

documents indicated a continued lack of appropriate planning to

screen and treat inmates, and to contain TB transmission in

accordance with general standards of care.

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as well as to determine if certain inmates require isolation to limit the risk of transmission.
TB-suspect inmates at DCJ must contend also with the deficiencies in care noted previously. There is a lack of necessary policies and procedures; inadequate follow-up care and assessment; and significant lags in inmates’ receiving appropriate diagnosis and medication. Tests are not consistently performed on inmates who display symptoms of TB, contrary to generally accepted correctional medical care standards. For example, on January 15, 2006, inmate J.M. was coughing up blood, a symptom of possible TB. Yet, by late March 2006, over two months later, J.M. had not received a chest x-ray to identify or rule out TB.
Overall, our review of DCJ’s screening program yielded disconcerting results. Nationwide, 15 to 25% of inmates have latent tuberculosis. Yet, at DCJ, only 2% of the 11,668 TB skin tests read between December 1, 2005 - February 28, 2006 were read as positive. Such a low percentage identified, compared to the national average, suggests that Jail staff are either not conducting or interpreting tests properly.
Additionally, we found a several week backlog for x-rays of inmates suspected of having TB. Our review of the Jail’s computer system revealed that on March 21, 2006 the unanswered backlog for x-rays reached 891. As a result, inmates who are TBsuspect are inappropriately housed with the general inmate population, while they wait weeks for chest x-rays.
(2) Insufficient Containment
DCJ fails to ensure the adequate containment of TB. Inmates with suspected TB should be placed in specialized respiratory isolation (“negative pressure”) rooms to reduce the risk of transmission through airborne particles. When properly used, these rooms are effective in preventing contagion. In addition, staff who are potentially exposed to the risk should wear and be trained in the use of specialized respirators. However, DCJ does not comply with these generally accepted standards of care.
The risk of TB transmission is heightened by DCJ’s practices and inattention to precautionary measures. DCJ’s negative pressure isolation cells in the Jail are sufficient and capable of creating negative pressure when properly utilized and maintained. However, we observed both inmate and staff conduct that defeat the negative pressure systems by leaving open cell doors and feeding ports (slots in cell doors through which inmate

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meals can be delivered). We also observed an inmate diagnosed with active tuberculosis defeating the system by covering the HVAC return vent with newspaper without effective staff intervention. Additionally, DCJ staff fail to take appropriate precautions in isolating inmates with active TB because such inmates are not consistently identified. DCJ uses its respiratory isolation cells to house inmates with active TB and also for overflow housing of general population inmates. Nonetheless, DCJ does not consistently identify those inmates who are placed in respiratory isolation cells for medical reasons.
(3) Inadequate Treatment
DCJ fails to ensure that inmates with TB receive complete treatments to decrease the risk for the emergence and transmission of multidrug-resistant TB.6 Treatment for TB requires at least a six-month course of antibiotics. Interruptions in an inmate’s antibiotic treatment can lead to the development of multidrug-resistant TB.
DCJ’s failures to adequately treat and manage communicable diseases has potentially resulted in inmates and staff being exposed to active TB. The following examples are illustrative:
! Inmate C.C. waited over two months to have an x-ray for suspected TB. Despite a medical order on January 9, 2006, the x-ray was not taken until two months later, on March 18, 2006. As a result of the x-ray, C.C. was then put into medical isolation.
! Inmate C.T. complained of coughing up blood and night sweats (both symptoms of active TB) seven days after admission to DCJ on March 14, 2006. Our review of his medical chart revealed that C.T. had not had an intake examination, chest x-ray, or evaluation by medical staff.
! Inmate C.V. was admitted to DCJ on January 6, 2006, with a history of treatment for active TB during the preceding two months. His diagnosis was confirmed to

6

Multidrug-resistant tuberculosis is a variant of the

tuberculosis bacteria that resists treatment with several anti-

tuberculosis drugs. If the wrong medications are used, this

condition is fatal in 25% of cases and can be transmitted to

others who come into close contact with the patient in a confined

space.

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be multidrug-resistant TB on January 13, 2006, yet C.V. was not seen by a physician for 11 days, nor did he receive any treatment in the interim.
! Inmate C.X. had been on TB medication for five weeks prior to admission to DCJ on February 14, 2006. C.X., however, was not put on medication necessary to complete his treatment and was thus exposed to developing multi-drug resistant TB.
b. Skin Infection
DCJ fails to adequately manage contagious skin infection. Generally accepted correctional medical care standards dictate that a jail adopt a skin infection control plan to guide the prevention of transmission of skin infections, including drugresistant infections such as MRSA. An effective control plan would delineate a course of care to prevent the spread of infection. DCJ lacks such a plan.
Although DCJ reports approximately 250 newly-identified skin infections each month, it has not developed or implemented a plan to address this serious issue. Without an adequate control plan, inmates are not properly treated and the risk of transmitting skin infection among the inmate population increases significantly. DCJ staff do not have specific training in treating skin infections or managing related wounds. As a result, inmates receive inappropriate wound care and, thus, are more likely to develop complications such as deep tissue infections, which may lead to hospitalization or death. For example, in October 2005, both inmate L.B. and inmate R.O. had to be hospitalized to treat deep tissue infections after Jail nursing staff failed to treat them with the proper antibiotics for their respective wounds. Despite his hospitalization, R.O. still had not been evaluated by a DCJ physician by February 2006.
DCJ’s inadequate care for skin infections is compounded by inadequacies in other areas of care, including the failure to respond to inmate requests for care; properly assess and treat inmates to identify and contain the spread of infections; and maintain adequate medical documentation. Indeed, we noted numerous instances where multiple requests for care for skin infections had gone unanswered.
5. Inadequate Access to Health Care
The process by which inmates at DCJ are permitted to request medical care is inadequate and presents a significant barrier to

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receiving adequate medical care. Specifically, there are no protocols for collecting, processing, distributing, logging, and triaging medical requests. Additionally, the current process deprives inmates of any professional medical privacy.
Generally accepted correctional medical care standards dictate that facilities like DCJ have a logging system to track requests for care, to evaluate whether inmates are seen in response to their requests, and to identify those still in need of care. Moreover, facilities must provide appropriate policies and procedures to guide nursing staff on how to conduct sick calls, and when to refer requests to higher levels of care. The failure of DCJ’s medical requests system to meet these essential standards hinders the ability for inmates to seek, and for clinicians to provide, appropriate medical care.
At DCJ, medical and mental health requests are initiated by the submission of a sick call slip. Inmates complete a slip stating their reason for requesting care. While there are locked boxes for the slips to be placed, these boxes are located outside of inmate housing units. Thus, inmates must give the slips to detention officers, who then are expected to put them in the locked box. In many units, inmates utilize cardboard cookie and cracker boxes to collect completed slips within their unit for pick-up by an officer. In others, detention officers sort the slips and deliver them to either nursing or mental health staff. This process offers inmates no confidentiality and, as discussed below, can create a barrier to needed care.
Our investigation revealed several instances where inmate medical requests were either lost or unanswered, resulting in the denial of care for serious medical conditions. For example, inmate A.H. was admitted to DCJ on December 15, 2005, with an ulcerating vascular tumor on his leg. Although A.H. requested care, he did not receive treatment for his tumor for over a month, even after our consultant directed Jail staff to his condition. With this kind of ulceration, A.H. is at risk of serious deep tissue and possible blood infection. Similarly, inmate A.A. was admitted to DCJ on December 18, 2005, three weeks pregnant and bleeding, as reflected on her intake form. On January 13, 2006, she submitted a sick call complaining of continued bleeding. At the time of our February 2006 tour, she had not been evaluated by the Jail’s medical staff, despite her requests.
Even when DCJ does respond to medical requests, inmates are often not directed to the appropriate level of care:

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! Inmate F.A. filled out a request for care on February 9, 2006, noting chest pain with left arm numbness (both symptoms of a possible heart attack). Although DCJ nursing staff reviewed the slip, F.A. was not referred to a physician for evaluation.
! Prior to our first tour in February 2006, inmate L.E. submitted a slip complaining of a swollen testicle. At the time of our March 2006 tour one month later, L.E. had still not been evaluated by the appropriate medical staff.
! Inmate A.G. had seven nurse visits before he was sent to see a physician in response to his complaint of a skin infection. As a result of this delay, A.G. had to be hospitalized in November 2005 for dehydration and an abscess (an infected collection of pus which may require surgical removal).
DCJ lacks an effective system for triaging medical requests. Contrary to generally accepted professional standards of medical care, all requests are given equal treatment regardless of the seriousness of the medical issue because there are no nursing protocols for triaging medical requests. This results in a significant backlog of potentially urgent requests.
We found that nursing staff respond to sick call requests on the housing unit rather than in the medical clinic. Cell-side responses provide inmates with no privacy or opportunity for appropriate examination. At the Decker facility, for example, the nurse conducting sick call does not carry the basic medical equipment essential for appropriate clinical evaluation such as a stethoscope.
The deficiencies in the medical requests system are also aggravated by the failures in DCJ’s grievance system. Inmates consistently reported that the grievance system at the Jail is not effective when inmates seek relief for inadequacies in medical care. In this respect, both systems fail to address inmates’ medical needs. For example, inmate A.K. was hospitalized with bacterial endocarditis, a potentially lethal infection of a heart valve. On December 14, 2005, he had his aortic valve replaced with the insertion of a pacemaker at Parkland. However, when he returned to the Jail, DCJ health care staff did not follow up on A.K.’s medical needs, including a failure to administer his prescribed medication. A.K. attempted to use the grievance process to address this significant lack of care and, perhaps most importantly, to receive the needed

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medication. However, despite sick calls, hospitalization, and filing a grievance, A.K. never received his prescribed medication.
6. Inadequate Follow-up Care
DCJ fails to provide appropriate follow-up care for inmates after discharge from the hospital. See, e.g., Lawson, 112 F. Supp. 2d at 634-637 (finding conscious disregard where jail staff observed the progression of an inmate’s medical condition, failed to comply with hospital discharge orders, and failed to render appropriate follow-up care and administer regular medications). Inmates who receive specialty care or return from hospitalization should be evaluated upon their return to the facility to ensure, at a minimum, that discharge instructions are noted and appropriate care is provided.
The Jail fails to provide timely follow-up care after inmates have received hospital care, including the failure to adequately document and execute relevant medical and discharge orders. For example:
! On March 10, 2006, inmate C.Z. was admitted to Parkland and was treated for severe bowel obstruction, a lifethreatening condition associated with the use of her prescribed pyschotropic medication, Seroquel. The hospital discharge instructions recommended decreasing her dose of Seroquel. This note was never acknowledged by DCJ staff. When C.Z. returned to the facility on March 14, 2006, her Seroquel dose was actually increased by 300% further putting C.Z. at increased risk of developing additional bowel obstructions.
! Inmate A.Q. suffers from rhabdomyolysis, a serious medical condition which, if left untreated, can result in kidney failure. He was hospitalized for this condition on October 13, 2005, but was not seen for follow-up by DCJ medical staff when he returned to the facility. There were also no hospital notes in A.Q.’s chart when we reviewed it in February 2006.
! Inmate A.P. was hospitalized for an overdose of antiseizure medication on October 11, 2005. DCJ never checked A.P.’s blood levels for this medication either before or after his hospitalization. Thus, A.P. may still be receiving a dangerous dosage and could suffer additional harm.

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! Inmate D.A. has not received his prescribed asthma medication following his discharge from the hospital on February 24, 2006. His medical record includes a discharge summary that clearly indicates that he was to be given asthma medication. D.A. is at risk of an exacerbation of his condition and another hospitalization.
! Inmate A.M. was admitted to DCJ with a wound on September 6, 2005 but did not receive medical care until October 4, 2005. Moreover, the treatment he received was inadequate; as a consequence, A.M. developed cellulitis (an infection of the skin and underlying tissues that can affect any area of the body), and had to be hospitalized ten days later. Following A.M.’s hospitalization, he was not seen by DCJ medical staff and by February 2006 still had not received his prescribed medication.
! Inmate A.O. was hospitalized with cellulitis on October 25, 2005 after having complained of a wound over a three-month period beginning July 7, 2005. A.O. was never seen by medical staff at the Jail and received no follow-up care following his hospitalization.
! Inmate C.F. was hospitalized on April 5, 2005 for pneumonia. C.F. returned to the Jail a month later with a prescription for an antibiotic. Our review of his medical records indicated that C.F. received neither his prescribed medication nor a follow-up clinical examination.
! On November 7, 2005, inmate A.I. was hospitalized for cellulitis. On returning from his four-day hospitalization, he was neither seen by medical staff at DCJ nor received his prescribed medication.
! Inmate A.J. was hospitalized for infected orthopedic hardware on November 11, 2005. There are no clinical notes documented in his medical record. Moreover, there is no indication that A.J. received any follow-up care after his hospitalization.
! Inmate O.H., a juvenile, was sent to the emergency room at Parkland on June 5, 2005, to receive sutures. Upon his return to DCJ, no one evaluated his wound or provided the appropriate follow-up care. As a result,

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O.H. had to cut his own sutures and later remove them himself.
7. Inadequate Record Keeping
DCJ fails to keep complete, accurate, readily accessible, and systematically organized medical records. A complete and adequate medical records system for a facility like DCJ is critical to ensure that medical staff is able to provide adequate care.
DCJ’s electronic medical record system (“EMR”) maintains records for some inmates. However, there is no central data repository to manage critical functions such as scheduling, locating patients, performance measurements, and registries of inmates with chronic or specialty needs. As a result, DCJ continues to lose track of such inmates and fails to provide adequate treatment for their conditions.
Our investigation revealed innumerable gaps and inconsistencies in DCJ’s medical documentation. For example, when an intake screening is recorded on paper it is rarely entered into the EMR. Due to a limited number of computer work stations, health care staff must record notes by hand and, if they have time, later enter such into the EMR. This duplicative system greatly increases the risk of omission or error. Furthermore, most EMR entries consist of scanned images of handwritten pages, which often are illegible. Without accurate medical records, DCJ cannot meet constitutional standards to provide adequate medical care.
Finally, DCJ’s EMR lacks any sort of backup system to protect against computer system downtime. For example, the EMR system was down for two weeks in early February 2006 and again for part of the day on February 24, 2006. During this time, staff could not access medical records or enter pertinent clinical information. The result was a serious lapse in continuity and coordination of care.
8. Inadequate Medication Administration
Medication administration at DCJ suffers significant delays, errors, and lapses, all of which are typically caused by inaccurate or inadequate documentation. We found that DCJ frequently fails to do the following: (1) administer medication in accordance with prescriptions; (2) maintain inmate medication administration records (“MAR”) concurrently with distribution;

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and (3) follow general standards of care to monitor and adjust inmates’ prescribed medication regimens.
Generally accepted correctional medical standards require that facilities administer medication and maintain adequate medication records to meet the medical needs of the inmates and to prevent medication errors and other risks of harm. Regular and systematic reviews of medication usage is also required to ensure that each inmate’s prescribed medication regimen continues to be appropriate and effective for his or her condition.
At DCJ, inmates routinely miss doses of life-sustaining medications, such as Coumadin, a blood thinner used to prevent blood clots in the deep veins of the legs, heart, and brain. According to the MARs we reviewed, inmates D.D. and D.E. each missed two successive days of their Coumadin in March 2006. Additionally, medication is often not distributed as appropriate. For example, a significant portion of the Jail failed to receive their medication on the morning of February 20, 2006, the first day of our tour. DCJ medical personnel acknowledged this failure in medication administration.
In one particularly egregious example of missed medication, Jail staff failed to provide inmate D.G. with prescribed medication that may have prevented his death. D.G. was admitted to DCJ on April 3, 2004 and had congestive heart failure, with symptoms that included swelling of his face and of his scrotum. The Jail transferred him to the hospital on April 10, 2004, but when he returned, DCJ failed to administer his prescribed medication. Two weeks later, on April 24, 2004, D.G died of congestive heart failure.
DCJ also fails to maintain MARs contemporaneously with medication administration. Contemporaneous documentation is a generally accepted standard of care necessary to ensure that errors do not occur. DCJ medical staff often leave records blank or fail to log critical clinical information contemporaneously with the distribution of medication to inmates. During our tour, we observed a medication technician serially initial a log of medication records after she had delivered medication to housing units. Such retrospective documentation is inconsistent with generally accepted professional standards of medical care and greatly increases the risk for error.
Our review of DCJ medication records revealed numerous instances of blank MARs. For example, on two floors of Lew Sterrett, approximately 15-20% of the boxes on the MARs were blank; on another floor in Lew Sterrett, more than 10% of the

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medication administration record boxes were blank; and on February 17 and 18, 2006, most of the afternoon shifts’ boxes were blank. Blank MARs are indicative of inadequate training, supervision, and staffing.
Additionally, blank MARs and otherwise poor record keeping greatly limit DCJ’s ability to manage and account for items such as narcotics and syringes. Generally accepted professional standards of medical care require correctional facilities to maintain regular counts on the inventories of items such as narcotics and syringes. DCJ has no system in place for reliable, periodic counts for these items. Together, the failure to maintain adequate MARs and maintain counts on inventories makes it almost impossible for DCJ to control and account for these items in a correctional jail setting.
MARs at the Jail do not adequately contain standard prescription information for each medication, including start date, stop date, prescribing practitioner, and nurses/technicians signatures to match to their initials. General standards dictate that each DCJ inmate on chronic medications should have a medication review, as part of a face-to-face encounter with the prescriber every three months, or sooner if medically appropriate. This allows for timely follow-up on the inmate’s condition and ensures the appropriateness of the continued medication, a practice which is lacking at DCJ. For instance, while reviewing data on the use of appropriate antibiotics, we found that seven of the 12 records reviewed had no documentation of any examination or diagnosis despite the receipt of medication.
DCJ also fails to ensure that medication distribution is hygienic. Medication rooms we inspected were cluttered, with medication on the floor, and with no soap or towels for hand washing. In the main infirmary area, we observed insulin being drawn in advance for more than 20 inmates. This is a dangerous practice that can cause serious medication errors. Giving a person with diabetes the incorrect dose of insulin can result in serious illness or death.

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9. Inadequate Medical Facilities
Medical facilities at DCJ lack adequate space, privacy, lighting, and sanitation to provide inmates with medical care consistent with generally accepted standards. In a facility the size of DCJ, approximately 700 inmates per day require face-toface medical care. Inadequate space is an especially significant problem because it limits DCJ’s ability to provide medical services such as intake screenings, sick calls, and health assessments as well as care for inmates with specialty, chronic, and acute needs.
Generally accepted professional standards of medical care require that for a proper clinical evaluation inmates be examined in a clean and private setting with sufficient lighting and access to necessary diagnostic tools. Medical examination rooms at DCJ do not have sufficient lighting and are not adequately clean. Likewise, some of these rooms lack accessible handwashing sinks, towels to dry hands, and contain unsecured syringes and dental tools. Notably, hazardous waste was observed on the floors of several medication areas.
10. Inadequate Specialty Care
Specialty care generally refers to care provided in various medical specialties, including orthopedics, gynecology, cardiology, and geriatric medicine. Access to speciality care at DCJ is severely lacking. For instance, between January 1 and February 20, 2006, Jail staff made 316 referrals for specialty care. However, by late March 2006, the Jail had not scheduled appointments for any of these referrals. Such a large backlog for specialty care is grossly inconsistent with generally accepted standards of care.
Additionally, geriatric care and facilities at DCJ are inadequate. Given DCJ’s large population, dozens of older inmates will require nursing care on a daily basis for their specialized needs. However, DCJ is not providing such care. For example, in February 2006, we observed inmate E.A. who has severe multiple sclerosis, Parkinson’s, atrial fibrillation, and dementia. Although he was incontinent of urine and feces, he was housed in the general population without nursing care. If not for the care volunteered and provided by another inmate, E.A. would likely have died.
The geriatric housing area located in George Allen is illequipped, overcrowded, and generally inadequate. The area is equipped with double bunk beds. Because falls and injuries often

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result from the use of such beds, elevated bunks pose a significant risk to elderly inmates. Also, due to overcrowding, many bunks are placed very close together, resulting in these medically vulnerable inmates sleeping face-to-face. This greatly increases the risk that respiratory infections may spread among this more susceptible population.
Prenatal care at DCJ is also inadequate. DCJ does not maintain a registry of pregnant inmates. Without such, it is very difficult for DCJ to provide and monitor the necessary specialized care, such as vaccinations. This is especially troubling in light of the preventable illnesses that can occur in correctional facilities. For example, if a pregnant inmate is found to be susceptible to viral hepatitis B and contracts it while at DCJ, this infection can be transmitted to the baby. DCJ fails to screen or immunize pregnant inmates against hepatitis B.
11. Inadequate Staffing, Training, and Supervision
DCJ maintains an insufficient number of medical and custody staff to provide adequate medical services. Delays in access to medical care are exacerbated by an insufficient number of staff trained to identify, respond, and provide the necessary medical treatment. Generally accepted standards of care require that facilities maintain adequate staffing to provide inmates with necessary medical care.
An example of the type of harm that arises from these failures is the death of inmate W.T. on November 13, 2005. W.T. had a history of schizophrenia and was receiving daily doses of Lithium (an anti-depressant) and Zyprexa (an anti-psychotic). On November 13, she fell from her top bunk as the result of an apparent seizure. Officers responded, but did not send W.T. for a medical evaluation. Instead, the officers reported to the nurses on duty that W.T. was dizzy. Based on the information provided by the officers, the nurses decided not to assess W.T.’s condition. Within three hours, W.T. was found dead. This death may have been prevented had the officers recognized that W.T.’s condition was critical and communicated this to the nursing staff.
Our investigation also revealed substantial nursing vacancies, including vacancies for five registered nurses and ten vocational nurses in February 2006. Some of these vacancies are being temporarily filled with agency nurses who are unfamiliar with jail policies and procedures. This staffing shortage has been acknowledged by representatives of Parkland.

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Moreover, DCJ is currently operating with an interim medical director and an outside health services administrator to provide leadership for medical care at the Jail. Full-time, on-site administrators are needed to ensure appropriate medical treatment is provided. In addition, there is insufficient staff to support and provide the required medical care. A facility the size of DCJ should have staff dedicated to training, infection control, quality management, nursing direction, and utilization management to monitor under and over-utilization of on-site and outside services.
Finally, currently deficient medical services are hindered further by DCJ’s shortage of correctional officers to escort inmates to medical units.
12. Inadequate Quality Assurance Review
DCJ fails to engage in consistent, effective quality assurance review in order to track and trend medical-related incidents at the facility. Investigative review, tracking, and trending of such incidents is a critical component to implement and monitor corrective action in order to avoid future incidents and to keep inmates safe of medical-related harm.
For example, DCJ failed to conduct a mortality review following the questionable death of C.G. who died five days after entering the Jail. Although he reported a history of congestive heart failure at intake in July 2004, C.G. received no clinical evaluation and no medication while at DCJ. This inmate’s death may have been related to a lack of medical care at DCJ, however no autopsy or mortality review was conducted to ensure that proper policies and procedures are in place to correct any failures and ensure adequate care, prospectively.
13. Inadequate Dental Care
DCJ fails to provide adequate dental care to its inmates. Failure to treat inmates for dental-related conditions will expose them to risk of infection and significant pain. During our initial tour in February 2006, we found that no dental care was provided to inmates. DCJ’s dentist started work on February 21, 2006, but lacked an adequate examination room to provide dental care – the dental chair had no water, no suction, no light, no clean instruments, and no dental x-ray equipment. These equipment deficiencies were still evident during our subsequent on-site tour.

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Notably, at the time of our March tour, there was a backlog of 1,200 requests for dental care and inmates with serious dental needs, such as tooth abscesses, which can cause bone infection if not appropriately treated.
B. MENTAL HEALTH CARE
Jail officials violate the Eighth Amendment when they exhibit deliberate indifference to inmates’ serious mental health needs. Gates, 376 F.3d at 333. Deliberate indifference may include intentionally denying or delaying access to medical care, or intentionally interfering with treatment or medication that has been prescribed. Id. See also Woodall v. Foti, 648 F.2d 268, 272 (5th Cir. 1981) (finding that an inmate stated a claim of “deliberate indifference” where prison officials knew of his diagnoses as a pedophile and a manic depressive with suicidal tendencies, but refused to treat him). Consequently, a prison’s failure to take any steps to protect a suicidal detainee from self harm may constitute a constitutional violation. Partridge v. Two Unknown Police Officers of the City of Houston, 791 F.2d 1182, 1188 (5th Cir. 1986).
We find that DCJ fails to provide inmates with mental health care that complies with these constitutional standards. DCJ fails to address the specific needs of inmates with mental illness, including: (1) failure to timely and appropriately evaluate inmates for treatment; (2) inadequate assessment and treatment; (3) inadequate psychotherapeutic medication administration; and (4) inadequate suicide prevention.
1. Failure to Timely and Appropriately Evaluate Inmates for Treatment
DCJ fails to properly identify inmates with mental illness through adequate screening. Adequate screening of incoming detainees for mental health care needs is instrumental to a facility’s ability to provide adequate mental health care to inmates, and to reduce potential harm to those whose conditions would otherwise go unrecognized at intake and throughout the initial medical screening. Mental health screening should comport with constitutional requirements and generally accepted standards of care to aid in classification, identification of emergent mental health care needs, provision of continuous care, and management of medication.
Follow-up of known or newly identified mental health problems is a key focus of intake screening. Mental health screening information should be incorporated into an inmate’s

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medical record. This ensures the prompt continuation of necessary medication for all inmates with chronic mental health conditions. Persons with potentially serious chronic mental health illness (i.e., active psychosis, suicidal) should be referred from screening for prompt mental health evaluations and examinations by a psychiatrist.
As discussed above, DCJ’s medical screening and follow-up practices deny care to inmates. DCJ does not have policies and procedures to govern screening, including screening for mental health needs. Additionally, intake screening officers and intake nurses receive no training in detecting or querying inmates with mental illness. Screening is currently done by paramedics without policies or training on appropriate standards of care.
For mental health screening, DCJ staff utilize a self-report form entitled “Mental Disability/Suicide Intake Screening Form” that is not then incorporated into the medical record. Consequently, we found that less than 20 per cent of inmates referred for a mental health assessment were evaluated within seven days after intake. In addition, these mental health assessments are typically done by mental health liaisons who have no specialized training in mental health care and are inadequately supervised. We found that even for those inmates affirmatively identified with serious mental illness, the subsequent referral process to mental health is flawed.
2. Inadequate Assessment and Treatment
DCJ fails to appropriately assess and treat inmates with mental illnesses. Such failure is not in keeping with generally accepted professional standards of correctional mental health care and causes harm to inmates. The Jail’s failure to provide adequate mental health assessment and treatment to inmates has resulted in inmates’ mental health deterioration and unnecessary suffering.
In one case, despite several referrals for psychiatric care, an inmate’s condition was allowed to deteriorate for almost two months before Jail staff administered any care; and then, only after he had been laying prostrate in his own excrement for three to four days. The inmate, D.C., was not receiving his prescribed anti-psychotic and anti-seizure medication while he was at the Jail in February 2004. After he was discovered, D.C. was hospitalized for dehydration and consequent kidney failure.

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Our investigation revealed significant problems with mental health treatment records, specifically, the lack of adequate assessments. Mental health assessments frequently fail to account for inmates’ psychiatric histories as a result of the inadequacy of medical documentation and general procedures detailed above. Currently, when a nurse believes that an inmate requires a mental health evaluation, the nurse notifies an individual mental health worker by e-mail. However, logs of these referrals are not kept. This type of referral system lends itself to losing track of inmates who may need urgent attention, thereby placing such inmates at risk of serious harm. Our consultant also found that treatment plans were infrequently done on a timely basis and treatment team meetings do not occur.
Consequently, the Jail fails to provide the essential components of adequate treatment programs in a correctional mental health system. The following programs fail to comply with generally accepted professional standards of correctional mental health care by lacking: crisis intervention, with beds available in a health care setting for short-term treatment; acute care (including inpatient level psychiatric care); and chronic care to include a special needs unit for inmates with chronic mental illness.
The crisis level of care lacks the capacity for necessary short-term treatment due to the lack of a licensed infirmary. There is simply no physical space for evaluating and treating inmates. DCJ does not have access to an acute care program that would provide appropriate access for inpatient hospitalization. Also, a chronic care program for inmates with serious mental illnesses does not exist. While the Jail does provide segregated housing units that are designated for inmates with serious mental illnesses, these housing units lack an adequate treatment program that is an essential component of chronic care programs. Accordingly, DCJ fails to provide the generally accepted necessary components of a correctional mental health system.
As a result of not having access to an acute or chronic care program, inmates who are the most symptomatic and impaired from their mental health illnesses are generally inappropriately locked down in single cells for 23 hours per day. Many detainees with serious mental illness are harmed by the lack of adequate treatment as manifested by either increased symptoms of their underlying psychiatric disorder or lack of improvement regarding their current symptoms. The following examples are illustrative:

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! Inmate T.W., admitted to DCJ on February 10, 2006, was housed on a mental health housing unit. His health care record had a notation at intake that he had been receiving pyschotropic medications and needed to be evaluated. However, at the time of our second tour in late March, more than one month later, T.W. had still not been assessed by mental health staff.
! Inmate D.B. was on a hunger strike as early as January 27, 2006, and had been diagnosed as being psychotic by a nurse practitioner on March 2, 2006. Yet, D.B. had no medical evaluation regarding her nutrition and state of hydration, and no psychiatric care for her psychosis until she had to be hospitalized for lethargy (an abnormal state of drowsiness or dullness) on March 11, 2006, nearly three months later.
! In September 2005, inmate J.P. was assessed at intake with a diagnosis of bipolar disorder. Over the next six months, J.P. suffered from a significant lack of continuity of care. During that time, four clinicians each made different diagnoses (from active psychosis to lacking a psychotic illness) and prescribed various medications to J.P. without apparent reference to notes in his medical file. Indeed, by March 12, 2006, J.P.’s mental health had deteriorated to the point that Jail staff repeatedly observed him eating his own feces.
3. Inadequate Psychotherapeutic Medication Administration
DCJ fails to timely and appropriately evaluate inmates for the administration of pyschotropic medications and to monitor their continued administration. Many DCJ inmates require pyschotropic medications to avoid the unnecessary suffering of acute episodes of mental illness. Moreover, inmates are prescribed pyschotropic medications during intake but do not receive timely evaluations to determine whether such administration is appropriate. Generally accepted correctional mental health care standards require that a physician see an inmate patient usually before, but clearly shortly after, a prescription for pyschotropic medication is written in order to evaluate whether the medication should be maintained and to evaluate the continued administration for proper dosage and effectiveness. Inmates who remain untreated, or who are treated without being seen by a physician, may suffer from a worsening of

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their symptoms, including suicidal and homicidal thoughts, or from potentially lethal side effects of medication. DCJ consistently fails to comply with these standards.
We found significant problems at the Jail with regard to psychotherapeutic medication management, including: delays ranging from days to weeks, for inmates to begin receiving their pyschotropic medication; inappropriate breaks in medication administration due to housing changes and insufficient staffing; numerous medication errors; and medications routinely prescribed with 11 pre-approved refills, a dangerous practice resulting in inadequate medication monitoring.
Our review of Jail records revealed numerous inmates suffering from mental illness who did not receive their prescribed medications in a timely manner. This practice has resulted in serious harm to inmates. For example, despite a documented 20-year history of schizophrenia, inmate O.C. did not receive his prescribed pyschotropic medication for a five week period between December 25, 2005, and February 2, 2006. This overall lack of care and monitoring of pyschotropic medication at DCJ is not in keeping with constitutional requirements or standard practices of care.
4. Inadequate Suicide Prevention
The current suicide prevention practices at DCJ are grossly inadequate. Constitutional requirements and generally accepted professional standards of correctional mental health care mandate the development of suicide prevention standards. These standards require an appropriate policy and procedure; education and training for all staff members; appropriate screening to assess suicide risk; appropriate housing for those identified as at risk; appropriate supervision, observation, and monitoring of those inmates so identified; appropriate referrals to mental health providers and facilities; appropriate communication between correctional health care and correctional personnel; appropriate intervention addressing procedures of how to handle a suicide in progress; and appropriate notification, reporting, and review if a suicide does occur.
DCJ’s current practice of suicide prevention does not comport with generally accepted professional standards of correctional mental health care. The Jail’s written policy on suicide prevention fails to ensure appropriate management of suicidal inmates and lacks major components of an adequate

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suicide prevention program. For example, DCJ’s policy does not require that staff be trained on suicide recognition and intervention.
The current intake screening/assessment process fails to assess adequately the suicide risk factors of inmates. The process is not under the direction of trained mental health staff. As a result, correctional staff inappropriately have the authority to place any inmate who they deem to be suicidal into a “suicide cell,” which is a closed observation cell in which the inmate is under continuous lock down. There are two housing tiers designated as suicide tiers with eight cells in each tier that are classified as suicide cells. These cells are reportedly visually checked by an officer at regular intervals. However, because this check is not formally logged, monitoring is haphazard and places inmates in potential danger.
Moreover, placement in a suicide cell appeared to be arbitrary. The assessment is seldom performed by a mental health staff member so placement in a suicide cell is often inappropriate and utilized as a form of punishment. Mental health staff repeatedly reported that it is their perception that few of the persons placed in these cells are actually suicidal. In addition, mental health staff reported that they disagreed clinically with existing suicide practices, especially the stripping of inmates of all clothing and granting them only a paper gown.
As stated above, intake officers received no training in suicide screening and the communication between mental health staff and correctional staff is informal. The significant communication problems between custody and mental health staff result in a fragmented, uncoordinated system. It is often unclear who initiated suicide precautions during the central intake process. In fact, our mental health consultant found that suicide precautions were often initiated under a DCJ clinician’s name without his knowledge or approval.
Inmates placed on suicide watch are being observed by correctional officers who are ill-trained and who often have a myriad of other responsibilities in addition to the observation task. This is especially problematic at the George Allen facility where the physical layout does not allow for direct observation of the inmate on suicide watch. Additionally, the room in which inmates are placed on suicide watch contains a myriad of suicide hazards such as exercise equipment.

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The current suicide prevention program also fails to contain different levels of supervision of the inmate based on the presenting risk factors for suicide. Moreover, due to a lack of training, correctional staff are ill-prepared to handle a suicide in progress, including how to cut down a hanging victim and employ other first-aid measures. Finally, contrary to generally accepted practice, there is no administrative review following a suicide or a suicide attempt to identify what could have been done to prevent the incident.
Our review of the records of several inmate suicides revealed significant problems. The following examples are illustrative:
! C.L., a 27-year-old inmate, died on October 10, 2005, of toxic effect of an overdose of nortriptyline, an antidepressant medication that had not been prescribed to him. His suicide intake screening assessment had never been completed. C.L.’s problem list in his medical record included “mental health issues.” A nursing clinical note, dated February 15, 2005, indicated that his sister had called concerned that C.L. had voiced suicidal thoughts. Yet, C.L. never received a mental health evaluation while he was incarcerated at DCJ.
! While on suicide watch, inmate K.B. hung himself in July 2003. The physician assistant subsequently reported that he had not been able to interview the inmate due to the lack of an available detention officer escort. As a result, K.B.’s transfer to a closed behavioral observation tank was delayed. This case highlights issues related to inadequate supervision, poor communication between custody and mental health staff, and the lack of adequate numbers of detention officers for escort/transfer purposes.
! Inmate M.K. hung herself on January 5, 2003 after having been admitted on December 4, 2002. Her record contained the following inmate request form dated two days before her death on January 3, 2003. The note indicated the following:
I need to see the doctor to get my medicine straightened out. I am not getting my meds that my doctor faxed prior orders for me, and I

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brought in the medication myself and paid for it. I cannot afford to be treated this way! Please help me! I need my medicine.
There is no indication that M.K. received her medication before her death. The case reflects inadequate screening for mental illness, inadequate screening for suicide prevention purposes, lack of timely access to needed medications, and the lack of timely response to an inmate request form.
C. SANITATION AND ENVIRONMENTAL CONDITIONS
Prison officials must ensure that inmates receive adequate food, clothing, and shelter, Farmer, 511 U.S. at 832, and that prisoners are not “deprive[d] . . . of the minimal civilized measure of life’s necessities.” Rhodes v. Chapman, 452 U.S. 337, 347 (1981). Certain prison conditions are so base, inhuman and barbaric that they violate the Eighth Amendment. Palmer v. Johnson, 193 F.3d 346, 352 (5th Cir. 1999) (citation omitted). One such condition is the deprivation of basic elements of hygiene. Id. See also Gates, 376 F.3d at 338 (finding that filthy cell conditions constituted an Eighth Amendment violation). DCJ fails to ensure that sanitary and environmental conditions are in accordance with these constitutionally minimal standards.
1. Inadequate Sanitation of Laundry
DCJ laundry procedures fail to protect inmates from the risk of contagious diseases and/or exposure to bodily fluids and excretions. DCJ lacks adequate procedures for distributing or requesting replacement uniforms. Likewise, inmate uniforms and linens are inadequately cleaned and ragged.
Equipment at the central laundry facility is outdated and inadequate to handle the volume of laundry that the Jail produces. Because inmate laundry is often returned from the laundry facility still soiled, many inmates resort to washing their laundry by hand in toilets, sinks, and mop buckets, using detergent available from the DCJ commissary. This practice is unhygienic and contributes to the spread of contagious diseases, such as MRSA. Moreover, as a result of these laundering practices, inmates hang their laundry in their cells to dry, limiting security staff’s ability to observe inmates, creating a security and fire risk.

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2. Inadequate Protection From Biohazards
Current Jail practices expose inmates and staff to infectious diseases and aerosolized pathogens through improper contact with blood and other body fluids. The Jail fails to adequately contain, secure, store, dispose, and quarantine biohazardous materials.
Inmates and staff do not receive adequate safety equipment, cleaning chemicals, or supervision when cleaning and disposing of biohazardous materials. Biohazard spill kits are not readily accessible in the housing areas and biohazardous waste is not properly disposed of. Biohazardous waste is stored with office supplies, potentially exposing staff to aerosolized pathogens. Pathogens generally include any organism such as bacteria and viruses that cause disease in human beings. Thus, inmates and staff may be exposed to increased risk of illness when exposed to such pathogens. Accordingly, biohazardous waste should be marked properly and appropriately disposed as such.
We also found that containers located in the medical areas for the disposal of sharp biohazardous tools are improperly installed, thereby compromising readily safe disposal. Further, sharp medical tools, such as needles and dental utensils, are left unsecured and in the open, creating a significant safety and security risk for both staff and inmates.
3. Lack of Environmental Control
The Jail lacks adequate control over razors and commissary items distributed to inmates. Hundreds of razors were observed throughout the Jail - virtually all with the blades missing. These ubiquitous razor blades create two problems. First, these blades pose a serious security hazard. There are countless razor blades in the hands of DCJ inmates and all are potential weapons. Second, the sharing of razors amongst inmates can lead to the spread of diseases such as MRSA, hepatitis, and AIDS.
Because the Jail fails to control inmate commissary, inmates stockpile commissary items, which indicates that there may be a significant underground market among the inmates. We saw several stockpiles of commissary items like food and razors amassed by inmates that were too large to be for individual consumption. This situation can lead to security and control problems such as inmate-on-inmate violence, as well as an increase in pest problems such as rodents.

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Additionally, the Jail allows brooms and mops to remain in cells for extended periods of time. Such a practice ignores the fact that these items can be used as, or converted into, weapons.
4. Inadequate Sanitation of Facilities
It is the Jail’s duty to ensure housing units and bathroom areas are adequately cleaned. Cleaning can be performed by inmates, but appropriate materials and supervision is required. The Jail’s sanitation practices are grossly inadequate and vary widely among each facility. Cleaning was not uniform throughout the facilities, indicating that oversight by staff is better in some areas than in others. Parts of the Jail are filthy, subjecting inmates to increased risk of health problems. Bacteria like MRSA can survive in a dried state on various jail surfaces for significant lengths of time. DCJ’s failure to keep the Jail adequately clean greatly increases the risk that inmates will be exposed to such dangerous bacteria.
There is inadequate cleaning and maintenance of toilet and shower areas throughout the Jail. Numerous showers and toilets were in need of repair, rendering them inoperable or difficult to use. Several combination sink and toilet units were seen leaking, causing the floor area to remain wet for extended periods of time. This situation promotes the growth of mold and bacteria that can lead to infections as well as creates a slip hazard, a critical risk to security if staff need to respond to an urgent matter. Moreover, floor and shower drains are in poor condition and need to be thoroughly cleaned. We observed drain flies and large concentrations of fly larvae in the bathroom areas, which is indicative of an unsanitary environment.
5. Inadequate Fire and Life Safety Systems
DCJ fails to ensure adequate fire and life safety systems throughout the Jail. It is critical that smoke detection systems are provided in all sleeping areas, especially where only a limited number of housing areas are equipped with smoke removal systems. Fire equipment, such as air tanks and fire extinguishers, must have up-to-date inspections and be properly maintained. Also, safety tools must be accessible and in good working condition. DCJ, however, does not meet these standard system requirements.
Some areas of the Jail are not equipped with smoke detection equipment. Also, DCJ does not ensure that all staff maintain a working knowledge of, and the ability to execute, the Jail’s emergency evacuation procedures. Many staff members did not know

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the location of emergency keys or of the markings that enable the keys to be identified by touch. Moreover, some emergency keys lacked these markings. This is a significant departure from generally accepted professional standards of care. Further, during our February tour, we identified the fire hazard of allowing inmates to keep excessive amounts of newspaper in their cells. We understand that DCJ has taken measures to address the presence of newspapers in inmate cells, however we have not had the opportunity to fully evaluate these measures.
IV. RECOMMENDED REMEDIAL MEASURES
In order to address the constitutional deficiencies identified above and protect the constitutional rights of inmates, DCJ should implement, at a minimum, the following measures in accordance with generally accepted professional standards of corrections care:
A. Medical Care
1. Intake Screening
a. Ensure that adequate intake screening and health assessments are provided. Develop and implement an appropriate medical intake screening instrument that identifies observable and non-observable medical needs, including infectious diseases, and ensure timely access to a physician when presenting symptoms require such care.
b. Ensure that acute and chronic health needs of inmates are identified in order to provide adequate medical care.
c. Ensure that medical screening information is reviewed in a timely manner by trained medical care providers.
d. Provide adequate screening and health assessments for juveniles in accordance with generally accepted standards of care and ensure adequate evaluation for mental illness and suicide risk.
e. Ensure that tuberculosis screening is conducted in a timely manner.

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

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

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

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b. Ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in medical exam rooms. Ensure that hand washing stations in medical areas are fully equipped, operational, and accessible.
10. Specialty Care
a. Ensure that specialty consultations are timely and that any resulting reports are forwarded to DCJ staff. Specialist recommendations should be implemented in a timely manner or, where deemed inappropriate, a DCJ physician should properly document why such recommendations were not implemented. Provide adequate long-term care planning for inmates with chronic illnesses.
b. Ensure that inmates are provided adequate access to specialty care in accordance with generally accepted professional standards of care.
c. Ensure that pregnant inmates are provided adequate care in accordance with generally accepted professional standards of care.
11. Staffing, Training, and Supervision
a. Provide adequate staffing, training, and supervision of medical and correctional staff necessary to ensure adequate medical care is provided.
b. Ensure that medical staffing is adequate for inmates’ serious medical needs and that physicians adequately monitor their patients.
c. Provide adequate physician oversight and supervision of medical staff.
d. Ensure that there is an adequate number of correctional officers to escort inmates to medical units.
12. Quality Assurance Review
a. Ensure that DCJ’s quality assurance system is adequate to identify and correct serious deficiencies with the medical system.

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b. Ensure that DCJ’s quality assurance system is capable of assisting in managing and treating inmate medical needs. At a minimum, such a system should be reliable and capable of tracking medical-related incidents.
13. Dental Care
a. Ensure that inmates receive adequate dental care in accordance with generally accepted professional standards of care. Such care should be provided in a timely manner.
B. Mental Health Care:
1. Timely and Appropriately Evaluate Inmates
a. Ensure that DCJ properly identifies inmates with mental illness through adequate screening.
b. Ensure that inmates with potentially serious chronic mental health illness are referred for prompt mental health evaluations and examinations by a psychiatrist.
c. Provide adequate mental health assessment and treatment in accordance with generally accepted professional standards of mental health care.
d. Ensure that adequate crisis services are available to address the psychiatric emergencies of inmates.
e. Provide staffing adequate for inmates’ serious mental health needs. Provide adequate on-site psychiatry coverage. Ensure that psychiatrists see inmates in a timely manner. Ensure that pyschotropic medication prescriptions are reviewed by a psychiatrist on a regular, timely basis.
f. Provide adequate screening to properly identify inmates with mental illness. Ensure that DCJ’s intake evaluation process includes a mental health screening that is incorporated into an inmate’s medical record.
g. Develop and implement an appropriate intake screening instrument that identifies mental health needs, and ensure timely access to a mental health professional when presenting symptoms require such care.

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

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b. Ensure that adequate psychotherapeutic medication administration is provided in accordance with generally accepted professional mental health care standards.
c. Ensure that changes to inmates’ pyschotropic medications are clinically justified. Screen inmates on pyschotropic medications for movement disorders and provide treatment where appropriate.
d. Ensure that inmates receive adequate screening and evaluation for the administration of pyschotropic medications in a timely manner.
4. Suicide Prevention
a. Provide adequate treatment for inmates with selfinjurious behavior.
b. Develop policies and procedures to ensure appropriate management of suicidal inmates and the establishment of a suicide prevention program.
c. Ensure that all staff are educated and trained on suicide recognition and intervention.
d. Screen all inmates upon intake, including questioning to assess current and past suicide risk.
e. Ensure that suicidal inmates are housed in an area that is safe for them with appropriate supervision and observation by staff.
f. Provide different levels of supervision of an inmate based on the presenting risk factors for suicide.
g. Provide adequate suicide prevention training to all staff.
h. Ensure that a component of administrative review is implemented following a suicide or a suicide attempt to identify what could have been done to prevent the suicide.
5. Other Issues
a. Ensure that administrative segregation and observation status are not used to punish inmates for symptoms of mental illness and behaviors that are, because of mental illness, beyond their control.

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b. Ensure that DCJ mental health records are centralized, complete, and accurate.
c. Ensure that DCJ’s quality assurance system is adequate to identify and correct serious deficiencies with the mental health system.
d. Ensure that a psychiatrist or physician conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. Seclusion or restraint orders should include sufficient criteria for release.
C. Sanitation and Environmental Conditions:
1. Sanitation of Laundry
a. Ensure that laundry procedures protect inmates from exposure to contagious disease, bodily fluids, and pathogens. Develop and implement a policy for handling, washing, and drying of laundry. Train staff and educate inmates regarding laundry sanitation policies.
2. Protection from Biohazards
a. Develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials.
b. Ensure that any inmate or staff asked to clean up a biohazard be properly outfitted with protective materials and trained in universal precautions before cleaning. Ensure proper supervision of biohazard cleaning.
c. Use cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
d. Develop and implement policies and procedures for the control of chemicals in the facility, and supervision of inmates who have access to these chemicals.
e. Install biohazard disposal containers in medical areas so that there is no unnecessary risk to staff.
f. Secure all sharp medical tools.

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g. Destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria.
3. Environmental Control
a. Ensure adequate control and observation of Jail cells, particularly with regard to razors, fire loading materials, commissary items, and cleaning supplies.
4. Sanitation of Facilities
a. Develop and implement policies and procedures to ensure adequate cleaning and maintenance of the facilities with meaningful inspection processes and documentation. Such policies should include oversight and supervision, as well as establish daily cleaning requirements for toilets, showers, and housing units.
b. Ensure prompt and proper maintenance of shower, toilet, and sink units.
5. Inadequate Fire and Life Safety
a. Ensure that all facilities have adequate fire and life safety equipment, which is properly maintained and inspected.
b. Implement competency based testing for staff regarding fire/emergency procedures. Train staff in use of cut-down tools.
c. Ensure that emergency keys are appropriately marked and consistently stored in a quickly accessible location.
d. Ensure that fire alarms are installed and maintained in all housing areas.
* * * * * * * * * * * * * * * * *
Please note that this findings letter is a public document. It will be posted on the Civil Rights Division’s website. While we will provide a copy of this letter to any individual or entity upon request, as a matter of courtesy, we will not post this letter on the Civil Rights Division’s website until ten calendar days from the date of this letter.
We hope to continue working with the County in an amicable and cooperative fashion to resolve our outstanding concerns regarding DCJ. Assuming there is a spirit of cooperation from

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the County and DCJ, we also would be willing to send our consultants’ evaluations under separate cover. These reports are not public documents. Although the consultants’ evaluations and work do not necessarily reflect the official conclusions of the Department of Justice, their observations, analysis, and recommendations provide further elaboration of the issues discussed in this letter and offer practical technical assistance in addressing them.
We are obligated to advise you that, in the entirely unexpected event that we are unable to reach a resolution regarding our concerns, the Attorney General may initiate a lawsuit pursuant to CRIPA to correct deficiencies of the kind identified in this letter 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working cooperatively with you and are confident that we will be able to do so in this case. The lawyers assigned to this investigation will be contacting the facility’s attorney to discuss this matter in further detail. If you have any questions regarding this letter, please call Shanetta Y. Cutlar, Chief of the Civil Rights Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/S/ Wan J. Kim Wan J. Kim Assistant Attorney General
cc: Ms. Maurine Dickey Dallas County Commissioner District 1
Mr. Mike Cantrell Dallas County Commissioner District 2
Mr. John Wiley Price Dallas County Commissioner District 3
Mr. Kenneth A. Mayfield Dallas County Commissioner District 4

Bill Hill, Esquire District Attorney Dallas County

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Ms. Lupe Valdez Sheriff Dallas County

The Honorable Richard B. Roper, III United States Attorney Northern District of Texas

 
 Case: 3:07-cv-1559 As of: 05/08/2013 06:16 PM CDT 1 of 3
CLOSED,ECF,SANDERSON
U.S. District Court Northern District of Texas (Dallas) CIVIL DOCKET FOR CASE #: 3:07−cv−01559−N

United States of America v. Dallas County, Texas et al Assigned to: Judge David C Godbey Cause: 42:1983 Civil Rights Act
Plaintiff

Date Filed: 09/12/2007 Date Terminated: 11/04/2011 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by John R Parker−DOJ US Attorney's Office 1100 Commerce St 3rd Floor Dallas, TX 75242−1699 214/659−8728 Fax: 214/767−2916 Email: john.parker@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED Bar Status: Admitted/In Good Standing

David Deutsch US Department of Justice − Civil Rights Division Special Litigation Section 950 Pennsylvania Ave NW Washington, DC 20530 202/514−6270 Bar Status: Government Attorney

William E Nolan US Department of Justice − Civil Rights Division Special Litigation Section 950 Pennsylvania Ave NW Washington, DC 20530 202/514−6270 Email: william.nolan@usdoj.gov ATTORNEY TO BE NOTICED Bar Status: Government Attorney

V. Defendant Dallas County, Texas
Defendant

represented by Peter L Harlan Dallas County District Attorney's Office Frank Crowley Courts Building 133 N Riverfront Blvd., 11th Floor Suite C4−2 LB 19 Dallas, TX 75207 214/653−3690 Fax: 214/653−2899 FAX Email: pharlan@dallascounty.org LEAD ATTORNEY ATTORNEY TO BE NOTICED Bar Status: Admitted/In Good Standing

Case: 3:07-cv-1559 As of: 05/08/2013 06:16 PM CDT 2 of 3

Lupe Valdez Sheriff of Dallas County, Texas (in her official capacity)

represented by Peter L Harlan (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED Bar Status: Admitted/In Good Standing

Date Filed 09/12/2007 09/12/2007 09/12/2007 09/12/2007 09/12/2007 09/13/2007
09/19/2007 09/25/2007
10/04/2007
11/06/2007 11/06/2007 07/15/2008 10/15/2008 01/14/2009
06/10/2009

# Docket Text
1 COMPLAINT against Dallas County, Texas, Lupe Valdez filed by United States of America. (Gov't−No Fee) (npk) (Entered: 09/12/2007)
***Magistrate Judge Sanderson chosen by random selection to handle matters that may be referred in this case. (npk) (Entered: 09/12/2007)
2 CERTIFICATE OF INTERESTED PERSONS/DISCLOSURE STATEMENT by United States of America. (npk) (Entered: 09/12/2007)
3 Certificate of the Attorney General by United States of America (npk) (Entered: 09/12/2007)
4 Order Designating Case for ECF − see order for specifics. (Signed by Judge David C Godbey on 9/12/07) (npk) (Entered: 09/12/2007)
5 ORDER: A hearing is set in this case on Tuesday, September 25, 2007, at 9:00 a.m. to consider approval of the proposed consent decree. The hearing will be held in Courtroom 1358. (Signed by Judge David C Godbey on 9/13/07) (skt) (Entered: 09/14/2007)
6 NOTICE of Attorney Appearance by Peter L Harlan on behalf of Dallas County, Texas, Lupe Valdez. (Harlan, Peter) (Entered: 09/19/2007)
Minute Entry for proceedings held before Judge David C Godbey : Hearing held on 09/25/2007. Plaintiff's exhibits 1 and 2 returned to Daniel Weiss. Attorney Appearances: Plaintiff − John Parker, Daniel Weiss and David Deutsch; Defense − Leslie Sweet and Peter L. Harlan. (Court Reporter Linda Robbins.) Time in Court: 1 hour. NO PDF ATTACHED − THIS IS A VIRTUAL MINUTE ENTRY. (cxj) (Entered: 09/25/2007)
7 TRANSCRIPT of Hearing to Consider Approval of Proposed Consent Decree held on September 25, 2007 before Judge David C. Godbey. Court Reporter Name/Phone Number: Linda Robbins/214−748−8068. District Clerk Phone Number: 214−753−2633. ***The Official Record of the transcript is on file with the clerk's office. Contact either the clerk's office or the court reporter at phone numbers listed above to obtain a copy of the Official Record.*** (klm) (Entered: 10/05/2007)
8 AGREED ORDER re Proposed Consent Decree. (see order for specifics) (Signed by Judge David C Godbey on 11/6/2007) (tln) (Entered: 11/07/2007)
CLOSED IN ERROR***Civil Case Terminated per 8 Agreed Order. (dnc) Modified on 7/19/2010 (caw). (Entered: 07/19/2010)
9 NOTICE of Filing first Independent Monitor's Report filed by United States of America (Attachments: # 1 Appendix Part 1 Medical/Sanitation, # 2 Appendix Part 2 Mental Health) (Parker, John) (Entered: 07/15/2008)
10 Inmate Declaration filed by Lakeith Amir−Sharif (Non−party) (mfw) (Entered: 10/16/2008)
11 NOTICE of Filing of Second Independent Monitor's Report filed by United States of America (Attachments: # 1 Appendix Independent Monitor's Report (Mental Health Care), # 2 Appendix Independent Monitor's Report (Medical and Sanitation)) (Parker, John) (Entered: 01/14/2009)
12 NOTICE OF FILING OF THIRD OFFICIAL INDEPENDENT MONITOR'S REPORT filed by United States of America (Parker−DOJ, John) (Entered: 06/10/2009)

Case: 3:07-cv-1559 As of: 05/08/2013 06:16 PM CDT 3 of 3

06/10/2009 06/10/2009 06/10/2009 01/15/2010
07/09/2010 12/16/2010 06/18/2011
11/04/2011 11/04/2011

13 ADDITIONAL ATTACHMENTS 4th Monitoring Report to 12 Notice (Other) by Plaintiff United States of America. (Parker−DOJ, John) (Entered: 06/10/2009)
14 ADDITIONAL ATTACHMENTS Mental Health Report to 12 Notice (Other) by Plaintiff United States of America. (Parker−DOJ, John) (Entered: 06/10/2009)
15 CERTIFICATE OF SERVICE by United States of America re 12 Notice (Other), 14 Additional Attachments to Main Document, 13 Additional Attachments to Main Document Certificate of Service (Parker−DOJ, John) (Entered: 06/10/2009)
16 NOTICE of Filing of Fourth Independent Monitor's Report filed by United States of America (Attachments: # 1 Appendix Medical and Sanitation Assessment, # 2 Appendix Mental Health System Assessment) (Parker−DOJ, John) (Entered: 01/15/2010)
17 NOTICE of Filing Fifth Independent Monitor's Report filed by United States of America (Attachments: # 1 Exhibit(s), # 2 Exhibit(s)) (Parker−DOJ, John) (Entered: 07/09/2010)
18 NOTICE of Filing of Seventh Independent Monitor's Report filed by United States of America (Attachments: # 1 Exhibit(s) Medical and Sanitation Report, # 2 Exhibit(s) Mental Health Report) (Parker−DOJ, John) (Entered: 12/16/2010)
19 NOTICE of Filing of Eighth Independent Monitor's Report filed by United States of America (Attachments: # 1 Exhibit(s) Medical and Sanitation Report, # 2 Exhibit(s) Mental Health Report, # 3 Exhibit(s) Mental Health Report Appendix) (Parker−DOJ, John) (Entered: 06/18/2011)
20 NOTICE of Termination (Joint) filed by Dallas County, Texas, United States of America, Lupe Valdez (Parker−DOJ, John) (Entered: 11/04/2011)
***Civil Case Terminated per 20 Joint Notice of Termination and per DJ chambers. (axm) (Entered: 11/08/2011)