u.s. Department of Justice
Civil Rights Division

Office of tlte Assislalll Attorney General

WasMllgtoll, D.C. 20530
AUG 262011

VIA E-MAIL AND U.S. MAIL
Howard R. Bradley County Mayor 501 S. Main Street Courthouse, Room 108 Springfield, TN 37172
Re: Investigation of Robertson County Detention Facility
Dear Mayor Bradley:
We write to report the findings of the Civil Rights Division's investigation of conditions at the Robertson County Detention Center ("RCDF" or "Jail"), conducted pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 ("CRIPA"). The Civil Rights Division commenced its investigation at the request of the United States Attorney's Office for the Middle District of Tennessee, after that office received complaints from prisoners regarding RCDF's provision of nutrition and medical care. During our investigation, we assessed RCDF's compliance with the Constitution, which requires the Jail to provide detainees with humane conditions of confinement, including adequate medical and mental health care, food, clothing, and shelter.
While we found RCDF's practices with respect to nutrition, medical care, and environmental health and safety adequate or minimally adequate to comply with the Constitution, we found a pattern or practice of constitutional violations in RCDF's provision of mental health care. Specifically, RCDF's mental health practices place prisoners at a substantial and unreasonable risk of serious harm. In the other areas we investigated, we have serious concerns that do not yet rise to the level of constitutional violations, including numerous medical practices that could result in constitutional violations if left unremedied. By implementing the remedies set forth below, the County will fulfill its duty to uphold the Constitution and protect the health and safety of those in its custody.
In making these findings, we note that RCDF has been cooperative throughout our investigation and receptive to our preliminary findings and initial recommendations. We are thus

-2-
confident that RCDP will take appropriate measures to remedy the deficiencies we detail in this letter, and look forward to working cooperatively with RCDP as it does so.

I.

Summary of Findings and Conclusions

We have concluded that Robertson County ("the County") fails to provide mental health care to prisoners at RCDP in violation of the Pourteenth Amendment to the Constitution. Addressing these deficiencies should be RCDP's highest priority, as we believe that these lapses, if not corrected, have a strong likelihood of resulting in unnecessary injury and/or loss of life. Our specific findings of practices that do not comport with the requirements of the Constitution include:

• RCDP fails to protect prisoners from harm by permitting Licensed Practical Nurses ("LPNs") - individuals with little or no mental health training - to independently manage suicide precautions. The Constitution requires the Jail to provide prisoners with mental health needs with access to medical personnel who are qualified to diagnose and treat mental illness.

• RCDP fails to provide prisoners with serious mental illnesses with timely and competent mental health care. Specifically, (a) prisoners with chronic mental illnesses who are not capable of requesting mental health care are effectively denied treatment; (b) prisoners who request mental health care experience delays that violate constitutional standards; and (c) nurses are responsible for providing mental health care beyond their training and qualifications.

While we do not find a current violation of the Constitution, we find that certain medical practices at RCDP may pose unreasonable risks to prisoners' safety and health and, ifleft mrremedied, may violate the Constitution. Additionally, we find that while the J ail's nutrition and sanitation meet minimum constitutional requirements, certain ofRCDP's practices in these areas are deficient or cause us concern.

II.

Investigation

On July 13, 2010, we notified you that we were opening an investigation of conditions at RCDP pursuant to CRIPA. B ased on the allegations and information we received from the United States Attorney's Office, the initial focus of our investigation was the nutritional adequacy of the diet provided to RCDP prisoners. In 2009, Chief Judge Todd Campbell conducted a six-day evidentiary hearing to assess a prisoner's claim that he had lost significant weight during his confinement at RCDP. United States v. Williams, No. 3 :09-00090 (M.D. Tenn. 2009). During the course of the hearing, numerous RCDP inmates testified that they had also lost substantial amounts ofweight while at the Jail.

On October 12-15, 201 0, we conducted an onsite inspection ofthe Jail to assess RCDP's provision of nutrition, medical care, and environmental health and safety. Expert consultants in all three of these areas accompanied us. We toured the facility, observed facility processes, interviewed staff and prisoners, and reviewed an array of documents, including policies and

-3-
procedures. Pollowing our onsite inspection, we requested additional documents related to suicide prevention measures and mental health care at RCDP, including prisoners' mental health records, suicide precaution logs, and policies and procedures. An expert consultant in the area of correctional mental health care conducted an offsite review of these documents. Consistent with our pledge of transparency, and to provide technical assistance where appropriate, we conveyed our preliminary determinations regarding nutrition and diet, medical care, and enviromnental health and safety to RCDP administrators and staff during exit presentations at the close of our onsite visit.
We are confident that the new leadership at RCDP will take appropriate measures to address the deficiencies we detail in this letter. Sheriff Bill Holt and the entire RCDP staff have been helpful and professional throughout the course of our investigation. RCDP has provided us with access to prisoner records and personnel, and responded to our requests, before, during, and after our onsite visit, in a transparent and forthcoming matmer. We also appreciate RCDP's recep tiveness to our consultants' onsite and post-tour recommendations, and note that at every opportunity, the Sheriff and RCDP's administration have expressed their commitment to working with the United States to provide prisoners with reasonably safe and humane conditions of confinement, as required by the Constitution. We expect we will continue to work with RCDP in a cooperative mamler as the Jail addresses the issues we have identified both previously and in this letter.
III. Background
RCDP is located in Springfield, Tennessee, approximately thirty miles north of Nashville. The Robertson County Sheriffs Office, headed by Sheriff Bill Holt, operates the Jail. After serving as Chief Deputy, Sheriff Holt was elected Sheriff in August 2010.
RCDP houses pre-trial federal and state detainees and sentenced state prisoners. At the time of our tour, the Jail housed 280 prisoners in a building that RCDP opened in July 2009. The Jail was in the process of renovating the former jail, originally constructed in 1997. Once renovations to that facility are complete, RCDP will have the capacity to house over 600 prisoners.
RCDP contracts with private companies to provide food and medical services to the Jail. ABL Management, Inc. ("ABL"), a food provider, manages the Jail's food services and Southern Health Providers, Inc. ("SHP"), a medical services provider, supplies onsite medical and mental health care to prisoners.
IV. Findings and Conclusions
We conclude that RCDP fails to provide prisoners with constitutionally adequate mental health care and have serious concerns about medical care, nutrition, atld enviromnental health. These findings are detailed below.

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A. Legal Standards Governing Our Investigatory Conclusions
The Eighth Amendment affords convicted prisoners protection from cruel and unusual punishment. U . S . Const. amend. VIII. While the constitutional rights of convicted prisoners and pre-trial prisoners are guaranteed by the Fourteenth Amendment, the Supreme COUli has consistently held that pre-trial prisoners "retain at least those constitutional rights . . . enjoyed by convicted prisoners [under the Eighth Amendment]." Bell v. Wolfish, 441 U.S. 520, 545 (1979); Danese v. Asman, 875 F.2d 1239, 1243 (6th Cir. 1989). The Eighth Amendment requires prison officials to '''provide hUinane conditions of confinement.'" Spencer v. Bouchard, 449 F.3d 721, 727-28 (6tll Cir. 2006) (quoting Farmer v. Brennan, 511 U.S. 825, 832 (1994». Specifically, prison officials "must ensure that imnates receive adequate food, clothing, shelter, and medical care, and must 'take reasonable measures to guarantee the safety of the imuates.'" Id.
The Constitution protects prisoners not only against ongoing harms, but also against the risk offuture hann. Helling v. McKinney, 509 U.S. 25, 33 (1993) ("That the Eighth Amendment protects against future harm to imnates is not a novel proposition . . . . It would be odd to deny an injunction to imnates who plainly proved an unsafe, life-threatening condition in their prison on the ground that nothing yet had happened to them."). Conditions posing a substantial risk of serious hann to prisoners therefore violate the Constitution, even if no prisoner has suffered actual harm at the time the violation is found. See Farmer, 511 U.S. at 845-47; Helling, 509 U.S. a t 3 5 (finding that risk of future harm to prisoner's health stated a cause o f action under the Eighfu Amendment); Blackmore v. Kalamazoo Cnty., 390 F.3d 890, 899 (6th Cir. 2004) (noting that the Constitution "does not require actual hann to be suffered"). The Supreme Court has clearly stated that "a remedy for unsafe conditions need not await a tragic event." Helling, 509 U.S. at 33.
B. RCDF Provides Constitutionally Inadequate Mental Health Care
Corrections officials violate the constitutional rights ofprisoners ifthey are deliberately indifferent to their serious medical needs, including prisoners' psychological needs. Estelle v. Gamble, 429 U.S. 97, 104 (1976); Horn v. Madison Cnty. Fiscal Ct., 22 F.3d 653, 660 (6th Cir. 1994). Corrections officials act with deliberate indifference if they "(1) subjectively lm[ow] of a risk to the imuate's health, (2) dr[aw] the inference that a substantial risk ofharm to the imuate exist[s], and (3) consciously disregard[] that risk." Jones v. Muskegon Cnty., 625 F.3d 935, 941 (6th Cir. 2010). In essence, prison officials act with deliberate indifference by "'denying or delaying access to medical care' for a serious medical need." Phillips v. Roane Cnty., Tenn., 534 F.3d 531, 539 (6th Cir. 2008) (quoting Estelle, 429 U.S. at 104-05). Our investigation revealed that RCDF's mental health care system fails to meet constitutional standards. By permitting unqualified persoill1el to manage suicide precautions for prisoners at risk of engaging in self­ harm without supervision and failing to provide prisoners with serious mental illnesses with competent and timely mental health care, RCDF fails to provide constitutionally adequate mental health care.
,

5 -

-

1. RCDP violates constitutional standards by permitting LPNs to manage suicide 
 precautions. 


Prisoners have an "established right to medical attention once . . . prisoner[s'] suicidal tendencies are known" to prison officials. Comstock v. McCary, 273 F.3d 693, 711 (6th Cir.

2002). Medical attention provided solely by nurses who are not qualified and trained to treat

prisoners' psychiatdc needs is not sufficient to meet constitutional standards. Rather, prisoners with psychiatric needs have a right to "reasonable access to medical persOimel qualified to diagnose and treat" mental illness. Inmates ofAllegheny Cnty. Jail v. Pierce, 612 F.2d 754, 762

(3d Cir. 1979) (emphasis added). RCDF violates this basic tenet by permitting its LPNs­

individuals with

. SUlCI'de

watchi.

little

or

no

mental

health

training

-

to

both place

prisoners

on

and

remove

t11em

from

The Sixth Circuit has recognized that prison officials may violate the Constitution by
removing pdsoners from suicide watch without first maldng a "reasoned assessment or evaluation of the patient's suicide risk." Comstock, 273 FJd at 710-11 (finding constitutional violation where psychologist removed prisoner from suicide watch based on an "evaluation [that] was unreasonable and constituted deliberate indifference to the risk that [the prisoner] would harm himselfwhen presented with the opportunity."). Presently, RCDF's sole physician is the only RCDF staff person qualified based on his training to conduct such a reasoned assessment. He is only onsite two hours each week and there is no psychiatrist on staff.2 Despite his limited time ansite, the physician acts as the Medical Director and is responsible for overseeing RCDF's entire clinical operation and for providing direct patient care for prisoners with medical or mental health care needs. To compensate for the lack of onsite physician time, the nursing staff provide clinical care that exceeds their licensure and training. RCDF's policies recognize that LPNs are not qualified or trained to independently make a reasoned assessment or evaluation of a prisoner's suicide dsk. See, e.g., SHP Chronic Care Protocol (protocol emphatically warns "Remember, only the Medical Team Administrator, Psych Nurse or Psychiatrist can remove a prisonerfrom Suicide Observation.,,).3

RCDF's use ofLPNs to make determinations regarding suicide precautions deviates from minimum constitutional requirenlents, RCDF's own policies, medical community practice, and the recommended guidelines of the National COl1il1l ittee for Correctional Health Care ("NCCHC"), and ultimatelyplaces prisoners at risk ofsedous harm. See Ramos v. Lamm, 639 F.2d 559, 576 (lOth Cir. 1980) (finding that prison officials failed to provide constitutionally adequate medical care where non-physician medical staffwere "being used as 'physiciM substitutes' Md . . . being

There are two types of licensed nurses, LPNs and registered nurses, or RNs. Registered

nurses have a more advanced degree and more training thM LPNs. LPNs are supervised by

registered nurses to carry out some clinical functions. A registered nurse can develop a nursing

diagnosis, but not a medical diagnosis.

2

SHP policies reflect the need for a psychiatric provider at RCDF. For example, the Chronic

Care Protocols state that after the medical staff and psychiatric nurse screen M imnate, "a

referral may be made to see the Psychiatrist."
3
The SHP Chronic Care Protocol alternately refers to the "Psych Nurse" as the "Psych

RN." The current psychiatric nurse is a registered nurse.

-6­
forced to make decisions and perform services for which they are neither trained nor qualified."). The following example demonstrates RCDP's constitutionally infinn practice of removing prisoners from suicide watch without providing a reasoned and comprehensive evaluation of their suicide risk by a trained mental health professional:

•

On October 10, 2010, RCDP staffplaced Prisoner A on suicide watch and started

him on an antidepressant. There was no progress note in his record documenting

the rationale for placing him on suicide watch or ordering the antidepressant.

Two days later, an LPN removed him from suicide watch. Neither the psychiatric

RN nor the physician conducted a mental health assessment of Prisoner A before

the LPN removed him from suicide watch. Nevertheless, the LPN ordered that

Prisoner A be placed on razor restriction and prohibited him from having sheets in

his cell, indicating that the nurse believed that Prisoner A was still at risk of

engaging in self-harm.

Our review also revealed numerous instances where RCDP nurses removed prisoners from suicide watch after prisoners signed contracts essentially promising not to harm themselves. Por someone with suicidal ideation or who is actively suicidal, these "contracts for safety" have little protective validity, yet RCDP is using them in place of an evaluation by a qualified mental health practitioner. The following examples illustrate this practice:

•

On September 16, 2010, RCDP staff placed Prisoner B in isolation.4 According

to a nurse's notes, Prisoner B was removed from isolation after signing a contract

promising not to engage in self-harm. This occurred although the psychiatric RN

had specifically noted that Prisoner B should not be pennitted to contract for

safety.

•

Prisoner C was placed on suicide watch on August 29, 2010, due to suicidal

ideation. The next day, an LPN removed Prisoner C from suicide watch after she

signed a contract. The psychiatric nurse saw Prisoner C for the first time ten days

later.

•

On April 28, 2010, RCDP staff placed Prisoner D on suicide observation after he

used a pencil to engage in self-injurious behavior. Two days later, RCDP staff

removed Prisoner D from observation after he signed a contract promising not to

engage in self-harm. RCDP did not conduct a formal mental health assessment of

Prisoner D before removing him from observation.

This practice falls below constitutional standards. See Comstock, 273 P.3d at 710-11 (psychologist placed prisoner at risk of harm by removing him from suicide watch based on an
evaluation that "left him no way to corroborate [the prisoner's] self-serving statement that he was feeling better"); see also Farmer, 511 U.S. at 843 n. 8 (A prison official may "not escape

4

In order to do so, RCDP staff removed another inmate with a mental health condition

from isolation, indicating problems with crowding in the cells designated for mental health

observation.

-7­
liability ifthe evidence show[s1 that he merely refused to verify underlying facts that he strongly suspected to be true, or declined to confirm inferences of risk that he strongly suspected to exist.").

The physician and psychiatric nurse have little or no involvement in the management of suicide precautions. During the first day of our onsite tour, we were told that there were not any prisoners on suicide watch. However, we observed two prisoners in suicide smocks (commonly called "turtle suits"). These two prisoners were in isolation cells and had all oftheir clothes removed except for the soft upper body cloth suit. Neither the medical staff, including the physician, nor the psychiatric nurse was able to provide information regarding the status of these two prisoners.

Our review of prisoners' records confinued our onsite observations that prisoners on suicide watch are not adequately supervised or monitored. Prisoners on suicide watch often had no clear doclunentation in their chart outlining when and why they were placed on a suicide watch, or when they were removed. Suicide precaution logs revealed that these forms often appeared to be completed in advance, indicating that RCDF staff did not conduct intern1ittent checks. Moreover, we discovered numerous cases where either more than fifteen minutes elapsed between checks or checks were not staggered. RCDF's failure to adequately monitor and supervise prisoners on suicide watch contravenes RCDF's own policy and the constitutional requirement that, at a minimum, correctional mental health programs must include "a basic program for the identification, treatment, and supervision of inmates with suicidal tendencies." Ruiz v. Estelle, 403 F. Supp. 1265, 1339 (S.D. Tex. 1980), aff'd in part and rev'd in part on other grounds, 679 F.2d 1115 (5th Cir. 1982); see SHP Suicide Prevention Policy (requiring staggered checks every 10-15 minutes); see also Lindsay M. Hayes, Guide to Developing and Revising Suicide Prevention Protocols Within Jails and Prisons, Nat'l Ctr. on Insts. & Alternatives 5 (2011) (recommending that a prisoner who is actively suicidal should be observed "on a continuous, uninterrupted basis," and a prisoner who is "not actively suicidal, but expresses suicidal ideation . . . and/or has a recent prior history of self-destructive behavior" should be observed "at staggered intervals not to exceed every 10 minutes (e.g., 5, 10, 7 minutes». "

Finally, RCDF uses seclusion and restraint inappropriately and without necessary safeguards when responding to the risk of suicide. Specifically, RCDF nurses and custody staff use the restraint chair as a form of "suicide watch" without an order from the physician. The records we reviewed demonstrated that RCDF staff place prisoners in the restraint chair, confine them to the chair for hours at a time, and then remove them, without ever providing the prisoner with a face-to-face evaluation by the physician. The following examples illustrate this practice:

•

Prisoner E entered RCDF on September 11, 2010, with a dual diagnosis ofmental

illness and substance abuse. Custody and nursing staff placed Prisoner E in

restraints and subsequently placed him on suicide watch. The psychiatric nurse

did not evaluate Prisoner E until after he had been on suicide watch for 48 hours and had been at the Jail for more than two weeks. Even then, she did not conduct

a comprehensive mental health evaluation or develop an adequate treatment plan.

-8­

•

On May 15, 201 0, Prisoner F entered RCDF. Based on his previous admission to

RCDF, it was clear that Prisoner F had a history of suicidal ideation. The day of

his admission, RCDF staff placed him in the restraint chair without a physician's

order or a face-to-face evaluation. According to his chart, on May 28, 2010,

custody staff observed Prisoner F consume a handful of pills. As a result of this

suicide attempt, staff transferred Prisoner F to a hospital critical care unit. The

psychiatric nurse did not see Prisoner F until a week after his return from the

hospital. P risoner F never received follow-up care by the physician.

RCDF does not maintain complete records regarding the use of seclusion or the restraint chair. Moreover, RCDF does not have a medical or mental health policy specific to the use of involnntary psychotropic medication or restraints. The use of restraint and seclusion are safety interventions only and do not constitute a valid form of mental health treatment. The use of restraint and seclusion may lead to the worsening of a mentally ill individual's symptoms and carries the risk of physical injury. 5

2. RCDF violates the Constitution by failing to provide seriously mentally ill prisoners 
 timely and competent mental health care. 


In order to meet the minimum required by the Constitution, a correctional mental health care program must include "the participation of trained mental health professionals, who must be employed in sufficient numbers to identify and treat in an individualized manner those treatable inmates suffering from serious mental disorders." Ruiz, 403 F. Supp. at 1 339. Moreover, this treatment must be provided in a timely manner. See Phillips, 534 F.3d at 539 (prison officials violate constitutional standards by "denying or delaying" prisoner's access to treatment for a serious medical need); Blackmore, 390 FJd at 900 (noting that a "delay alone in providing medical care creates a substantial risk of serious harm"). RCDF fails to provide prisoners identified as seriously mentally ill or suicidal with timely and competent mental health care. Specifically, prisoners with chronic mental illnesses who are not capable of requesting mental health care are effectively denied treatment, prisoners who request mental health care experience unreasonable delays, and nurses are responsible for providing mental health care beyond their training and qualifications.

a. RCDF does not provide prisoners with chronic mental illnesses with adequate mental health care and treatment.

Despite the existence of a policy entitled "Chronic Care Protocols: Diagnosed Mentally III Patients," RCDF does not have an established system for providing chronic care to psychiatric

5

See, e.g., Nat'l Ass'n of State Mental Health Program Dirs. ("NASMHPD"),

NASMHPD's Position Statement on Seclusion and Restraint, at 1 (July 15, 2007),

http://www.nasmhpd.org/position_statement.cfin. NASMHPD is an organization made up of

directors of state public mental health systems. According to NASMHPD, "seclusion and

restraint are safety interventions oflast resort and are not treatment interventions." Id.

NASMHPD's Position Statement emphasizes that "[t]he use of seclusion and restraint creates

significant risks for all individuals involved . . . includ[ing] serions injury or death . . . ." Id.

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patients. Mental health services at RCDP are primarily provided at the request of the·prisoners.6 As a result,prisoners who are too ill to write a request for an appointment are,in effect,denied constitutionally adequate mental health care. See Casey v. Lewis, 834 P. Supp. 1477,1550 (D. Ariz. 1993) (finding prison officials deliberately indifferent where "severely mentally ill inmates cmIDot make their needs known to mental health staff."); see also Hoptowit v. Ray, 682 P.2d 1237,1253 (9th Cir. 1982) (Jail officials must provide prisoners with a mechanism "to make their medical problems known to the medical staff."). This practice places seriously mentally ill prisoners at considerable risk ofharm,including decompensation.

We did not review a single record that contained an appropriate treatment plan. The following exmnple demonstrates the constitutionally inadequate mental health care RCDP provides to prisoners with severe and chronic mental illnesses:

•

Prisoner G entered the Jail on July 21,2010,with a history of severe mental

illness and prior suicide attempts. Despite these risk factors,intake staff never

referred Prisoner G to mental health services. Prisoner G did not receive mental

health care until August 11,2011,after he engaged in self-harm by inserting a

foreign object into his urinary and digestive tracts. Even then,he was not referred

to the physician. Instead,he was seen in an intermittent fashion by the psychiatric

nurse,who conducted visits cell-side,preventing confidential commlmications. This is the only form ofmental health treatment RCDP provided to Prisoner G.

Indeed,instead of providing seriously mentally ill prisoners with chronic care,RCDP essentially relies on "therapeutic 10ckdown," in which a detainee is isolated in his or her cell and denied any staff interaction,including contact with mental health staff. This use of long-term seclusion is contrary to generally accepted professional standards of mental health care and the Constitution. While the psychiatric nurse provides these prisoners with minimal medication management, RCDP provides no other treatment modalities. In order to provide constitutionally adequate mental health care,"the prescription of [psychotropic] drngs cannot supplant the necessity ofpsychiatric cOUllseling." Balla v. Idaho State Bd. a/Carr., 595 P. Supp. 1558, 1577 (D. Idaho 1984); see also Coleman v. Wilson, 912 F. Supp. 1282,1298 n.10 (E.D. Cal. 1995) (a constitutionally adequate mental health care system includes, at a minimum,"a . treatment program that involves more than segregation and close supervision ofmentally ill prisoners").

b. RCDP does not respond to requests for mental health care in a timely manner.

RCDP's mental health care system fails to provide timely treatment in violation of the Constitution. See LeMarbe v. Wisnes/d, 266 P.3d 429,439 (6th Cir. 2001) ("[A] deliberately indifferent delay in giving or obtaining treatment may also amount to a violation Imder the Eighth Amendment."). Even those prisoners who are able to request mental health services must wait significant periods of time before seeing the psychiatric nurse. The psychiatric nurse works at the facility one day per week for six to eight hours and essentially acts as the sole provider ofmental

6

SHP policy expressly permits this practice. See Chronic Care Protocols ("At all times,

Inmates must complete and submit a sick call request form to see the Psych RN or Psychiatrist.").

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health care to RCDF prisoners. Our review revealed that,on average,it takes approximately two to three weeks for the psychiatric nurse to respond to a prisoner referral. Delays of two weeks or more for mental health care effectively deny prisoners access to medical care in violation of the Constitution. See Ramos, 639 F.2d at 578 (staff shortages leading to prisoners being placed on waitlist of two to five weeks constitutes effective denial of mental health care and demonstrates deliberate indifference). Shorter delays also deny prisoners access to medical care when the need is urgent. See, e.g., Fitzke v. Shappell, 468 F.2d 1072,1076-77 (6th Cir. 1972) (delay of 12-17 hours in receiving treatment where circumstances indicated prompt need for medical attention stated a cause of action for denial ofmedical care). The following examples demonstrate RCDF's delays in providing mental health care:

•

Prisoner C was placed on suicide watch on August 29,2010,due to suicidal

ideation. On August 30, 2010,a nurse removed Prisoner C from suicide watch

after she signed a contract. TIle psychiatric nurse saw Prisoner C for the first time

ten days later,on September 9, 2010. On November 3, 2010, Prisoner C again

requested to see the psychiatric nurse. Despite Prisoner C's depression and

suicidal ideation,the psychiat1"ic nurse did not respond to her request for more

than two weeks.

•

Upon his admission in July 2010,Prisoner H reported his history ofmental illness

and treatment with Seroquel. Outside records documented that Prisoner H had,in

fact, been receiving this medication prior to his arrival at RCDF. Despite his

request to receive this medication,RCDF staff did not provide Prisoner H with

SeroqueJ until two months after his admission.

•

Prisoner I had a known history of mental ilmess and suicidal ideation.

Specifically,Prisoner I cut her arms with a razor blade while on suicide

observation at RCDF. Prisoner I had also attempted suicide prior to her

incarceration by stabbing herselfin the stomach. An RCDF nurse noted in

Prisoner 1's record that "it is felt by staff that [Prisoner I] is trying to end her own

life due to the serious charges she faces." On April 8,2010,Prisoner I submitted

a request for mental health care. Despite her risk factors, the psychiatric nurse did

not see Prisoner I until nearly one week after her request for mental health

services.

•

Prisoner J entered RCDP on March 6, 2010. Ten days later, Prisoner J was placed

on suicide watch due to suicidal ideation,auditory hallucinations, and engaging in

self-harm. Prisoner J filed multiple sick call requests in order to be seen for

adjustment ofhis psychotropic medication. On average, the psychiatric nurse

took about three weeks to respond to his requests. During these delays,he was

placed in restraints and subject to uses of force by custody staff.

RCDF's practice of permitting two to three weeks - or more-to elapse between a prisoner's request for mental health care and the provision of care does not meet constitutional standards.

-11­
c. RCDF pennits nurses to provide mental health care beyond their training and qualifications.

RCDF's practice of permitting nurses who are not trained and qualified to provide mental
health care to manage psychotropic medications and treat prisoners with serious mental health needs violates the Constihltion and generally accepted practices. See, e.g., Inmates ofAllegheny Cnty. Jail, 612 F.2d at 762; Balla, 595 F. Supp. at 1577 (finding that "minimally adequate psychiatric care" includes adequate coverage by a psychiatrist to "provide treatment to those
imnates capable of deriving benefit").

The "appropriate supervision and periodic evaluation" ofprisoners on psychotropic medications is "constitutional minima . . . specific to mental health care." Madrid v. Gomez, 889 F. Supp. 1146, 1258 (N.D. Cal. 1995). RCDF prisoners are being treated with anti-psychotics and major mood stabilizers. Yet, the physician does not consistently evaluate prisoners on psychotropic medications, nor does he review the prescribed psychotropic medications to ensure their appropriateness and to prevent negative interactions with other medications.7 Instead, the psychiatric nurse essentially prescribes and manages medications for patients with mental health conditions, responsibilities that are beyond the scope of a nurse's training. The following examples demonstrate RCDF's practice of permitting staff to provide mental health care beyond their licensure and training:

•

Prisoner K entered the Jail on September 7, 2010, with a history ofmental illoess.

The psychiatric nurse saw Prisoner K two weeks after he requested an

appoinhnent. Prisoner K reported to the nurse that, prior to arriving at RCDF, he

was prescribed Cymbalta, a drug commonly used to treat depression. The

psychiatric nurse independently gave Prisoner K permission to take Cymbalta if

his family was able to provide the medication. The psychiatric nurse never

referred Prisoner K to the physician for an evaluation or an alternative drug.

Moreover, the prisoner's family should not be responsible for his medical or

mental health care while in the custody of the Jail.

•

Prisoner L entered RCDF on July 30, 2010, with a history of anxiety and

treatment with psychotropic medication. RCDF intalce staff did not refer Prisoner

L to a qualified mental health professional within 14 days of arrival as required by

the standard of care. Instead, an LPN managed his treahlient with preformatted

treahnent protocols and telephone orders.

•

On May 15, 2010, Prisoner F entered RCDF. The psychiatric nurse mismanaged

the doses of Prisoner F's psychotropic medications, causing Prisoner F to be

overly sedated and lethargic. Prisoner F never received follow-up care by the

physician.

7

Certain medications, including Depakote and Lithium, require monitoring by diagnostic

blood tests to ensure that the medications are not causing harm to the patient.

-12­
The physician is the only RCDF medical professional who is equipped by his training and licensure to manage and treat patients with a medical andlor mental health diagnosis. In order to ensure that prisoners receive constitutionally adequate mental health care, RCDF must ensure that a physician is available to train nursing staff and to provide oversight. RCDF must increase its mental health staffing to meet the needs of its population and limit the psychiatric nurse's and LPNs' job responsibilities to those services they are trained and licensed to perform.
C. RCDF's Medical Care Is Deficient and Creates a Risk of a Constitutional Violation
RCDF provides prisoners with medical care minimally adequate to comply with the Constitution. We did not identify a pattern or practice of incidents in which prisoners suffered hann due to RCDF's medical practices, or in which RCDF's medical practices placed prisoners at an unreasonable risk ofhann. Nonetheless, we identified numerous practices in the area of medical care that could result in constitutional violations if left unremedied. The Constitution protects a prisoner's "right not to have his serious medical needs disregarded by his doctors." LeMarbe, 266 F.3d at 440. Prison officials knowingly disregard, or act with deliberate indifference to this right by '''denying or delaying access to medical care' for a serious medical need." Phillips, 534 F.3d at 539 (quoting Estelle, 429 :U.S. at 104-05). Officials also violate the Constitution when they are deliberately indifferent to "an unreasonable risk of serious damage to . . . [a prisoner's] future health." Helling, 509 U.S. at 35.
Our review revealed that RCDF's medical practices place prisoners at risk of receiving delayed or deficient medical care. Specifically, RCDF permits unqualified staff to conduct health assessments, provides poor medication management, and lacks a chronic care program. In addition, RCDF should improve its management of infectious diseases. Although we did not identify any instances of serious hann from these systemic deficiencies during our review, these deficiencies could place prisoners at risk ofharm, and, if left unremedied, may result in constitutional violations.
As discussed in our assessment of mental health care, many of these lapses are directly related to RCDF's inadequate medical staffing. Due to the inadequate physician support at RCDF, nurses practice and provide medical care beyond their training and licensure. Specifically, nurses make decisions regarding which drugs should be prescribed and conduct health assessments with little or no oversight. Moreover, nurses are permitted to use "medical protocols" to prescribe medications. The use of inappropriate health staff for the management and evaluation of serious medical conditions could place the prisoners at risk for both unnecessary morbidity and mortality.
Specific deficiencies we observed included the following:
• LPNs conduct comprehensive medical assessments of prisoners, a function LPNs are not licensed or qualified to perform.
• RCDF dispenses medications to prisoners without any supporting medication orders or progress notes. Dispensing medications without a progress note,

- 13­
physician order, or other documentation is dangerous and can have a lethal outcome for the patient.
• RCDP's medication verification procedures result in unnecessary and unreasonable delay in providing medication to prisoners.
• RCDP lacks a defined system to track or manage prisoners with chronic medical conditions.
• RCDP does not have a procedure in place to test prisoners annually for tuberculosis and does not track Methicillin-resistant Staphylococcus aureus8 or any other infectious disease information.
If left unremedied, RCDP's provision ofmedical care by unqualified staffmay result in a denial of care and violate the Constitution.
D. RCDF Provides Prisoners with Adequate Nutrition
We found that RCDP provides prisoners with constitutionally adequate nutrition. All prisoners must receive adequate food and water. Farmer v. Brennan, 511 U.S. 825, 832 (1994); Helling, 509 U.S. at 31-32. To be adequate, the food provided must be sufficient to maintain normal health. Cunningham v. Jones, 567 P.2d 653, 660 (6th Cir. 1977). Por prisoners to maintain normal health, the food they receive must contain both adequate nutrients and calories. See. e.g., Hutto v. Finney, 437 U.S. 678, 683, 686-87 (1978) (discussing caloric intake); Phelps v. Kapnolas, 308 F.3d 180, 187 (2d Cir. 2002) (diel musl be nulriliunallY adequale).
On December 22, 2010, we provided RCDP with our preliminary findings regarding the nutritional adequacy of the meals that the Jail provides. In that letter, we stated that we had found'information to support prisoners' claims that, in 2008 and part of 2009, they were not receiving enough food, likely due to the actions of a former food service contract employee. While we conclude here that RCDP has resolved its issues related to the provision of adequate nutrition, we note that this incident tmderscores how important it is for the Jail to supervise ldtchen operations, and more broadly, the operations of all of its contractors.
Although our review indicates that RCDF's menu is constitutionally adequate, we have some concerns regarding RCDP's food preparation, portioning, and service practices that can

8

MRSA is a potentially dangerous drng-resistant bacteria that can cause serions systemic

illness, permanent disfigurement, and death. A MRSA infection is sometimes confused by

detainees and medical staff for a spider or insect bite, causing delays in treatment while the

infection worsens or spreads. MRSA is resistant to common antibiotics, snch as methicillin,

oxacillin, penicillin, and amoxicillin. MRSA is usually spread by direct physical contact, but

may also spread through indirect contact, by touching objects snch as towels, sheets, wound

dressings, and clothes. MRSA can be difficult to treat and can develop into life-threatening blood or bone infections. See generally Ctrs. for Disease Control & Prevention, Methicillin­

resistant Staphylococcus Aureus (MRSA) Infections, http://www.cdc.gov/mrsalindex.html (last

updated Apr. 8, 2011).

-14­
impact the adequacy ofnutrition provided to prisoners. We discuss these practices and some recommended actions below. As a general proposition, however, RCDF should consider developing a standing committee devoted to food and food related issues in order to identify issues and implement conective actions where needed. This committee should be comprised of RCDF administrative staff, first line jail supervisors, correctional officers, kitchen =ployees, and medical representatives, and include a mechanism for prisoner feedback.
Additionally, in order to avoid any issues before they develop, RCDF should take a more active role managing its food service operation. While a contractor provides RCDF's food service, the Sheriff and RCDF are ultimately responsible for the food service operation. In particular, RCDP should regularly review key docnments and observe kitchen operations. Such oversight will ensure that RCDP's food contractor meets its contractual obligations and provides safe and nutritious meals as required by the Constitution.
I. RCDF's menu provides nutritionally adequate meals.
RCDP appears to provide nutritionally adequate meals. RCDP should ensure, however, that a qualified dietician approves its menus in advance. RCDP utilizes a four-week cycle menu, . ostensibly approved by a dietician on staff with RCDP's food contractor. At the time of our tour, the menu had been changed several months prior to our visit, yet the kitchen staff did not have an updated, dietician-approved menu reflecting the changes. Additionally, RCDP staff infonned us that a new menu was scheduled to go into effect in the month following our tour. To prevent the reoccurrence of the concerns that initially prompted our investigation, it is vital that a qualified, credentialed dietician reviews all menus prior to their implementation so that the Jail is assured that the menu it serves is calorically and nutritionally adequate. This is especially important at RCDF, where no commissary is available to prisoners, as RCDF's kitchen provides prisoners' only source of nutrition.
Pollowing our visit to the Jail, RCDF provided us with a copy of RCDP's revised, dietician-approved menu (hereinafter the "October 2010 menu"), and a nutritional analysis of that menu. Based on our expert dietician's review, the October 2010 menu - cunently in effect at RCDP-should provide prisoners with adequate nutrients and calories to maintain normal health, assnming it is implemented as written.
Specifically, the nutritional analysis for the October 2010 menu indicates that RCDP served an average of 2,900 calories/day per prisoner during the menu's four-week cycle. Daily caloric needs are predicted by an individual ' s Estimated Energy Requirement ("EER"), which varies by age, gender, weight, height, and level of physical activity. Our expert dietician evaluated the EER for two reference individuals, a male and a female between the ages of 19-30, who engage in low levels ofphysical activity, as representative of the energy needs of a majority of RCDP prisoners. Based on these reference individuals, the October 2010 menu is adequate to meet the maintenance energy needs of the majority of prisoners at RCDF. The October 2010 menu also meets the major nutrient requirements for men and women aged 19 to 70 and pregnant women.

-15­
2. RCDF's food preparation, portioning, and service practices impact nutritional adequacy.
In addition to a nutritionally sufficient menu,nutritional adequacy requires RCDF to prepare and portion meals in a manner consistent with the menu's requirements,and to provide every prisoner with his or her prescribed diet. Overall,our investigation indicated that RCDF prisoners were receiving adequate nutrition in accordance with the Jail's menu and the Constitution. We observed,however,several practices that could impact the level of nutrition each prisoner actually receives.
As we stated in our December 22, 2010 letter,to reduce the need for any variances from standardized recipes,the food contractor should provide,and the kitchen staff should follow, standardized recipes scaled to the number of meals needed. These recipes should be updated when RCDF's population changes significantly,or when suppliers or ingredients change. Facilities commonly either maintain copies of recipes scaled to their particular needs or use computer software to generate recipes adjusted to the needed number of meals. These tools reduce reliance on quick estimates,and increase the accuracy of the nutritional analysis of the menu in use. Finally,kitchen staff should record the recipe number used on the daily food production schedule to ensure compliance with the menu,and the food contractor's regional supervisor and food service director should monitor both the adequacy of the docll1nentation and the cooking for compliance with the standardized recipes.
Additionally,for prisoners to receive the benefits of RCDF's menu,the Jail must provide each prisoner with the correct tray at every meal. To ensure that RCDF is doing so,tht: Jail should develop and implement a policy and procedure to ensure that correctional officers consistently document receipt of meal trays. Each officer responsible for distributing meals should confirm a prisoner's identity by checking his or her wrist identification band before handing the food tray to the prisoner,and then document the fact that the prisoner received his or her meal. This documentation should include any meal refusals.
E. Environmental Health and Safety at RCDF Comport with Constitntional Standards
We found that the environmental conditions at RCDF did not violate the Constitution. In certain areas,however,RCDF's practices fall below national standards. The Eighth Amendment guarantees that prisoners will not be "deprive[d] of the minimal civilized measure of life's necessities." Rhodes v. Chapman, 452 U.S. 337,347 (1981). As the Due Process Clause of the Fourteenth Amendment affords at least the same protections to a pre-trial detainee in a jail, RCDF must be sure that it does not deprive prisoners of the minimal civilized measures of life's necessities. Accordingly,RCDF must provide essential sanitation and meet prisoners' basic hygiene needs. Flanory v. Bonn, 604 F.3d 249,253-55 (6th Cir. 2010). Conditions violate the Constitution when they pose an unreasonable risk of serious harm to a prisoner's current or future health,and where the risk is so grave that it offends contemporary standards of decency to expose anyone unwillingly to that risk. Helling, 509 U.S. at 33-36; Flanory, 604 F.3d at 255 (citing Helling).

1 6 -

-

At the time of our tour, RCDF was undergoing extensive remodeling of its facility following the construction of a new addition that had been open for approximately one year. As a result, the facility is clean and in generally excellent condition. Nonetheless, RCDF must remain attentive to issues of food safety, chemical control, pest control, fire safety, and other issues of cleanliness and sanitation, all of which may pose mmecessary risks to prisoner health and safety without the implementation of effective programs and services. We identified many of our concems and provided guidance as to how to address them during our tour, and so discuss these issues only briefly here.

Specific deficiencies we observed included the following:

• RCDF staff lack control over many kitchen tools and implements that could be used as weapons.

• RCDF's food service manager and staff lack basic food safety training.

• RCDF kitchen sanitation is inadequate in certain areas.

• RCDF fails to screen food service employees and inmate staff for communicable diseases that cOl\ld be transmitted by foods.

• RCDF has no documented program or process for maintaining and controlling the chemicals used throughout the facility. These unsecured chemicals can be used as weapons or, if ingested, may pose a suicide risk.

• RCDF lacks a written emergency plan including evacuation routes and secure areas for prisoners to be housed in the event of an emergency.

• RCDF lacks control over items in the medical clinic, including medical sharps and biohazard waste, that may pose a risk to prisoners and staff.

V.

Summary of Remedial Measures

To remedy its failure to provide constitutionally adequate mental health care to RCDF prisoners, the County should promptly implement the minimmTI remedial measures set forth below. Specifically, RCDF should:

•

Gain access to a qualified provider or contract psychiatrist(s) at least every two

weeks;

•

Modify the psychiatric nurse's job description and job responsibilities to prohibit

her from independently prescribing medications and practicing medicine;

•

Require the medical director, or any contract psychiatrist RCDF hires, to

supervise the psychiatric nurse on a regular basis;

-17­

•

Ensure that appropriate mental health assessments are conducted within 24 hours

of a prisoner's arrival at RCDF, or sooner if clinically appropriate for prisoners

identified as potentially suicidal (and ensure that those prisoners identified as

potentially suicidal are on constant watch until they receive their mental health

assessment);

•

Develop more defined referral parameters to ensure that prisoners with mental

health needs are referred to the physician. Intake staff and nurses must be

provided with clear guidance regarding which prisoners should be referred to the

physician and how quickly that referral should take place. These guidelines

should require an inunediate referral for emergent issues, a referral within 24

hours when an expedited evaluation is necessary, and a referral within 72 hours

for a routine evaluation;

•

Ensure that LPNs are not permitted to remove prisoners from suicide watch;

•

Ensure that there is no ambiguity regarding the status of a prisoner who is on

suicide watch. Qualified medical staff should determine the appropriate level of

care and/or housing based on the clinical status of the prisoner and additional

information provided by the security staff. Prisoners on suicide watch should be

evaluated daily and the medical staff must be aware of all prisoners on a watch;

•

Enhance communication between custody and medical staff and implement

policies and procedures that provide for the timely treatment and regular

monitoring of prisoners on suicide watch;

•

Develop and implement written policies for the use of restraints on prisoners with

mental illness, requiring written approval by a qualified mental health

professional prior to use of restraints, monitoring, and docIDnentation;

•

Ensure that all custody and medical staff are trained on the policies and

procedures governing appropriate use of restraints on prisoners with mental

illness;

•

Ensure that prisoners who request mental health care through the sick call system

for urgent needs are seen by a qualified mental health professional within 24 to 72

hours;

•

Require the RCDF physician to conduct a screening evalnation and

comprehensive evaluation of all prisoners taking psychotropic medications within

30 days of their arrival at the Jail. The physician should monitor these prisoners

periodically to ensure they are stable, that the medications are worldng

effectively, and that the medications are not causing unwanted toxic or metabolic

side effects;

-18­

•

Develop procedures to ensure that prisoners who are prescribed psychotropic

medications that require blood tests are closely monitored;

•

Develop a system to conduct qualitative reviews of adverse events performed

from a mental health perspective;

•

Document all medications, including psychotropic medications, ordered for

prisoners on the medication order form. Progress notes should support the order

to dispense the medication; and

•

Institute a chronic care program to address the needs of prisoners with serious

mental illnesses. Prisoners with chr nic mental illness should be placed on a

chronic mental health list for follow-up as clinically appropriate every 30, 60, or

90 days without having to request follow-up. Basic services must include, at a

mlmmum :

I.

Identification and referral of imnates with mental health needs;

2.

Crisis intervention services;

3.

Psychotropic medication management, when indicated;

4.

Individual counseling, group counseling, psychosocial! psycho­

educational programs; and

5.

Treatment documentation and follow-up.

********
W e hope to continue working with the County in an amicable and cooperative fashion to resolve our outstanding concerns regarding conditions at RCDF. Since our onsite visit, RCDF has reported that the Jail has taken various steps to address many of the concerns we raised at our exit presentation at the close of that visit. We appreciate the Jail' s proactive efforts, and are confident that the Jail will be able to resolve all the matters we raised.
CRIPA obligates us to advise you that, in the event we are unable to reach a resolution regarding our concerns, the Attorney General may initiate a lawsuit pursuant to CRIPA to correct the constitutional deficiencies we have identified in this letter 49 days after the appropriate
officials have been notified of them. 42 U.S.C. § 1 997b(a)(l). 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 you to discuss this matter in further detail.
Please note that this letter is a public document. It will be posted on the Civil Rights Division's website. As a matter of courtesy, we will not post this letter to the website until five business days from the date of this letter. We will also provide a copy of this letter to any individual or entity upon request.

- 19­ Should you have any questions or concerns regarding this letter, please feel free to contact Jonathan M. Smith, Chief of the Civil Rights Division's Special Litigation Section, at (202) 514-5393.
Sincerely,
Thomas E. Perez Assistant Attorney General
Enclosures
cc: Sheriff Bill Holt Robertson County
Captain Tony Crawford 
 Jail Administrator 
 Robertson County Detention Facility 
 Clyde W. Richert III 
 County Attoniey 

The Honorable Jerry E. Martin 
 United States Attorney 
 Middle District of Tennessee 

U.S. Marshal Denny W. King U.S. Marshals Service 
 Middle District of Tennessee 


 
 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF TENNESSEE

UNITED STATES OF AMERICA,

)

)

PLAINTIFF,

)

)

v.

)

)

ROBERTSON COUNTY;

)

HOWARD BRADLEY, COUNTY MAYOR,

)

in his official capacity; ROBERTSON COUNTY )

COMMISSIONERS, in their official capacity; )

BILL HOLT, ROBERTSON COUNTY SHERIFF, )

in his official capacity;

)

)

DEFENDANTS.

)

)

CIVIL ACTION NO:

COMPLAINT

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

attorneys, hereby alleges upon information and belief:

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

pursuant to the Civil Rights ofInstitutionalized Persons Act of 1980,42 U.S.C. § 1997, to

enjoin the named Defendants from depriving persons incarcerated at the Robertson County

Detention Facility ("RCDF") in Springfield, Tennessee, of rights, privileges, or immunities

secured and protected by the Constitution of the United States.

JURISDICTION AND VENUE

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

3. The United States is authorized to initiate this action pursuant to 42 U.S.c. § 1997a.

4. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C.

§ 1997b have been met. The Certificate of the Attorney General is appended to this

Complaint as Attachment A and is incorporated herein.

Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 1 of 8 PageID #: 1

-2-
5. Venue in the United States District Court for the Middle District of Tennessee is proper pursuant to 28 U.S.C. § 1391. PARTIES
6. Plaintiff is the United States of America. 7. Defendant ROBERTSON COUNTY (the "County") is a governmental subdivision created
under the laws of the State of Tennessee and governed by the Defendants HOWARD BRADLEY, COUNTY MAYOR, and ROBERTSON COUNTY COMMISSIONERS. 8. Defendant HOWARD BRADLEY, COUNTY MAYOR, is the Chief Executive Officer of the County. HOWARD BRADLEY, COUNTY MAYOR, is sued in his official capacity. 9. Defendant ROBERTSON COUNTY COMMISSIONERS is the legislative body of the County, and is sued in its official capacity. 10. Defendant BILL HOLT is the Robertson County Sheriff and has responsibility for the operations of RCDF and to protect the safety of prisoners. Sheriff HOLT is sued in his official capacity. 11. Defendants ROBERTSON COUNTY and Sheriff HOLT are together responsible for the conditions of confinement and health and safety of persons incarcerated at RCDF. 12. Defendants are legally responsible, in whole or in part, for the operation and conditions of RCDF, and for the health and safety of persons incarcerated there. This action concerns the administration of persons confined at RCDF, which houses pre-trial federal and state detainees and sentenced state prisoners. 13. At all relevant times, defendants or their predecessors in office have acted or failed to act, as alleged herein, under color of state law.
FACTS 14. RCDF is an institution within the meaning of42 U.S.C. § 1997(1).
Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 2 of 8 PageID #: 2

-3-
15. Persons confined to RCDF include both pre-trial federal and state detainees and sentenced state prisoners.
16. Defendants have deliberately disregarded known or serious risks of harm to prisoners at RCDF.
17. Defendants have failed to take reasonable measures to protect prisoners against the serious harm from suicide and self harm by permitting unqualified personnel to manage suicide precautions for prisoners at risk of engaging in suicide and self-harm. Defendants use nurses who are not qualified and trained to treat prisoners' psychiatric needs to both place prisoners on and remove them from suicide watch.
18. Defendants failed to remove prisoners from suicide watch without providing a reasoned and comprehensive evaluation of their suicide risk.
19. In place of an evaluation by a qualified mental health practitioner, Defendants' nurses remove prisoners from suicide watch after prisoners sign contracts promising not to harm themselves. For someone with suicidal ideation or who is actively suicidal, these "contracts for safety" fail to protect prisoners from attempting and/or completing suicide.
20. Defendants do not adequately document when and why prisoners are placed on a suicide watch, or when they are removed.
21. Defendants do not adequately supervise prisoners on suicide watch. 22. Defendants use seclusion and restraint inappropriately and without necessary safeguards
when responding to the risk of suicide. Specifically, Defendants' nurses and custody staff use the restraint chair as a form of "suicide watch" without an order from the physician. 23. Defendants fail to provide prisoners with chronic and/or serious mental illnesses timely and adequate mental health treatment. Mental health services at RCDF are primarily provided at the request of the prisoners. As a result, prisoners who are too ill to write a request for an
Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 3 of 8 PageID #: 3

-4-
appointment are, in effect, denied constitutionally adequate mental health care. This practice places seriously mentally ill prisoners at considerable risk of harm, including further deterioration of their mental health status. 24. Instead of providing seriously mentally ill prisoners with chronic care, RCDF relies on "therapeutic lockdown," in which a detainee is isolated in his or her cell and denied any staff interaction, including contact with mental health staff. 25. Defendants provide seriously mentally ill prisoners with only minimal medication management and do not provide other treatment modalities, including individual and/or group therapies. 26. Defendants do not provide prisoners who are capable of requesting mental health care effective treatment. Prisoners who request mental health care must wait significant periods of time before seeing a qualified mental health professional, often two to three weeks or more. 27. Defendants do not provide mentally ill prisoners with appropriate multi-disciplinary treatment plans and/or sufficient and appropriate medication administration. 28. The factual allegations set forth in paragraphs 14 through 27 have subjected prisoners at RCDF to a pattern and practice of egregious and flagrant conditions of confinement which deprive them of rights, privileges, and immunities secured and protected under the Constitution of the United States causing such prisoners to suffer grievous harm. 29. The factual allegations set forth in paragraphs 14 through 28 have been obvious and known to Defendants for a substantial period of time, yet Defendants have deliberately failed to adequately address the conditions described.
Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 4 of 8 PageID #: 4

-5VIOLATIONS ALLEGED
30. The allegations of Paragraphs 1 through 29 are hereby re-alleged and incorporated by reference.
31. Through the acts and omissions alleged in paragraphs 16 through 29, Defendants have subjected prisoners at RCDF to a pattern and practice of egregious and flagrant conditions of confinement which deprive them of rights, privileges, and immunities secured and protected under the Constitution of the United States causing such prisoners to suffer grievous harm. U.S. Const. Amends. VIII and XIV.
32. Through the acts and omissions alleged in paragraphs 16 through 29, Defendants have exhibited deliberate indifference to the health and safety of RCDF prisoners, in violation of the rights, privileges, or immunities of those prisoners as secured or protected by the Constitution of the United States. U.S. Const. Amends. VIII and XIV.
33. Unless restrained by this Court, Defendants will continue to engage in the acts and omissions, set forth in paragraphs 16 through 29, that deprive persons confined in RCDF of privileges or immunities secured or protected by the Constitution of the United States. PRAYER FOR RELIEF
34. The Attorney General is authorized under 42 U.S.C. § 1997 to seek equitable and declaratory relief.
35. WHEREFORE, the United States prays that this Court enter an order: a. declaring that the acts, omissions, and practices of Defendants set forth in
paragraphs 16 through 29 above constitute a pattern or practice of conduct that deprives prisoners confined at RCDF of rights, privileges, or immunities secured or protected by the Constitution of the United States and that those acts, omissions, and practices violate the Constitution ofthe United States;
Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 5 of 8 PageID #: 5

-6-
b. permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practices set forth in paragraphs 16 through 29 above and requiring Defendants to take such actions as will ensure lawful conditions of confinement are afforded to prisoners at RCDF; and
c. granting such other and further equitable relief as it may deem just and proper.

FOR THE UNITED STATES:

Respectfully submitted,

~AS~.~E~
Assistant Attorney General Civil Rights Division

Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 6 of 8 PageID #: 6

-7-
Deputy Chief Special Litigation Section WILLIAM G. MADDOX Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave, NW Washington, D.C. 20530 (202) 514-6255 William.maddox@usdoj .gov
Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 7 of 8 PageID #: 7

~ffi(t ef f~t Atterntt! Q?)tntrn(
BCtlt4ingttln. it QT. 20,5.30
CERTIFICATE OF THE ATTORNEY GENERAL I, Eric H. Holder, Jr., Attorney General ofthe United States, certify that with regard to the foregoing Complaint, United States v. Robertson County, Tennessee, I have complied with all subsections of 42 U.S.C. § 1997b(a)(1). I certify as well that I have complied with all subsections of 42 U.S.C. § 1997b(a)(2). I further certify, pursuant to 42 U.S.C. § 1997b(a)(3), my belief that this action by the United States is of general public importance and will materially further the vindication of rights, privileges, or immunities secured or protected by the Constitution. In addition, I certify that I have the "reasonable cause to believe," set forth in 42 U.S.C. § 1997a, to initiate this action, and that all prerequisites to the initiation ofthis suit under 42 U.S.C. §§ 1997a and 1997b have been met. Pursuant to 42 U.S.c. § 1997a(c), I have personally signed the foregoing Complaint. Pursuant to 42 U.S.C.§ 1997b(b), I am personally signing this Certificate. Signed this 4th day of _-=A..:,[p::..::r::...:i::.=l=---_ _, 2013, at Washington, D.C.
fbIgj~., Jr. Attorney General of the United St
Case 3:13-cv-00392 Document 1 Filed 04/26/13 Page 8 of 8 PageID #: 8

 
 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF TENNESSEE

UNITED STATES OF AMERICA,

)

)

PLAINTIFF,

)

)

v.

)

)

ROBERTSON COUNTY;

)

HOWARD BRADLEY, COUNTY MAYOR

)

(in his official capacity); ROBERTSON COUNTY )

COMMISSIONERS (in their official capacity); )

BILL HOLT, ROBERTSON COUNTY SHERIFF )

(in his official capacity);

)

)

DEFENDANTS.

)

)

Civil No. - - - -

SETTLEMENT AGREEMENT

I. INTRODUCTION

1. Robertson County, Robertson County Mayor Howard Bradley, the Robertson County Commissioners, Robertson County Sheriff Bill Holt, ("Defendants") and the United States of America (collectively, "the Parties") enter into this agreement ("Agreement") with the goal of ensuring that prisoners at the Robertson County Detention Facility ("RCDF" or "Jail") are provided with constitutional mental health care.

2. RCDF is an integral part of the public safety system in Robertson County. Through this Agreement, the Parties seek to ensure that prisoners' constitutional rights are protected. By providing for constitutional conditions at RCDF, the Sheriff and County will also provide for the safety of staff and promote public safety in the community. The Parties recognize that the conditions at RCDF and the treatment of prisoners confined there have an impact on prisoners' successful re-integration into the community upon release, the re-offense rates of released prisoners, and public confidence in the criminal justice system.

3. The Civil Rights Division ofthe United States Department of Justice commenced an investigation of the conditions of confinement at the Robertson County Detention Facility at the request of the United States Attorney's Office for the Middle District of Tennessee ("USAO"). The USAO made the request after receiving complaints from prisoners regarding conditions at RCDF and following a District Court evidentiary hearing to assess a prisoner's claim based on those conditions. United States v. Williams, No.3 :09-00090 (M.D. Tenn. 2009). The United States of America, through

Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 1 of 23 PageID #: 41

the United States Department of Justice ("the United States"), notified the County of Robertson, Tennessee ("County") of its intention to investigate conditions of confinement at the Jail pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 ("CRIPA"). The United States' investigation included onsite interviews of Jail staff and prisoners, and a review of relevant Jail policies and procedures, reports, logs, and other relevant documents and data.
4. On August 26,2011, the United States issued an investigative findings letter which concluded that certain conditions at the Jail violated the constitutional rights of prisoners detained or committed to the Jail ("Findings Letter") (attached as Appendix A). Specifically, the United States found a pattern or practice of constitutional violations in RCDF's provision of mental health care.
5. From the beginning, and continuing throughout the United States' investigation of conditions of confinement at RCDF, Defendants have acted expeditiously to begin addressing concerns the United States has raised with respect to conditions at RCDF, including concerns related to the provision of mental health care. This Agreement memorializes the actions that Defendants will implement to address the United States' findings related to mental health care.
6. This Agreement shall be filed in the United States District Court, Middle District of Tennessee, and shall resolve the United States' claims that the County is in violation of the Eighth and Fourteenth Amendments to the Constitution in its operation and management of the Jail.
7. The Court has jurisdiction over this action pursuant to 28 U.S.C. §1331; 28 U.S.C. § 1345; 42 U.S.C. § 1997; and 42 U.S.c. §§ 12131-12132. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).
8. The Agreement shall constitute the entire integrated Agreement of the Parties. Except for the United States' August 26,2011, Findings Letter, no prior contemporaneous communications, oral or written, or prior drafts shall be relevant or admissible for purposes of determining the meaning of any provisions of the Agreement in this litigation or in any other proceeding.
II. DEFINITIONS
As used in this Agreement, the following definitions apply:
a. "RCDF" or "Jail" shall refer to the Robertson County Detention Facility in Springfield, Tennessee, or any facility that is used to replace or supplement the Jail.
b. "RCSO" shall refer to the Robertson County Sheriffs Office, which is responsible for all corrections and security functions at the Jail.
2
Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 2 of 23 PageID #: 42

c. "County" shall refer to the County of Robertson its departments, programs, divisions, and agencies, including RCSO.

d. "Defendants" shall refer to Robertson County, Howard Bradley, County Mayor (in his official capacity), the Robertson County Commissioners (in their official capacity) and Bill Holt, Robertson County Sheriff (in his official capacity).

e. "United States" shall refer to the United States Department of Justice, including the Civil Rights Division and the United States Attorney's Office for the Middle District of Tennessee, which represent the United States in this matter.

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

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

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

1.

"Independent Consultant" ("IC") shall mean an individual jointly selected by both

Parties to provide technical assistance to Defendants and ensure implementation of the

Agreement.

J.

"Interdisciplinary Team" shall refer to a team consisting of treatment staff from various

disciplines, including medical, nursing, and mental health and one or more members

from corrections.

k. "LPN" shall mean individuals licensed as Licensed Practical Nurses by the State of Tennessee.

l. "Prisoners" or "Prisoner" shall be construed broadly to refer to one or more individuals detained at, or otherwise housed, held, in the custody of, or confined at RCDF.

m. "Psychiatrist" shall mean a medical or osteopathic doctor licensed to practice medicine or osteopathy in the State of Tennessee, who has completed a residency in psychiatry in a program accredited by the American Association of Medical Colleges or the American Osteopathic Association.

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

o. "Qualified Medical Staff" shall mean a physician, physician assistant, nurse practitioner, registered nurse, or licensed practical nurse who is currently licensed by the State of Tennessee and provides medical care and services to prisoners at RCDF.

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

q. "Restraint" shall mean any method that restricts, limits, or directs an individual's freedom of movement, including mechanical restraints (e.g., restraint chair, handcuffs, belly chains, leg shackles) and physical restraints (e.g., manual holds). The term "restraint" does not include verbal directives, room confinement or use of handcuffs or shackles for and during transport.

r. "Serious injury" means any injury that requires immediate medical attention or hospitalization other than first aid.

s. "Serious suicide attempt" means a suicide attempt that is considered to be either potentially life threatening or that requires hospitalization for medical treatment.

t.

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

self-harm.

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

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

w. Throughout this Agreement, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance. "Substantial Compliance" indicates that Defendants have achieved compliance with most or all components of the relevant provision of the Agreement for both the quantitative (i.e., 90% performance measure) and qualitative (i.e., consistent with the larger purpose of the Agreement) measures. "Partial Compliance" indicates that compliance has been achieved on some of the components of the relevant provision of the Agreement, but significant work remains. "Non-compliance" indicates that most or all of the components of the Agreement provision have not yet been met.

III. SUBSTANTIVE PROVISIONS
The County shall take all actions necessary to comply with the substantive provisions of this Agreement listed below. These provisions are intended to ensure that prisoners with mental illness or at risk of suicide receive proper treatment and do not experience unnecessary suffering
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or harm while incarcerated. The failure to provide necessary treatment not only harms prisoners, but affects public safety if prisoners' mental health deteriorates during incarceration. Accordingly, the County shall ensure constitutionally adequate intake, assessment, treatment, and monitoring of prisoners with mental health needs or at risk for self-injurious behavior.
A. Suicide Prevention
The County shall protect the safety of prisoners at risk for self-injurious behavior or suicide by providing timely and adequate access to Qualified Mental Health Professionals, including giving priority access to individuals most at risk of harm and who otherwise meet the criteria for being at high risk for suicide.
1. Policies
The County shall implement comprehensive policies and protocols to ensure that prisoners at risk of self harm are identified, protected, and treated in a manner consistent with the Constitution. The County shall continuously track and analyze prisoners' risk of self harm and implement measures to protect prisoners by reducing or eliminating the risk of harm. At a minimum, the policies and protocols shall:
a. Ensure that all prisoners are appropriately screened for risk of self harm using an appropriately validated screening instrument. At a minimum, the screening instrument should include inquiry regarding the following:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as the death of a family member or close
friend; (5) history of suicidal behavior by family members and close friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court, transferring agency, or
similar individuals regarding the prisoner's potential suicide risk; (8) medication history; and (9) risk of withdrawal from drugs or alcohol, including whether the prisoner
is under the influence of drugs or alcohol, the amounts taken, the date of last dose and history of withdrawal symptoms.
b. Ensure that all prisoners are screened by Qualified Medical Staff upon arrival to RCDF, but no later than within 24 hours, to identify the prisoner's risk for suicide or self-injurious behavior. If a prisoner will be discharged in less than 24 hours, Qualified Medical Staff should perform a screening prior to the prisoner's release.
c. Classify prisoners based on the results of the screening factors as low, moderate, or high risk.
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d. Ensure that prisoners are protected from identified risks for suicide or self­ injurious behavior commensurate with their level of risk by:

(1) Ensuring that any prisoner classified as high risk is searched and monitored with constant supervision until the prisoner is transferred to a QMHP for assessment. Constant supervision means in-person observation of the prisoner on a continuous, uninterrupted basis. Other aids, e.g., closed-circuit television, can be used as a supplement to, but never as a substitute for, such observation. If RCDF cannot provide continuous observation, the prisoner should be transferred to an appropriate mental health facility.

(2) Ensuring that any prisoner classified as moderate risk is searched and monitored with close supervision until the prisoner is transferred to a QMHP for assessment. Close supervision requires staff to observe prisoners at staggered intervals not to exceed every 15 minutes.

(3) Ensuring that any prisoner classified as low risk is searched and monitored until the prisoner is transferred to a QMHP for assessment. Prisoners classified as low risk shall be .observed by staff at staggered intervals not to exceed every 30 minutes.

(4) Ensuring that a QMHP conducts appropriate mental health assessments within the following periods from the initial screen:

1.

14 days, or sooner, if medically necessary, for prisoners classified

as low risk;

11. 48 hours, or sooner, if medically necessary, for prisoners

classified as moderate risk; and

111. immediately, but no later than two hours from the time the QMHP

comes on duty at RCDF, for prisoners classified as high risk. If a

prisoner classified at high risk is set to be released prior to a

QMHP arriving on duty at RCDF, RCDF shall call the local

mobile crisis unit for an on-site assessment prior to release.

e. Appropriate mental health assessments include an assessment of the following factors:
(1) Whether the suicide risk screening indicates low, moderate or high risk; (2) Any suicide attempt in the past; (3) Any suicidal ideations, with intent/plan within the past 30 days; (4) Any command hallucinations to harm self within the past 30 days; (5) Any combination of the following:

1.

Suicidal ideations within the past year with or without intent/plan;

11. Suicidal gestures (current and/or within past year);

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111. One or more ofthe following diagnoses:

a.

Bipolar Disorder, Depression

b.

Maj or Depression with or without Psychotic

Features

c.

Schizophrenia

d.

Schizoaffective Disorder

e.

Any diagnosis within the Pervasive Developmental

Disorder Spectrum

f.

Any other factor(s) determined by the

Interdisciplinary Team as contributing to suicide

risk (e.g. recent loss, family history of suicide, etc.)

(6)

Any history of self-injurious behavior resulting in injury requiring

medical attention within the past year.

f.

Ensure that QMHPs perform an appropriate mental health assessment following

any adverse triggering event while a prisoner remains in RCDF custody,

including any of the following:

(1) Any suicide attempt; (2) Any suicidal ideation, with or without a plan; or (3) Any aggression to self resulting in major injury.

g. Ensure that QMHPs, as part of the prisoner's Interdisciplinary Team, maintain a risk profile for each individual based on the assessment factors identified above and develop and implement interventions to minimize the risk of harm to each individual.

h. Ensure adequate and timely treatment for prisoners, whose assessments reveal mental illness and/or suicidal ideation, including timely and appropriate referrals for specialty care and visits with QMHPs, as clinically appropriate.

1.

Ensure appropriate levels of supervision, as defined above, of actively suicidal

prisoners and prisoners with lower levels of risk. Correctional officers shall

document their checks in a format that does not have pre-printed times and staff

shall document their visual verification of the prisoner's welfare accurately and

completely. A supervisor shall conduct and document a review of all documents

related to this provision before the end of the shift during which it occurred to

ensure compliance with policy and this Agreement.

J.

Set forth the conditions of the watch, including allowable clothing, property, and

utensils, in accordance with generally accepted correctional standards of care.

These conditions shall be altered only on the written instruction of a QMHP,

except under emergency circumstances.

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k. Ensure that a QMHP or QMS, not including a licensed practical nurse, regularly, but no less than once per day, reassesses prisoners on suicide precautions to determine whether the level of precaution or supervision should be raised or lowered. It is expected this reassessment will be made on-site and in person on Monday through Friday, and will be made by a QMHP or QMS by telephone communication with the assistance of a LPN on the weekends. These reassessments shall be documented and recorded in the prisoner's medical chart.

l.

Ensure that all mental health care staff within the Jail have access to critical

information for prisoners on suicide precautions (e.g., progress notes from all

-treating clinicians). Following each assessment, mental health care staff shall

provide correctional staff with pertinent and relevant information regarding a

prisoner on suicide precautions to the extent that it affects the correctional staff's

duties and responsibilities for supervising prisoners on suicide precautions.

m. Ensure that only a QMHP may promote, demote, or terminate a prisoner's suicide precaution level or status. LPNs and correctional officers may only modify suicide precautions or remove prisoners from suicide watch upon the documented order of a QMHP.

n. Ensure that all prisoners discharged from suicide precautions receive a follow-up assessment within eight days, in accordance with a treatment plan developed by aQMHP.

2. Training

a. The County shall ensure that all staff have the adequate knowledge, skill, and ability to address the needs of prisoners at risk for suicide. Within 180 days of the Effective Date, the County will institute a suicide prevention training program. The County shall review and revise its current suicide prevention training curriculum to include the following topics:

(1) suicide prevention policies and procedures (as revised consistent with this Agreement);
(2) analysis of facility environments and why they may contribute to suicidal behavior;
(3) potential predisposing factors to suicide; (4) high-risk suicide periods; (5) warning signs and symptoms of suicidal behavior; (6) case studies of recent suicides and serious suicide attempts; (7) mock demonstrations regarding the proper response to a suicide attempt;
and (8) the proper use of emergency equipment.

b. Ensure that all correctional, medical, and mental health staff are trained on the suicide screening instrument.

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c. Ensure that a minimum of four hours of in-service suicide prevention training is completed annually by all correctional, medical, and mental health staff, to include training on updated policies, procedures, and techniques.
d. Ensure that correctional staff is trained in observing prisoners on suicide watch and step-down unit status.
e. Ensure that all correctional staff are certified in cardiopulmonary resuscitation ("CPR").
f. Ensure that an emergency response bag that includes appropriate equipment, including a first aid kit and emergency rescue tool, shall be in close proximity to all housing units. All staff coming into regular contact with prisoners shall know the location of this emergency response bag and be trained to use its contents.
B. Mental Health Treatment
The County shall ensure that prisoners suffering from mental illness receive treatment appropriate to their condition and adequate to prevent unnecessary suffering or risk of harm. Proper treatment will also assist prisoners in successfully reentering the community upon release. To achieve this outcome, the County shall provide sufficient staffing to meet the demands for timely access to QMHPs and/or QMS and ensure that qualified staff perform comprehensive assessments, provide comprehensive multidisciplinary treatment planning and medication management, and monitor medication side effects.
1. Policies
The County shall implement comprehensive policies and protocols to ensure that RCDP delivers mental health services that include an array of services. These policies and protocols must also provide for necessary and appropriate mental health staff; require a treatment plan for prisoners with serious mental illness; and contain mechanisms sufficient to measure whether care is being provided in a manner consistent with the Constitution. At a minimum, the policies and protocols shall:
a. Ensure that all prisoners are appropriately screened for mental illness using an appropriately validated screening instrument.
b. Ensure that treatment plans adequately address prisoners' serious mental health needs and that the plans contain interventions specifically tailored to the prisoners' diagnoses and problems.
c. Ensure adequate on-site psychiatric coverage for prisoners' serious mental health needs and ensure that psychiatrists see such prisoners in a timely manner.
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d. Ensure that prisoners with chronic mental illness are placed on a chronic mental health list for follow-up every 30,60, or 90 days, as clinically appropriate. Prisoners with chronic mental illnesses shall not be required to submit a request for mental health services in order to receive such services at regular intervals.

e. Ensure timely and appropriate therapy, counseling, and other mental health programs for all prisoners with serious mental illness. This includes adequate space for treatment, an adequate number of QMHPs to provide treatment, access to licensed in-patient psychiatric care when clinically appropriate, and an adequate array of structured therapeutic programming.

f.

Ensure an adequate array of crisis services to appropriately manage the

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

limited to administrative segregation or observation status. Prisoners shall have

access to appropriate licensed in-patient psychiatric care.

g. Ensure that the Jail's QMHPs or QMS maintain a log of prisoners receiving mental health services, which shall include both those prisoners who receive counseling and those who receive medication. The log shall be updated every time a prisoner receives mental health services. The log shall include each prisoner's name, diagnosis or complaint, and next scheduled appointment. Each clinician shall have ready access to a current log listing any prescribed medication and dosages for prisoners on psychotropic medications.

2. Training

a.

Ensure that all mental health staff performing mental health assessments receive

comprehensive training concerning the policies, procedures, and practices for the

delivery of mental health services, including the screening, assessment, and

referral processes.

b.

Ensure that all nurses performing health screenings receive comprehensive

training concerning the policies, procedures, and practices for the mental health

screemng process.

c.

Randomly test five percent of relevant staff on an annual basis to determine their

knowledge of the policies, procedures, and practices for the mental health

screening, assessment, and referral processes. The testing instrument and

policies shall be approved by the United States. The results of these assessments

shall be evaluated to determine the need for changes in training practices. The

review and conclusions will be documented and provided to the IC, the County,

and the United States.

d.

Develop and implement written training protocols in the area of mental health for

correctional staff, including an introductory training provided to new hires,

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which will include training on basic mental health information (e.g., recognizing mental illness, specific problematic behaviors, additional areas of concern); identification, timely referral, and proper supervision of prisoners with serious mental health needs; appropriate responses to behavior symptomatic of mental illness; suicide prevention; and an annual refresher training on relevant topics. The training will be conducted by a QMHP. The County will document and track training and attendance by staff, who must attend the training provided for in this provision in order to continue their employment.

3.

Psychotropic Medication Management

The County shall ensure the accurate administration of psychotropic medication and maintenance of medication records. At a minimum, the County shall:

a. Ensure that prisoners have proper diagnoses made by a psychiatrist, psychologist or medical doctor for each psychotropic medication they receive.

b. Ensure a medication continuity system so that incoming prisoners receive psychotropic medications for serious mental health needs in a timely manner, as medically appropriate.

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

d. Ensure that individuals receiving psychotropic medication are adequately monitored for potential negative side-effects of such medications.

e. Ensure that one unified health record is maintained for each prisoner that includes complete records for both physical and mental health and a complete list of medications the prisoner is taking. The County will also ensure that such unified health records are available to all medical and mental health staff who are necessary to facilitate continuity of care.

4. Use of Restraints

The County shall prevent the unnecessary or excessive use of restraints on prisoners with mental illness or requiring suicide precautions. At a minimum, the County shall:

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a. Develop and maintain comprehensive policies and procedures for the use of restraints for prisoners with mental illness in accordance with generally accepted standards of care.
b. Ensure that a QMHP by preference, and if not available, a QMS provides written approval prior to the use of restraints on prisoners suffering from mental illness or requiring suicide precautions. The QMHP or QMS shall document the basis for and duration of the use of restraints and the performance and results of welfare checks on such restrained prisoners. The parties acknowledge that there may be situations which arise of immediate nature where such prior written approval is not practical for the safety of the inmate, other inmates or the facility staff. In such cases, written approval shall be obtained as soon as practicable and the same documentation obtained.
c. Ensure that restrained mental health prisoners are monitored at least every 15 minutes by a Correctional Officer and further monitored by a Qualified Medical Staff to assess their physical condition every 2 hours.
5. Mental Health Staffing
a. The County shall ensure that the Jail's mental health staffing is sufficient to provide adequate care for prisoners' serious mental health needs, fulfill constitutional mandates and the terms of this Agreement, and allow for the adequate operation of the Jail, consistent with constitutional standards.
b. The County will ensure that all persons providing mental health treatment meet applicable state licensure andlor certification requirements, and practice only within the scope of their training and licensure.
6. Release and Transfer
a. RCDP shall notify a QMS prior to the release or transfer of a prisoner with mental health needs from RCDP custody as soon as information relating to his or her release or transfer becomes available.
b. When a QMS is notified of the release or transfer of a prisoner with mental health needs, the QMS shall prepare and send with the transferring or released prisoner a summary detailing major mental health concerns and listing current medications and dosages, as well as medication history while at RCDP, in order to ensure continuity of care.
c. RCDP shall provide released prisoners with a three day supply of appropriate prescription medication. RCDP shall also provide released prisoners with the contact information for local mental health crisis services and schedule if requested an appointment with a mental health provider in the community andlor will offer to schedule the initial appointment. RCDP shall supply sufficient
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medication for the period of transit for prisoners who are being transferred to another correctional facility or other institution not to exceed a three day supply.

IV. QUALITY IMPROVEMENT AND RISK MANAGEMENT

The County will develop, implement, and maintain a system to ensure that trends and incidents involving restraint use, psychotropic medications, and avoidable suicides and self­ injurious behavior are identified and corrected in a timely manner.

A. Within 90 days of the Effective Date, the County shall develop and implement written Quality Improvement policies and procedures adequate to identify and address serious deficiencies in prisoner suicide prevention and mental health care.

B. Within 90 days of the Effective Date, the County will implement monthly quality assurance mechanisms at the individual and system levels to prevent or minimize harm to prisoners. These quality assurance mechanisms shall track and analyze patterns and trends regarding levels of risk for suicide and self-injurious behavior, restraint and psychotropic medication use and, more generally, the provision of mental health care at RCDF. Each monthly report shall include:

(1) relevant aggregate data, including:

1.

number of incidents related to self-harming behavior, including

suicide gestures, attempts, or completed suicides, and any

purposeful self-injurious act or attempted act that inflicted harm

requiring medical attention or likely would have if completed;

11.

all uses of restraints of prisoners with mental illness, including

instances of self-injurious behavior while restrained, use of

restraints on a prisoner on three or more occasions in a 30-day

period, and single uses of restraints exceeding one hour in

duration;

111.

number of prisoners prescribed psychotropic medications;

IV.

number of prisoners prescribed two or more psychotropic

medications;

v.

the number of prisoners who report having participated in general

mental health/therapy counseling;

vi.

the number of prisoners who have received one-on-one treatment

from the psychiatrist;

V11.

the time elapsed between prisoners' requests for mental health

services and the provision of services by a QMHP or QMS;

V111.

a list of prisoners with chronic mental illnesses, including the

dates prisoners were treated by a QMHP or QMS;

IX.

number of individuals with mental illness who return to RCDF

within 30-60 days.

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

1.

trends and/or patterns regarding the self-harm data (i.e., the

location and shift during which the majority of self-harm

occurred; circumstances surrounding the discovery of the self­

harm; the structures, objects, or instruments used to execute the

self-harm, prisoners frequently engaged in self-harm);

11.

whether prisoners at risk of self-harm are being appropriately

identified for care;

111.

whether incidents of self-harm are increasing or decreasing;

IV.

the severity of incidents of self-harm;

v.

whether restraints are being appropriately used against prisoners

with mental illness;

VI.

whether prisoners are receiving appropriate and adequate mental

health counseling and therapy;

V11.

the timeliness of mental health services provided;

V111.

referrals to outside care;

IX.

whether prisoners with chronic mental illnesses are receiving

mental health services at regular intervals without requesting such

serVIces;

x.

staff counseling and discipline for violating psychotropic

medication policies or restraint use polices; and

Xl.

the effectiveness of interventions undertaken in response to

identified trends from previous months.

(3) Based on these monthly assessments, the County shall recommend and implement changes to policies and procedures.

(4) The Jail shall ensure that all relevant facts and circumstances surrounding serious suicide attempts and completed suicides are investigated and reviewed by a multidisciplinary team, consisting of medical, mental health, and corrections staff. This team shall identify any areas in which staff performance could be improved or jail procedures that need to be adjusted to improve the ability to protect prisoners from self-harm. All reviews shall be documented and shall include the team's findings, concerns, recommendations and remedial actions.

v. REPORTING REQUIREMENTS AND RIGHT OF ACCESS
A. Within 120 days of the Effective Date, the County shall revise and/or develop as necessary other written documents such as screening tools, logs, handbooks, manuals, and forms, to effectuate the provisions of this Agreement. The County shall send newly­ drafted and revised policies and procedures, as they are promulgated, to the United States for review, consultation with the Independent Consultant ("IC"), and approval.

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The County shall provide initial and in-service training to all facility staff with respect to newly implemented or revised policies and procedures. The County shall document employee review and training in policies and procedures. On an annual basis, the County shall review all policies and procedures for the suicide and mental health issues addressed herein and submit them to the United States for review, consultation with the IC, and approval.
B. The County shall submit bi-annual compliance reports to the United States and the IC; the first of which shall be filed within 180 days of the date of this Agreement. Thereafter, the bi-annual reports shall be filed 15 days after the termination of each six­ month period thereafter until the Agreement is terminated. The report shall summarize Quality Improvement and Risk Management activities and contain the findings and recommendations developed in accordance with Section IV above. The report shall also _capture data that is tracked and monitored under the monthly reporting provisions contained in Section IV.
C. The County shall within 24 hours notify the United States upon the death of, or following the serious suicide attempt of, any prisoner. The County shall forward to the IC and the United States incident reports and medical and/or mental health reports related to deaths, autopsies, and/or death summaries of prisoners.
D. Each compliance report shall describe the actions the County has taken during the reporting period to implement this Agreement and shall make specific reference to the Agreement provisions being implemented.
E. The County shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the United States within 48 hours for inspection and copying. In addition, the County shall maintain and provide, upon request, all records or other documents to verify that they have taken such actions as described in their compliance reports (e.g., census summaries, policies, procedures, protocols, training materials, investigations, and inciclent reports).
F. The United States and its attorneys, consultants, and agents shall have umestricted access to the Jail, prisoners, staff, and documents as reasonably necessary to address issues affected by this Agreement.
G. Within 45 days of receipt of written questions from the United States concerning the County's compliance with the requirements of this Agreement, the County shall provide the United States with written answers and any requested documents.
VI. INDEPENDENT CONSULTANT
In order to facilitate implementation of this Agreement, ensure the Agreement is furthering the Parties' goal of providing constitutional mental health care, and reduce costs
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associated with potential disagreements between the Parties, the Parties shall jointly select an Independent Consultant ("IC"). The IC shall provide objective and neutral advice regarding the implementation of the Agreement. Specifically, the IC will provide an assessment ofRCDF's current level of compliance to the Parties through an initial baseline visit to RCDF and annual visits and reports. In addition, the IC shall provide Defendants with technical assistance as requested in order to help Defendants achieve compliance as effectively and efficiently as possible. The IC shall also review the provisions of the Agreement and recommend modifications in the event any provision as drafted does not further the purpose of the Agreement. Finally, because providing constitutional conditions at RCDF also promotes public safety in the wider community, the IC's reports will be made available to the public, as well as to the United States and the Court. The Parties agree that the IC is not an agent of the Court, nor does the IC have any authority to act on behalf of the Court.
A. IC Selection: The parties have jointly selected Lindsay Hayes to serve as the IC. Should the IC position become vacant and the parties cannot agree on a replacement, the parties shall recommend candidates to the Court, and the Court will appoint the IC from the names submitted by the parties. Neither party, nor any employee or agent of either party, shall have any supervisory authority over the IC's activities, reports, findings, or recommendations. The cost for the IC's fees and expenses shall be borne by Defendants. The selection of the IC shall be conducted solely pursuant to the procedures set forth in this Agreement, and will not be governed by any formal or legal procurement requirements. The IC may be terminated only for good cause, umelated to the IC's findings or recommendations, and only with prior notice to, and approval of, the parties acting jointly or by Court order. Should all of the parties agree that the IC is not fulfilling his or her duties in accordance with this Agreement, the parties may petition the Court for the IC's immediate removal and replacement. One party may unilaterally petition the Court for the IC's removal for good cause, and the other parties will have the opportunity to respond to the petition.
B. IC Qualifications: The IC shall have appropriate experience and education or training related to the subject areas covered in this Agreement.
C. IC Access: At a mutually agreeable time at or near the Effective Date, the IC shall visit the Jail to conduct a baseline assessment of the Jail's compliance with this Agreement. The IC shall then visit the Jail annually to conduct a compliance assessment. The Parties anticipate that Defendants may achieve substantial compliance in as little as two years. In order to accelerate termination of this Agreement, however, Defendants may also invite the IC to conduct compliance assessments more frequently than contemplated by this schedule. The IC shall then memorialize his or her findings in a report, described further in paragraphs F and H below. In order to facilitate the IC's visits, the IC shall have full and complete access to the Jail, all Jail records, prisoner medical and mental health records, staff, and prisoners. Defendants shall direct all employees to cooperate fully with the IC. All non-public information obtained by the IC shall be maintained in a confidential manner.
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D. IC Ex Parte Communications: The IC shall be permitted to initiate and receive ex parte communications with all parties.
E. Limitations on Public Disclosures by the IC: Except as required or authorized by the terms of this Agreement or the parties acting together, the IC shall not: make any public statements (at a conference or otherwise) or issue findings, except as required under paragraph F, listed below, with regard to any act or omission of Defendants or their agents, representatives, or employees, or disclose nonpublic information provided to the IC pursuant to this Agreement. Any press statement made by the IC regarding the oversight of this Agreement or his or her employment as IC must first be approved in writing by all parties. The IC shall not testify in any other litigation or proceeding with regard to any act or omission of Defendants or any of their agents, representatives, or employees related to this Agreement, nor testify regarding any matter or subject that he or she may have learned as a result of his or her performance under this Agreement. Reports issued by the IC shall not be admissible against Defendants in any proceeding other than a proceeding related to the enforcement of this Agreement by Defendants or the United States. Unless such conflict is waived by the parties, the IC shall not accept employment or provide consulting services that would present a conflict of interest with the IC's responsibilities under this Agreement, including being retained (on a paid or unpaid basis) by any current or future litigant or claimant, or such litigant's or claimant's attorney, in connection with a claim or suit against Defendants, their departments, officers, agents, or employees. The IC is not a State/County or local agency or an agent thereof, and accordingly the records maintained by the IC shall not be deemed public records subject to public inspection. Neither the IC nor any person or entity hired or otherwise retained by the IC to assist in furthering any provision of this Agreement shall be liable for any claim, lawsuit or demand arising out of the IC's performance pursuant to this Agreement. This provision does not apply to any proceeding before a court related to performance of contracts or subcontracts for oversight of this Agreement.
F. IC's Reports: The IC shall file with the Court and provide the Parties with reports describing the steps taken by Defendants to implement this Agreement and evaluate the extent to which Defendants have complied with each substantive provision of the Agreement. In the report, the IC shall also evaluate whether Defendants' compliance with the substantive provisions of the Agreement has resulted in the achievement of the Agreement's goal of providing constitutional mental health care. The IC shall issue an initial report after the IC's baseline visit, and then within a reasonable time following each compliance visit thereafter. The reports shall be provided to the parties in draft form for comment at least 14 days prior to their issuance. These reports shall be written with due regard for the privacy interests of individual prisoners and staff and the interest of Defendants in protecting against disclosure of non-public information.
G. Assessing Compliance with Goals of Agreement: In order to assess Defendants' progress toward achieving the Agreement's goal of ensuring that RCDF provides prisoners with constitutional mental health care, the IC shall develop qualitative and quantitative outcome measures. The IC shall analyze the data contained in Defendants'
17
Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 17 of 23 PageID #: 57

monthly quality assurance reports produced pursuant to Section IV of this Agreement, as well as other relevant data, to evaluate the constitutionality of RCDF's suicide prevention measures and mental health treatment. The IC shall include the outcome measures used, the data relied upon, and the IC's ultimate conclusions in the IC's report.

H. Assessing Compliance with Agreement Provisions: In the IC's report, the IC shall evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Non­ compliance. In order to assess compliance, the IC shall review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The IC shall be responsible for independently verifying representations from Defendants regarding progress toward compliance and examining supporting documentation. Each IC's report shall describe the steps taken by the IC to analyze conditions and assess compliance, including documents reviewed and individuals interviewed, and the factual basis for each of the IC's findings.

1.

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

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

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

the same purpose. If so, the IC shall identify such provisions to the Parties. Where the

Parties or the IC are uncertain whether a change to the Agreement is advisable, the

Parties may agree to suspend the current Agreement requirement for a time period

agreed upon at the outset of the suspension. During this suspension, the Parties may

agree to temporarily implement an alternative requirement. The IC shall assess whether

the suspension of the requirement, and the implementation of any alternative provision,

is as or more effective at achieving the purpose of the original Agreement requirement

and the Parties shall consider this assessment in determining whether to jointly stipulate

to make the suggested change, modification, or amendment. The Parties shall then

confer and, if necessary, modify the Agreement by mutual consent. The Parties shall

submit any modifications to the Court for its approval.

J. Availability of Reports: The Defendants agree to make the IC's Final Reports, which are filed with the Court, publicly available by electronic means on the Robertson County Sheriff s Office website within 10 days after the Reports are filed.

K. Compliance Coordinator: The Parties agree that the County will assign a current RCSO employee to serve as the RCSO Compliance Coordinator for the duration of this Agreement. The Compliance Coordinator will serve as a liaison between the Defendants and the IC and will assist with the Defendants' compliance with this Agreement. At a minimum, the Compliance Coordinator will: coordinate the Defendants' compliance and implementation activities; facilitate the provision of data, documents, materials, and access to the Defendants' personnel to the IC, the United States, and the public, as needed; ensure that all documents and records are maintained as provided in this Agreement; and assist in assigning compliance tasks to RCSO personnel, as directed by the Sheriff or his designee. The Compliance Coordinator will

18 Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 18 of 23 PageID #: 58

take primary responsibility for collecting information the IC requires to carry out the duties assigned to the IC.
L. IC's Budget: Defendants shall provide the IC with a budget not to exceed $15,000 per year for the first year, which includes the required baseline assessment, and in a yearly amount thereafter to be agreed by the parties to allow the IC to carry out the responsibilities described in this Agreement.
M. Technical Assistance by the IC: The IC shall provide Defendants with technical assistance as requested by Defendants. Technical assistance should be reasonable and should not interfere with the IC's ability to assess compliance. If requested by Defendants, the IC may visit the Jail to provide technical assistance at times other than the baseline and annual compliance visits. The IC may memorialize any technical assistance provided in a letter or report.
VII. ENFORCEMENT
A. During the period that the Agreement is in force, if the IC or the United States determines that Defendants have not made material progress toward substantial compliance with a significant obligation under the Agreement, and such failure constitutes a violation of prisoners' constitutional rights, the United States may initiate contempt or enforcement proceedings for an alleged failure to fulfill an obligation under the Substantive Provisions of this Agreement in Court.
B. During the period that the Agreement is in force, the County will provide the United States with a copy of revised RCDF policies and procedures for review and approval. The United States will review revised policies and procedures within 30 days of submission. The United States reserves the right to withhold consent to any policies or procedures that are inconsistent with this Agreement. The United States will not unreasonably withhold approval. The County will re-submit revised policies or procedures to the United States within 30 days. When disputes arise regarding policies and procedures, the United States may initiate judicial enforcement proceedings.
C. Prior to taking judicial action to initiate contempt or other enforcement proceedings, the United States shall give Defendants written notice of its intent to initiate such proceedings, and the parties shall engage in good-faith discussions to resolve the dispute.
D. The relevant Defendants shall have 30 days from the date of such notice to cure the failure (or such additional time as is reasonable due to the nature of the issue and agreed upon by the parties) and provide the United States with sufficient proof of its cure. At the end of the 30-day period (or such additional time as is reasonable due to the nature of the issue and agreed upon by the parties), in the event that the United States determines that the failure has not been cured, the United States may initiate contempt
19
Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 19 of 23 PageID #: 59

proceedings without further notice. The United States commits to work in good faith with Defendants to avoid enforcement actions.
E. In case of an emergency posing an immediate threat to the health or safety of any prisoner or staff member at the Jail, however, the United States may omit the notice and cure requirements and seek immediate enforcement of the Agreement.
VIII. CONSTRUCTION, IMPLEMENTATION, AND TERMINATION
A. Defendants shall implement all reforms within their areas of responsibility, as designated within the provisions of this Agreement. The implementation of this Agreement will begin immediately upon the Effective Date.
B. Except where otherwise agreed to under a specific provision of this Agreement, Defendants shall implement all provisions of this Agreement within 180 days of the Effective Date.
C. The Court shall retain jurisdiction of this action for all purposes until the County has achieved substantial compliance with each provision of the Agreement, provides constitutional mental health care to prisoners, and has maintained substantial compliance and provided constitutional mental health care for a period of one year.
D. Failure by any party to enforce this entire Agreement or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreement.
E. If any unforeseen circumstance occurs that causes a failure to comply with any requirements of this Agreement in a timely manner, Defendants shall notify the United States in writing within ten days after Defendants become aware of the unforeseen circumstance and its impact on the Defendant's ability to perform under the Agreement. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. Defendants shall implement all reasonable measures to avoid or minimize any such failure.
F. The Agreement 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 its fees and expenses incurred in connection with this cause.
H. If any provision of this Agreement is declared invalid for any reason by a court of competent jurisdiction, said finding shall not affect the remaining provisions of this Agreement.
20
Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 20 of 23 PageID #: 60

WK$SULO [[[[ Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 21 of 23 PageID #: 61


AGREED TO BY THE UNDERSIGNED: Dated this _ _ _ _ _ day of--.J~~~_ _, 2013. FOR THE UNITED STATES:
Deputy Chief Special Litigation Section
Attorney Special Litigation Section U.S. Department of Justice 950 Pennsylvania Ave, NW Washington, DC 20530 Tel: (202) 514-6255
22 Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 22 of 23 PageID #: 62

FOR ROBERTSON COUNTY: Robertson County Mayor BILL HOLT Robertson County Sheriff
C~~~IC~HE~ Robertson County Attorney Richert & Dilliha, PLLC
23 Case 3:13-cv-00392 Document 4 Filed 04/30/13 Page 23 of 23 PageID #: 63

 
 U.S. District Court Middle District of Tennessee (Nashville) CIVIL DOCKET FOR CASE #: 3:13−cv−00392

CASE−CLOSED

United States of America v. Robertson County et al Assigned to: District Judge William L. Campbell, Jr Cause: 42:1997 Civil Rights of Institutionalized Persons Act
Plaintiff

Date Filed: 04/26/2013 Date Terminated: 04/30/2013 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by William Maddox U. S. Department of Justice Special Litigation Section 950 Pennsylvania Avenue, NW Washington, DC 20530 (202) 514−6255 Email: william.maddox@usdoj.gov ATTORNEY TO BE NOTICED

V. Defendant Robertson County
Defendant Howard Bradley County Mayor
Defendant Robertson County Commissioners
Defendant Bill Holt Robertson County Sheriff

represented by Clyde Western Richert , III 516 S Main Street Springfield, TN 37172−2815 (615) 384−8774 Fax: (615) 384−6708 Email: crichert@r−dlaw.net ATTORNEY TO BE NOTICED
represented by Clyde Western Richert , III (See above for address) ATTORNEY TO BE NOTICED
represented by Clyde Western Richert , III (See above for address) ATTORNEY TO BE NOTICED
represented by Clyde Western Richert , III (See above for address) ATTORNEY TO BE NOTICED

Date Filed 04/26/2013
04/26/2013 04/26/2013

# Docket Text
1 COMPLAINT against Howard Bradley, Bill Holt, Robertson County, Robertson County Commissioners, filed by United States of America. (Attachments: # 1 Civil Cover Sheet)(dt) (Entered: 04/26/2013)
2 JOINT MOTION to Enter Settlement Agreement by United States of America. (Attachments: # 1 Proposed Settlement Agreement)(dt) (Entered: 04/26/2013)
Bar status for attorney William Maddox of DC verified as active this date. (dt) (Entered: 04/26/2013)

Case: 3:13-cv-392 As of: 06/29/2018 03:00 PM CDT 1 of 3

04/26/2013

3 NOTICE of Initial Case Management Conference set for 6/10/2013 at 12:00 Noon before Magistrate Judge Juliet E. Griffin. (dt) (Entered: 04/26/2013)

04/30/2013

4 ORDER: The parties stipulate that this Agreement complies in all respects with the provisions of 18 U.S.C. 3626(a). The parties further stipulate and agree and the Court finds that the prospective relief in this Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights as alleged by the United States in its Complaint and Findings Letter, is the least instrusive means necessary to correct these violations, and will not have an adverse impace on public safety or the operation of a criminal justice system. Accordingly, the parties agree and represent tht the Agreement complies in all respects with the provisions of 18 U.S.C. 3626(a). Signed by District Judge Kevin H. Sharp on 4/30/13. (DOCKET TEXT SUMMARY ONLY−ATTORNEYS MUST OPEN THE PDF AND READ THE ORDER.)(afs) (Entered: 04/30/2013)

07/01/2013

5 STATUS REPORT First Status Report 4.30.2013 by United States of America. (Attachments: # 1 Attachment Status Report)(Maddox, William) (Entered: 07/01/2013)

03/06/2014

6 STATUS REPORT Second Status Report by United States of America. (Attachments: # 1 Attachment 2nd Status Report)(Maddox, William) (Entered: 03/06/2014)

01/29/2015

7 STATUS REPORT Third Status Report by United States of America. (Attachments: # 1 Attachment Third Status Report)(Maddox, William) (Entered: 01/29/2015)

04/16/2015

8 STATUS REPORT Fourth Status Report by United States of America. (Attachments: # 1 Attachment Fourth Status Report)(Maddox, William) (Entered: 04/16/2015)

11/30/2015

9 STATUS REPORT Fifth Compliance Report by United States of America. (Attachments: # 1 Exhibit Fifth Compliance Report)(Maddox, William) (Entered: 11/30/2015)

12/12/2016 10 STATUS REPORT Sixth Status Report by United States of America. (Attachments: # 1 Attachment Sixth Status Report)(Maddox, William) (Entered: 12/12/2016)

03/31/2017

11 STATUS REPORT Seventh Monitoring Report by United States of America. (Attachments: # 1 Exhibit Seventh Monitoring Report)(Maddox, William) (Entered: 03/31/2017)

09/25/2017 12 STATUS REPORT Eighth Status Report by United States of America. (Attachments: # 1 Attachment Eighth Monitoring Report)(Maddox, William) (Entered: 09/25/2017)

03/14/2018

13 STATUS REPORT 9th and Final Monitor's Report by United States of America. (Attachments: # 1 Exhibit 9th and Final Monitor's Report)(Maddox, William) (Entered: 03/14/2018)

05/25/2018

14 Joint MOTION to Dismiss and Proposed Order by United States of America. (Attachments: # 1 Attachment Joint Motion for Final Dismissal and Proposed Order)(Maddox, William) (Entered: 05/25/2018)

05/29/2018

District Judge William L. Campbell, Jr added for consideration of the Joint Motion filed at DE 14 . Judge Kevin H. Sharp no longer assigned to case. (af) (Entered: 05/29/2018)

05/29/2018

Notice to Filer re DE 14 : Pursuant to Local Rule 5.01, all filings shall include a Certificate of Service and it shall identify by name the person served, what was served, the method of service, and date of service. Counsel SHALL FILE a conformed Certificate of Service for this document using the Certificate event located under Other Documents. (am) (Entered: 05/29/2018)

05/30/2018

15 Joint Motion to Dismiss and Proposed Order by United States of America. (Attachments: # 1 Attachment Joint Motion For Final Dismissal and Proposed Order)(Maddox, William) Modified Text on 5/30/2018 (am). (Entered: 05/30/2018)

05/30/2018

16 ORDER: The parties filed a Joint Motion for Order of Final Dismissal (Doc. Nos. 14, 15), indicating that all matters in dispute have been resolved. Accordingly, this action is DISMISSED, with prejudice, and the Clerk is directed to close the file. This Order shall constitute the final judgment in this case under Fed. R. Civ. P. 58. Signed by District Judge William L. Campbell, Jr on 5/30/2018. (am) (Entered: 05/30/2018)

Case: 3:13-cv-392 As of: 06/29/2018 03:00 PM CDT 2 of 3

05/30/2018 17 ENTRY OF JUDGMENT re: 16 Order. (am) (Entered: 05/30/2018) Case: 3:13-cv-392 As of: 06/29/2018 03:00 PM CDT 3 of 3

 
 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF TENNESSEE

UNITED STATES OF AMERICA,

)

)

PLAINTIFF,

)

)

v.

)

)

ROBERTSON COUNTY;

)

HOWARD BRADLEY, COUNTY MAYOR,

)

in his official capacity; ROBERTSON COUNTY )

COMMISSIONERS, in their official capacity; )

BILL HOLT, ROBERTSON COUNTY SHERIFF, )

in his official capacity;

)

)

DEFENDANTS.

)

__________________________________________)

CIVIL ACTION NO: 3:13-cv-00392

COMPLIANCE REPORT PLAINTIFF, THE UNITED STATES OF AMERICA, hereby files the Eighth Compliance Report.

Respectfully submitted,

/s/ William G. Maddox WILLIAM G. MADDOX Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave, NW Washington, D.C. 20530 (202) 514-6255
1

Case 3:13-cv-00392 Document 12 Filed 09/25/17 Page 1 of 1 PageID #: 450

Settlement Agreement Between the United States Department of Justice and Robertson County, Tennessee, 8th Monitoring Report
Summary
The following is an abbreviated summary of the most recent on-site assessment by the Independent Consultant in the Settlement Agreement Between the United States Department of Justice and Robertson County, Tennessee. The on-site assessment occurred during the two-day period of May 2-3, 2017. As discussed during the exit debriefing on May 3, the Independent Consultant’s on-site assessment was divided into the following four (4) categories:
1) Review of medical charts of six (6) inmates placed on, and discharge from, suicide precautions during the assessment period. With one exception, the review found that all required documentation was completed as required. The exception was the case of Inmate HD, who entered the RCDF on February 5, 2017 and was placed on suicide precautions two weeks later on February 20, 2017. The inmate had been placed on suicide precautions during a previous RCDF confinement from July 8 through July 11, 2016. Contrary to the Settlement Agreement and RCDF/SHP policies, the inmate was not referred to mental health staff by either correctional officers or nursing staff upon her February 5 admittance. In addition, despite the fact that the inmate was subsequently placed on suicide precautions for three days from February 20 through February 22, 2017, the mental health clinician suggested in the medical chart that “no treatment plan was indicated.”
The Independent Consultant recommended that RCDF and SHP officials develop a corrective action plan ensure that all inmates placed on suicide precautions during a prior RCDF confinement be referred to the QMHP for further assessment upon intake. In addition, any inmate on suicide precautions for more than 24 hours is required to have a treatment plan developed to reduce future suicidal ideation.
2) Review of 43 medical charts of inmates placed on the Mental Health Chronic Care List during the assessment period. The review found that timely assessments (both initial and/or follow-up QMHP and psychiatric) were provided in 93 percent (40 of 43) of the cases.
3) Review of data regarding the provision of group therapy treatment at the RCDF from January through April 2017. The data indicated there were approximately 218 inmates scheduled for group treatment during the time period, but only 56 percent (117 of 208) of inmates attended the schedule groups. There were various explanations for the low attendance rate, including scheduling groups during the early morning hours, scheduling groups that conflicted with other activities, availability of escort staff, allegation that certain correctional officers were discouraging inmate participation, and inmates’ general lack of interest.
The Independent Consultant recommended that RCDF and SHP further explore ways to increase group attendance, including finding alternate times/venue, increasing availability of escort officers, as well as determining whether any correctional officers are deterring inmates from attending group (e.g., determining whether certain housing units are responsible for higher group attendance rates).
Case 3:13-cv-00392 Document 12-1 Filed 09/25/17 Page 1 of 2 PageID #: 451

4) Review of all documentation regarding the suicide of Jerry Barlow that occurred in the RCDF March 9, 2017. The inmate did not have a history of suicidal behavior and there was no evidence to suggest that RCDF or SHP were aware that he was currently suicidal. The review found that, with one exception, there were no deficiencies noted. The exception was that correctional officers failed to conduct a security check within 40 minutes of the inmate being found hanging. The Independent Consultant recommended that the subsequent Mortality Review report be revised to include the date of the Committee’s review, as well as note the above security check violation. The Mortality Review report was revised and provided to the Independent Consultant on May 2, 2017. Conclusion There are 48 provisions to the Settlement Agreement, including 21 for Suicide Prevention, 25 for Mental Health Treatment, and 2 for Quality Improvement and Risk Management. Consistent with the findings from the previous assessment (in December 2016), all 48 provisions remain in Substantial Compliance. Pending one final on-site assessment, the Agreement remains on schedule to be successfully completed in August 2017. Submitted by: Lindsay M. Hayes, Independent Consultant June 5, 2017
Case 3:13-cv-00392 Document 12-1 Filed 09/25/17 Page 2 of 2 PageID #: 452

 
 Settlement Agreement Between the United States Department of Justice and Robertson County, Tennessee
3rd Monitoring Report
Submitted by:
Lindsay M. Hayes, Independent Consultant
May 31, 2014
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2
Introduction
In October 2010, the United States Department of Justice (USDOJ)’s Civil Rights Division (Special Litigation Section) conducted an investigation regarding alleged inadequate conditions of confinement within the Robertson County Detention Facility (RCDF) in Springfield Tennessee. The investigation resulted in a Findings Letter issued on August 26, 2011 alleging that the “RCDF’s mental health practices place prisoners at a substantial and unreasonable risk of serious harm. Shortly thereafter, the USDOJ and Robertson County began to negotiate a settlement agreement that eventually was finalized and became effective upon the signature of United States District Court Judge Kevin H. Sharp on April 30, 2013. According to the Settlement Agreement, “From the beginning, and continuing through the United States’ investigation of conditions of confinement at RCDF, Defendants have acted expeditiously to begin addressing concerns the United States has raised with respect to conditions at RCDF, including concerns related to the provision of mental health care. This Agreement memorializes the actions that Defendants will implement to address the United States’ findings related to mental health care.”
Even prior to the effective date of the Agreement, Robertson County officials expressed a strong desire to begin complying with provisions of the Agreement and requested that this writer, jointly chosen by the parties to be the Independent Consultant, conduct an on-site baseline assessment to determine the current level of compliance. That assessment was conducted in late February 2013 and resulted in the 1st Monitoring Report dated April 30, 2013. A second abbreviated site visit was conducted on October 30, 2013, resulting in the 2nd Monitoring Report dated January 28, 2014.
Monitoring Compliance with the Settlement Agreement
There are 48 provisions to this Settlement Agreement, including 21 for Suicide Prevention, 25 for Mental Health Treatment, and 2 for Quality Improvement and Risk Management. Pursuant to the Agreement, the following definitions are utilized to measure compliance with each provision:
Substantial Compliance indicates that defendants have achieved compliance with most or all components of the relevant provision of the Agreement for both the quantitative (i.e., 90% performance measure) and qualitative (i.e., consistent with the larger purpose of the Agreement) measures.
Partial Compliance indicates that compliance has been achieved on some of the components of the relevant provision of the Agreement, but significant work remains.
Non-Compliance indicates that most or all of the components of the Agreement provision have not yet been met.
According to the Agreement, “the Court shall retain jurisdiction of this action for all purposes until the County has achieved substantial compliance with each provision of the Agreement,
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3

provides constitutional mental health care to prisoners, and has maintained substantial compliance and provided constitutional mental health care for a period of one year.”
This report is formatted to present each provision, followed by the provision’s current status or rating (substantial, partial, or non-compliance) as determined by the Independent Consultant, a discussion section which provides justification for each rating, recommendations offered to raise each status to substantial compliance, and the evidentiary basis utilized in monitoring each provision.

Third Site Visit

The Independent Consultant conducted the third on-site visit to the Robertson County Detention Facility (RCDF) on April 30-May 1, 2014. The site visit included an initial meeting with the Sheriff, his Administrative Assistant, and the RCDF Administrator, as well as subsequent discussions with the RCDF Administrator, Southern Health Partners (SHP) Vice President of Operations, Medical Team Administrator (MTA), Qualified Mental Health Professional (QMHP), and Psychiatrist. In addition, numerous medical charts of inmates on the suicide precautions and chronic care lists for serious mental illness from January 2014 to April 2014 were reviewed. The intake screening process conducted by RCDF booking staff was also observed. Further, various draft policies and procedures, and other documents generated to show compliance with provisions of this Agreement, were reviewed. Finally, the Independent Consultant met with the RCDF Administrator and several Robertson County maintenance personnel to review requirements for protrusion-free cells for inmates on suicide precautions. A debriefing was held during the late afternoon of May 1 that included the Sheriff, his Administrative Assistant, and the RCDF Administrator.
As shown in the table below, Robertson County has made meaningful progress during the past six months, resulting 14 provisions now in Substantial Compliance (increase from 3 in October 2013), 30 provisions now in Partial Compliance (decrease from 45 in October 2013), and no provisions in Non-Compliance.

Substantive Area
Suicide Prevention Mental Health Quality Improvement TOTAL

Total Provisions
21 25 2 48

Substantial Compliance

# %

14 67%

4 16%

-

-

18 37%

Partial Compliance # % 7 33% 21 84% 2 100% 30 63%

NonCompliance

# %

-

-

-

-

-

-

-

-

Finally, as noted on the final page of this report (as well as in previous reports), to assist in expediting achievement of substantial compliance with each provision of this Settlement Agreement, it is strongly recommended that RCDF and SHP officials continue to meet on at least a monthly basis regarding the recommendations contained herein and provide a monthly report to the Independent Consultant regarding status of compliance with each provision.

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4

THE SETTLEMENT AGREEMENT: Substantive Provisions

The County shall take all actions necessary to comply with the substantive provisions of this Agreement listed below. These provisions are intended to ensure that prisoners with mental illness or at risk of suicide receive proper treatment and do not experience unnecessary suffering or harm while incarcerated. The failure to provide necessary treatment not only harms prisoners, but affects public safety if prisoners’ mental health deteriorates during incarceration. Accordingly, the County shall ensure constitutionally adequate intake, assessment, treatment, and monitoring of prisoners with mental health needs or at risk for self-injurious behavior.
A. SUICIDE PREVENTION
The County shall protect the safety of prisoners at risk for self-injurious behavior or suicide by providing timely and adequate access to Qualified Mental Health Professionals, including giving priority access to individuals most at risk of harm and who otherwise meet the criteria for being at high risk for suicide.

Provision A.1
Status Discussion

Policies: The County shall implement comprehensive policies and protocols to ensure that prisoners at risk of self harm are identified, protected, and treated in a manner consistent with the Constitution. The County shall continuously track and analyze prisoners’ risk of self harm and implement measures to protect prisoners by reducing or eliminating the risk of harm. At a minimum, the policies and protocols shall:
Partial Compliance
This provision is interpreted as a “catch-all” provision for all suicide prevention-related provisions, therefore, this provision cannot come into substantial compliance until all of the provisions under Suicide Prevention come into substantial compliance.

Following several draft revisions, the Southern Health Partners’ (SHP) suicide prevention policy for the RCDF (No. J-G-05) was finalized on March 17, 2014. As discussed in previous reports, the SHP policy needed to be slightly revised based upon the requirements of the Settlement Agreement.

Recommendations

In early January 2014, following several efforts by RCDF officials to develop an adequate suicide prevention policy and in an effort to expedite the process, the Independent Consultant developed the policy based upon earlier drafts. The revised policy was forwarded back to RCDF officials and also finalized on March 17, 2014.
None

Evidentiary

RCDF’s Suicide Prevention Policy, effective March 17, 2014.

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Basis

5
SHP’s Suicide Prevention Policy for the RCDF (No. J-G-05), effective March 17, 2014.

Provision A.1.a
Status Discussion

Ensure that all prisoners are appropriately screened for risk of self harm using an appropriately validated screening instrument. At a minimum, the screening instrument should include inquiry regarding the following:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as the death of a family member or
close friend; (5) history of suicidal behavior by family members and close
friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court,
transferring agency, or similar individuals regarding the prisoner’s potential suicide risk; (8) medication history; and (9) risk of withdrawal from drugs or alcohol, including whether the prisoner is under the influence of drugs or alcohol, the amounts taken, the date of last dose and history of withdrawal symptoms.
Substantial Compliance
The RCDF Intake Screening form administered by booking officers was revised to include inquiry regarding “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” (see above). In addition, an “Arresting Officer’s Questionnaire” was created to solicit information regarding a detainee’s mental status and potential for suicide risk upon admission into the RCDF. Further, booking officers are said to now utilize the “alert screen” of RCDF’s jail management system “XJail” software to determine if the newly admitted detainee was on suicide precautions during a prior RCDF confinement.
Finally, a critical issue to the appropriate screening of incoming detainees to identify the risk of suicide is the ability to provide reasonable privacy and confidentiality during the intake screening process. (Inmates cannot be expected to affirmatively respond to sensitive medical and mental health inquiries if reasonable privacy is not provided.)
As a result of the 1st Monitoring Report findings, the RCDF Administrator reconfigured the booking area so that the intake screening process is now

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6

conducted away from the booking counter and located next to the fingerprint machine on the back wall. Such a change better ensures confidentiality and privacy.

Recommendations

The Independent Consultant observed the intake process during this on-site assessment and verified that all of the above changes were made. As such, this provision is moved to Substantial Compliance.
None

Evidentiary Basis

Observation of Intake Process RCDF Intake Screening Form Arresting Officer’s Questionnaire XJail-jail management system software

Provision A.1.b
Status Discussion

Ensure that all prisoners are screened by Qualified Medical Staff upon arrival to RCDF, but no later than within 24 hours, to identify the prisoner’s risk for suicide or self-injurious behavior. If a prisoner will be discharged in less than 24 hours, Qualified Medical Staff should perform a screening prior to the prisoner’s release.
Substantial Compliance
According to SHP officials, a previous deficiency of health care staff not routinely completing the Suicide Prevention Screening Guidelines form on all new detainees has been corrected. Currently, each new detainee is required to be screened by either a nurse or QMHP within 24 hours of admission.

Recommendations

The Independent Consultant reviewed medical charts of newly admitted inmates in April 2014 and verified that Suicide Prevention Screening Guidelines forms were completed by nursing staff on a timely basis. As such, this provision is moved to Substantial Compliance.
None

Evidentiary Basis

Review of medical charts

Provision A.1.c Status
Discussion

Classify prisoners based on the results of the screening factors as low, moderate, or high risk.
Substantial Compliance
Both the RCDF and SHP’s suicide prevention policies have been revised to include the following three levels of observation:

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7

Level 1 requires constant observation for those inmates identified as being at high risk for suicide based upon “an overt attempt of a serious nature and have stated they will continue to attempt. These persons may also present psychotic symptoms and are deemed an immediate danger to themselves or others.”

Level 2 requires close observation at 15 minute intervals and can be said to be reserved for inmates identified as being at moderate risk for suicide based upon “presenting suicidal intention or have made a suicide threat or have made a suicide gesture or plan. These persons are not psychotic.”

Level 3 requires psychiatric observation at 30-minute intervals and can be said to be reserved for inmates “who were not presenting suicidal intent or plan, but may have a history of severe to moderate mental illness and require observation and possibly medical stabilization before being moved into a housing unit.”

As such, this provision is moved to Substantial Compliance. Recommendations None

Evidentiary Basis

RCDF’s Suicide Prevention Policy, effective March 17, 2014.
SHP’s Suicide Prevention Policy for the RCDF (No. J-G-05), effective March 17, 2014.

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Provision A.1.d
Status Discussion

8
Ensure that prisoners are protected from identified risks for suicide or self-injurious behavior commensurate with their level of risk by:
(1) Ensuring that any prisoner classified as high risk is searched and monitored with constant supervision until the prisoner is transferred to a QMHP for assessment. Constant supervision means in-person observation of the prisoner on a continuous, uninterrupted basis. Other aids, e.g., closed-circuit television, can be used as a supplement to, but never as a substitute for, such observation. If RCDF cannot provide continuous observation, the prisoner should be transferred to an appropriate mental health facility.
(2) Ensuring that any prisoner classified as moderate risk is searched and monitored with close supervision until the prisoner is transferred to a QMHP for assessment. Close supervision requires staff to observe prisoners at staggered intervals not to exceed every 15 minutes.
(3) Ensuring that any prisoner classified as low risk is searched and monitored until the prisoner is transferred to a QMHP for assessment. Prisoners classified as low risk shall be observed by staff at staggered intervals not to exceed every 30 minutes.
(4) Ensuring that a QMHP conducts appropriate mental health assessments within the following periods from the initial screen:
i. 14 days, or sooner, if medically necessary, for prisoners classified as low risk;
ii. 48 hours, or sooner, if medically necessary, for prisoners classified as moderate risk; and
iii. immediately, but no later than two hours from the time the QMHP comes on duty at RCDF, for prisoners classified as high risk. If a prisoner classified at high risk is set to be released prior to a QMHP arriving on duty at RCDF, RCDF shall call the local mobile crisis unit for an on-site assessment prior to release.
Substantial Compliance
Similar to the provision above (A.1.c), this provision had previously remained in partial compliance because the RCDF and SHP suicide prevention policies were in need of revision and the QMHP had only been recently hired in October 2013. In addition, this provision required a protocol pertaining to the assessment of inmates on suicide precautions prior to their release from

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Recommendations

custody. Because both policies have been revised and the QMHP is fully acclimated into the program, this provision is moved to Substantial Compliance.
None

Evidentiary Basis

RCDF’s Suicide Prevention Policy, effective March 17, 2014.
SHP’s Suicide Prevention Policy for the RCDF (No. J-G-05), effective March 17, 2014.

Provision A.1.e
Status

Appropriate mental health assessments include an assessment of the following factors:
(1) Whether the suicide risk screening indicates low, moderate or high risk;
(2) Any suicide attempt in the past; (3) Any suicidal ideations, with intent/plan within the past 30
days; (4) Any command hallucinations to harm self within the past 30
days; (5) Any combination of the following:
i. Suicidal ideations within the past year with or without intent/plan;
ii. Suicidal gestures (current and/or within past year); iii. One or more of the following diagnoses:
a. Bipolar Disorder, Depression b. Major Depression with or without Psychotic
Features c. Schizophrenia d. Schizoaffective Disorder e. Any diagnosis within the Pervasive
Developmental Disorder Spectrum f. Any other factor(s) determined by the
Interdisciplinary Team as contributing to suicide risk (e.g. recent loss, family history of suicide, etc.)
(6) Any history of self-injurious behavior resulting in injury requiring medical attention within the past year.
Partial Compliance

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Discussion

As detailed in the previous report, pursuant to SHP policy, two instruments are available as mental health assessments: a Mental Health Survey and a Psychiatric Nursing Initial Assessment form. In practice at the RCDF, however, the Mental Health Survey is rarely utilized. Upon initial referral, the QMHP often completes an Psychiatric Nursing Initial Assessment. The form lists most of the required factors listed within this provision, although they are not specifically identified.

Recommendations

Substantial compliance can be achieved with slight revision of the Psychiatric Nursing Initial Assessment form to include specific reference to the required factors referenced in this provision. During this recent site visit, the Independent Consultant reviewed and approved a revised Psychiatric Nursing Initial Assessment. The form will be audited during the next on-site visit.
None

Evidentiary Basis

Revised Psychiatric Nursing Initial Assessment form.

Provision A.1.f
Status Discussion
Recommendations

Ensure that QMHPs perform an appropriate mental health assessment following any adverse triggering event while a prisoner remains in RCDF custody, including any of the following:
(1) Any suicide attempt; (2) Any suicidal ideation, with or without a plan; or (3) Any aggression to self resulting in major injury.
Substantial Compliance
The QMHP was hired in October 2013 and a recent review of medical charts indicated assessments were conducted following any of the above listed triggering events.
None

Evidentiary Basis

Review of medical charts.

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Provision A.1.g Status Discussion
Recommendations

Ensure that QMHPs, as part of the prisoner’s Interdisciplinary Team, maintain a risk profile for each individual based on the assessment factors identified above and develop and implement interventions to minimize the risk of harm to each individual.
Substantial Compliance
With the hiring of a QMHP in October 2013, the RCDF now has an “interdisciplinary team” comprised of the Medical Team Administrator (MTA), RCDF Administrator, and Security Captain that meets on a minimum weekly basis to discuss inmates on suicide precaution, as well as other inmates requiring special handling. As such, this provision is moved to Substantial Compliance.
None

Evidentiary Basis

Review of medical charts.

Provision A.1.h
Status Discussion

Ensure adequate and timely treatment for prisoners, whose assessments reveal mental illness and/or suicidal ideation, including timely and appropriate referrals for specialty care and visits with QMHPs, as clinically appropriate.
Partial Compliance
With the hiring of a QMHP in October 2013, inmates identified as either mentally ill and/or suicidal are now much more likely to receive timely assessments.
However, review of the 10 medical charts of inmates on suicide precautions during the recent assessment found that inmates discharged from such precautions did not have a reasonably comprehensive suicide risk assessment documented in the discharging progress note. The standard of care requires that documentation of a comprehensive assessment of suicide risk include sufficient description of the current behavior and justification for either, placement on, or discharge from, suicide precautions. For example, the assessment should include a brief mental status examination, listing of chronic and acute risk factors, listing of any protective factors, level of suicide risk (e.g., low, medium, or high), and a treatment plan. A Suicide Risk Assessment should be completed when an inmate is placed on, and discharge from, suicide precautions. A sample “Suicide Risk Assessment” form is contained in the appendix of this report.
The issue as to whether or not inmates with serious mental illness are receiving timely referrals to the psychiatrist, as well as whether the

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Recommendations
Evidentiary Basis

psychiatrist is consistently devoting sufficient time per month on-site, will be addressed in Provisions B.1.c and B.1.d of this report.
1) Whenever an inmate is placed on, and discharged from, suicide precautions, the QMHP should complete a suicide risk assessment that includes a sufficient description of the current behavior and justification for either, placement on, or discharge from, suicide precautions, as well as a brief mental status examination, listing of chronic and acute risk factors, listing of any protective factors, level of suicide risk (e.g., low, medium, or high), and a treatment plan. A sample “Suicide Risk Assessment” form is contained in the appendix.
Review of medical charts.

Provision A.1.i
Status Discussion
Recommendations

Ensure appropriate levels of supervision, as defined above, of actively suicidal prisoners and prisoners with lower levels of risk. Correctional officers shall document their checks in a format that does not have preprinted times and staff shall document their visual verification of the prisoner’s welfare accurately and completely. A supervisor shall conduct and document a review of all documents related to this provision before the end of the shift during which it occurred to ensure compliance with policy and this Agreement.
Substantial Compliance
A previous concern that various observation forms were utilized by correctional officers to verify observation of an inmate on suicide precautions has been corrected with current use of only the SHP’s “Observation Cell Record” form. As verified by the Independent Consultant during the most recent site visit, the forms are now reviewed and signed by a RCDF supervisor each shift.
None

Evidentiary Basis

Review of “Observation Cell Record” forms.

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Provision A.1.j
Status Discussion

13
Set forth the conditions of the watch, including allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a QMHP, except under emergency circumstances.
Partial Compliance
This provision is interpreted to include not only the policy, procedures, and practices regarding allowable clothing, property, and utensils afforded inmates placed on suicide precautions, but (as noted above, “consistent with generally accepted correctional standards of care”) also the location in which they are housed and the expectation that they will be housed in cells that are “suicide resistant.”
Suicidal inmates are placed in several locations within the RCDF: 1) inmates requiring Level 1 constant observation or Level 2 close observation are placed in either Cell No. 5 or Cell No. 6 in the medical unit; 2) inmates requiring Level 2 close observation are placed in any of the nine (9) booking cells. In addition, inmates requiring Level 3 psychiatric observation are placed in one of the four (4) observation/isolation cells.
During the initial site visit in late February 2013, the Independent Consultant inspected each of these cell areas and found that the ceiling ventilation grates in all of the booking cells, as well as the observation/isolation cells, contained holes with a diameter greater than the industry standard of 3/16 per inch. Ventilation grates with this diameter allow for an inmate to weave a piece of clothing or other material through the grate hole and utilize the vent as an anchoring device in a hanging attempt. Within the medical unit, the designated cells contained double bunks in which the metal frames also served as potential anchoring devices in a hanging attempt, as well as contained bunk holes that could be easily be utilized as an anchoring device.
Following issuance of the 1st Monitoring Report in April 2013, the RCDF Administrator embarked upon a program to retrofit cells that were designated for suicide precautions. The result was removal of double bunks in the medical unit, covering of bunk holes, and replacement of ceiling ventilation grates. Various photographs of the renovation project were subsequently sent to the Independent Consultant for review. Inspection of the photographs found that although bunk holes had been covered from the bunks, there still appeared to be a significant gap between the bunk frame and the wall that could be utilized as an anchoring point in a suicide attempt by hanging. In addition, although the holes in the new ventilation grates appeared to be smaller in diameter, it was difficult to ensure that the holes were the industry standard of 3/16 per inch or smaller in diameter from review of the photographs. On September 15, 2013, an inmate on Level 2 suicide precautions was able to weave a piece of his sheet through the ventilation

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14

grate in his cell. As a result, the RCDC Administrator ordered that the ventilation grates be replaced again.

During the Independent Consultant’s recent site visit, the renovation project was inspected once again with the CDF and personnel from the Robertson County Maintenance Department. The inspection found that Cell No. 5 or Cell No. 6 in the medical unit still contain a gap between the bed and wall, as well as ventilation grates with holes that are larger than 3/16 inch diameter that could (and have been) utilized as an anchoring point in a suicide attempt by hanging. In addition, inspection of the nine (9) booking cells found that although one ceiling ventilation grate in each cell has been replaced with a grate of 3/16 inch diameter, the second grate in each cell remains dangerous and needs to be replaced.

Recommendations

In addition, both RCDF and SHP policies require that “all inmates on suicide precautions shall be allowed all routine privileges (e.g., family visits, telephone calls, recreation, etc.). In the recent review of medical charts, the Independent Consultant found one case that was potentially problematic in that, according to the QMHP progress note, the inmate “requested if I can move him to a medical watch so that he can use phone to call his mother.” If accurate, such a practice violates RCDF and SHP policies, as well as the provisions of this Settlement Agreement.
1) The gap between the bunk frame and the wall in each medical unit cell designated to house inmates on suicide precautions should be covered to ensure that the frame is not utilized as an anchoring device. Ventilation grates in both medical unit and booking cells should be replaced with grates that are no larger than 3/16 of an inch in diameter.

Evidentiary Basis

2) Conditions of suicide precautions should only be based upon the QMHP’s clinical judgment and current procedures contained within the RCDF and SHP suicide prevention policies should be followed. These procedures require a QMHP to determine the conditions of an inmate’s suicide precautions (e.g., clothing, possessions, privileges, etc.) on a case-by-case basis.
Inspection of cells within the medical unit and booking area. Review of medical charts.

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Provision A.1.k
Status Discussion

Ensure that a QMHP or QMS, not including a licensed practical nurse, regularly, but no less than once per day, reassesses prisoners on suicide precautions to determine whether the level of precaution or supervision should be raised or lowered. It is expected this reassessment will be made on-site and in person on Monday through Friday, and will be made by a QMHP or QMS by telephone communication with the assistance of a LPN on the weekends. These reassessments shall be documented and recorded in the prisoner’s medical chart.
Partial Compliance
With the hiring of a QMHP in October 2013, inmates on suicide precautions are now much more likely to receive daily assessments during the work week. However, review of 10 medical charts of inmates on suicide precautions found that only 3 of 10 (30%) inmates were seen consistently on a daily basis during the length of their suicide precautions. It should be noted that, in several cases, the inmates were not observed as required by nursing staff on the weekends when the QMHP was not on-site.

Recommendations

The lack of a reasonably comprehensive suicide risk assessment was previously addressed above in Provision A.1.h.
As previously offered in prior monitoring reports:
1) The QMHP should ensure that all suicide risk assessments and progress notes utilized to upgrade, downgrade, and discontinue suicide precautions provide adequate clinical justification for the decision based upon the criteria contained in the SHP suicide prevention policy highlighted above.

Evidentiary Basis

2) The MTA should ensure that all nursing staff are aware of the requirement to not only assess suicidal inmates on a daily basis when the QMHP is not onsite, but to also document that they conferred by telephone with the QMHP after-hours as necessary.
Review of medical charts.

Provision A.1.l
Status

Ensure that all mental health care staff within the Jail have access to critical information for prisoners on suicide precautions (e.g., progress notes from all treating clinicians). Following each assessment, mental health care staff shall provide correctional staff with pertinent and relevant information regarding a prisoner on suicide precautions to the extent that it affects the correctional staff’s duties and responsibilities for supervising prisoners on suicide precautions.
Substantial Compliance

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Discussion
Recommendations

With the hiring of a QMHP in October 2013, the QMHP and psychiatrist are now able to communicate and collaborate on individual cases, as well as provide correctional personnel with appropriate information as needed. As such, this provision is moved to Substantial Compliance.
None

Evidentiary Basis

Review of medical charts. Interviews with the QMHP, psychiatrist, and correctional personnel.

Provision A.1.m Status Discussion
Recommendations

Ensure that only a QMHP may promote, demote, or terminate a prisoner’s suicide precaution level or status. LPNs and correctional officers may only modify suicide precautions or remove prisoners from suicide watch upon the documented order of a QMHP.
Substantial Compliance
Review of medical charts during the recent assessment indicated that only a QMHP has been upgrading, downgrading, and discharging inmates from suicide precautions. Pursuant to both RCDF and SHP policy, nursing and correctional personnel can initiate suicide precautions pending an assessment by a QMHP. As such, this provision is moved to Substantial Compliance.
None

Evidentiary Basis

Review of medical charts.

Provision A.1.n
Status
Discussion

Ensure that all prisoners discharged from suicide precautions receive a follow-up assessment within eight days, in accordance with a treatment plan developed by a QMHP.
Partial Compliance
This provision specifically requires an assessment within 8 days following discharge from suicide precautions, as well as development of a treatment plan.
The SHP suicide prevention policy (J-G-05) exceeds this provision’s requirements by requiring a QMHP to conduct follow-up assessments of inmates discharged from suicide precautions (and were on such precautions for more than 24 hours) at intervals of 7 days, 14 days, 1 month, and then periodically until discharge from custody. A “SHP Suicide Watch Tracking Log” is utilized to manage this follow-up schedule.

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17

In addition, pursuant to the SHP suicide prevention policy, “The treatment plan will describe signs, symptoms, and the circumstances in which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the patient or medical staff can take if suicidal thoughts do occur. This treatment plan is to be documented in the patient’s medical record accordingly.”

Recommendations

The Independent Consultant reviewed 10 medical charts of inmates on suicide precautions during the most recent on-site assessment. For the most part, all the reviewed charts indicated that the inmate received follow-up assessments by the QMHP as required. However, treatment plans for these inmates was problematic. For example, most treatment plan sections of the progress notes simply indicated that “therapeutic support offered. Inmate provided with educational materials on coping with depression.” This does not exemplify adequate treatment planning. As required by policy, a treatment plan should specifically describe signs, symptoms, and the circumstances in which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the patient or medical staff can take if suicidal thoughts do occur.
As offered in previous monitoring reports:

Evidentiary Basis

1) Consistent with current SHP policy, every inmate on suicide precautions for longer than 24 hours should be provided with a treatment plan that describes “signs, symptoms, and the circumstances in which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the patient or medical staff can take if suicidal thoughts do occur.”
SHP’s Suicide Prevention Policy for the RCDF (No. J-G-05), effective March 17, 2014.

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Provision A.2.a
Status Discussion

18
Training: The County shall ensure that all staff have the adequate knowledge, skill, and ability to address the needs of prisoners at risk for suicide. Within 180 days of the Effective Date, the County will institute a suicide prevention training program. The County shall review and revise its current suicide prevention training curriculum to include the following topics:
(1) suicide prevention policies and procedures (as revised consistent with this Agreement);
(2) analysis of facility environments and why they may contribute to suicidal behavior;
(3) potential predisposing factors to suicide; (4) high-risk suicide periods; (5) warning signs and symptoms of suicidal behavior; (6) case studies of recent suicides and serious suicide attempts; (7) mock demonstrations regarding the proper response to a
suicide attempt; and (8) the proper use of emergency equipment.
Substantial Compliance
A SHP consultant previously developed a suicide prevention curriculum entitled “Suicide Training: Inside the Bars.” The PowerPoint curriculum, 72 slides in length, contained the following topics:
 Why are we doing this?  Constitutional responsibility to address suicide  What the research says – What experience says  Myths – Barriers to prevention & how to change it  Causal factors: environment, events, individual stressors, mental
illness/SA  Suicide requires intent, means and opportunity  Components to good prevention  Overview of WCD and SHP policy  Details of policy  Management options – in house, out of house  QPR and Debriefing
The curriculum was quite good and consistent with the required training topics within this Agreement.
The Independent Consultant received verification that correctional and health care staff were trained on the suicide prevention curriculum on November 19 and November 26, 2013, resulting in approximately 95% of required staff trained. As such, this provision is moved to Substantial Compliance.

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Recommendations None

Evidentiary Basis

Verification of training by RCDF Administrator.

Provision A.2.b Status Discussion
Recommendations

Ensure that all correctional, medical, and mental health staff are trained on the suicide screening instrument.
Substantial Compliance
The Independent Consultant received verification that correctional and health care staff were trained on the suicide prevention screening forms on April 4 and April 9, 2014, resulting in approximately 99% of required staff trained. As such, this provision is moved to Substantial Compliance.
None

Evidentiary Basis

Verification of training by RCDF Administrator.

Provision A.2.c Status Discussion
Recommendations

Ensure that a minimum of four hours of in-service suicide prevention training is completed annually by all correctional, medical, and mental health staff, to include training on updated policies, procedures, and techniques.
Partial Compliance
Annual suicide prevention training has not yet occurred, but is scheduled to begin in September 2014. This provision cannot be moved to substantial compliance until a round of annual in-service training is completed.
None

Evidentiary Basis

Provision A.2.d
Status

Ensure that correctional staff is trained in observing prisoners on suicide watch and step-down unit status.
Substantial Compliance

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Discussion
Recommendations

This provision appears redundant with Provision A.2.a. and because Substantial Compliance has been achieved with completion of the initial 4hour suicide prevention training described in Provision A.2.a., this provision is also moved to Substantial Compliance
None

Evidentiary Basis

See Provision A.2.a.

Provision A.2.e

Ensure that all correctional staff are certified in cardiopulmonary resuscitation (“CPR”).

Status Discussion
Recommendations

Substantial Compliance
The RCDC Administrator informed the Independent Consultant that most correctional staff received CPR training on November 19 and November 26, 2013, resulting in approximately 90% of required staff trained. (The MTA had previously reported, and training records reflected, that all medical staff were currently certified in CPR.) CPR cards were received in March 2014.
None

Evidentiary Basis

Discussion with RCDF Administrator.

Provision A.2.f
Status Discussion

Ensure that an emergency response bag that includes appropriate equipment, including a first aid kit and emergency rescue tool, shall be in close proximity to all housing units. All staff coming into regular contact with prisoners shall know the location of this emergency response bag and be trained to use its contents.
Substantial Compliance
First aid kits, automated external defibrillators (AED), and emergency rescue tools were previously found in each housing unit tower inspected by the Independent Consultant. First aid kits included microshields and similar equipment utilized for rescue breathing. In addition, the medical unit had an emergency response bag that includes portable oxygen and an AED.
In regard to a previous recommendation to establish an emergency medical code system, RCDF and SHP officials decided not to establish a code system,

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Recommendations

but rather revise the current protocol so that all first responders now specifically announce the nature of the emergency, including medical equipment required.
None

Evidentiary Basis

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B. MENTAL HEALTH TREATMENT
The County shall ensure that prisoners suffering from mental illness receive treatment appropriate to their condition and adequate to prevent unnecessary suffering or risk of harm. Proper treatment will also assist prisoners in successfully reentering the community upon release. To achieve this outcome, the County shall provide sufficient staffing to meet the demands for timely access to QMHPs and/or QMS and ensure that qualified staff perform comprehensive assessments, provide comprehensive multidisciplinary treatment planning and medication management, and monitor medication side effects.

Provision B.1
Status Discussion

Policies: The County shall implement comprehensive policies and protocols to ensure that RCDF delivers mental health services that include an array of services. These policies and protocols must also provide for necessary and appropriate mental health staff; require a treatment plan for prisoners with serious mental illness; and contain mechanisms sufficient to measure whether care is being provided in a manner consistent with the Constitution. At a minimum, the policies and protocols shall:
Partial Compliance
This provision is interpreted as a “catch-all” provision for all mental health treatment-related provisions, therefore, this provision cannot come into substantial compliance until all of the provisions under Mental Health Treatment come into substantial compliance.

Recommendations

The current assessment found that both RCDF and SHP still have policies regarding the provision of mental health services that are in need of further revision, including Mental Health (J-E-05), Basic Mental Health Services (JG-04), and Special Needs Treatment Plans (J-G-01).
See below

Evidentiary Basis

Documented in previous monitoring reports.

Provision B.1.a Status Discussion

Ensure that all prisoners are appropriately screened for mental illness using an appropriately validated screening instrument.
Partial Compliance As indicated in previous monitoring reports, this provision requires that all RCDF inmates are to be screened utilizing an appropriately validated screening instrument. The provision does not address the time frame by which the screening is to be completed and what entity is responsible (corrections,

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23
medical, or mental health) for the screening. In addition, the Independent Consultant is not aware of any validated screening instrument for mental illness in operation in any correctional facility throughout the country. With that said, current practices do not appear to be consistent with this provision.
National correctional standards (e.g., the National Commission on Correctional Health Care) require that initial mental health screening include a structured interview with inquiries into the following areas:
 psychiatric hospitalization and out-patient treatment  suicidal behavior and suicidal ideation  violent behavior  victimization  special education placement  cerebral trauma or seizures  sex offenses  psychotropic medications  drug or alcohol abuse  orientation to person, place, and time  emotional response to incarceration  screening for intellectual functioning (i.e., mental retardation,
developmental disability, and learning disability
National correctional standards require that the initial mental health screening be completed on all inmates within 14 days of admission into the facility.
Currently, all inmates entering the RCDF receive Medical Screening from a booking officer. The form contains some inquiry regarding suicide risk and mental health history, but not all of the above described areas are addressed. In addition, SHP utilizes a “Medical Staff Receiving Screening form,” but this instrument is not appropriate for this provision for two reasons: 1) the form is not currently utilized for all inmates, it is only utilize on inmates referred to medical staff from the booking officer’s Medical Screening form; and 2) the form is deficient in its very limited mental health inquiry.
According to SCP’s Mental Health policy (No. J-E-05), “all inmates patients with positive screening for mental health upon intake will receive a mental health evaluation. The post-admission evaluation will be performed within 14 days of intake.” This policy is defective because it assumes that the inmate had received initial mental health screening from an adequate screening instrument. Because the current screening forms utilized in the RCDF (i.e., the Medical Screening form administered by booking staff and the Medical Staff Receiving Screening Form) do not address all of the required areas, proper screening for mental illness is not being done.
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24

However, SCP does have a screening instrument entitled “Mental Health Survey” that would be appropriate for use as an initial mental health screening form. Currently, the mental health survey form is rarely used within the RCDF.

Unless instructed otherwise by the parties, the Independent Consultant will assume that substantial compliance with this provision can be obtained by medical staff administering the Mental Health Survey form to all inmates in the RCDF within 14 days of admission. Positive responses to the mental health survey form should then result in a referral to a qualified mental health professional for completion of a mental health evaluation. Currently, either the “Psychiatric Nursing Initial Assessment” or the “Initial Psychiatric Assessment” forms can be utilized completion of a mental health evaluation.

Recommendations

During this current on-site assessment, the Independent Consultant was informed by the MTA and SHP Vice President of Operations that, beginning in April 2014, the Mental Health Survey form was being completed by nursing staff on all inmates held in the RCDF within 14 days of admission. Because of the recent initiation of this protocol, medical charts could not be reviewed, and this provision will be fully audited during the next on-site visit.
None

Evidentiary Basis

Discussion with MTA and SHP Vice President of Operations.

Provision B.1.b Status Discussion

Ensure that treatment plans adequately address prisoners’ serious mental health needs and that the plans contain interventions specifically tailored to the prisoners’ diagnoses and problems.
Partial Compliance
Although SCP’s Special Needs Treatment Plans policy (No. J-G-01) addresses the requirement of treatment planning for inmates with serious mental illness, the Independent Consultant’s previous and current chart review found that treatment planning was not currently being utilized within the RCDF.
As required in this provision, treatment planning for inmates with serious mental illness must include specific interventions tailored to an inmate’s diagnosis. As discussed in other sections of this report, not all inmates with serious mental illness within the RCDF have seen the psychiatrist and/or have an active psychiatric diagnosis, therefore, treatment planning is not yet in place.

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Recommendations
Evidentiary Basis

Finally, unless instructed otherwise by the parties, the Independent Consultant will utilize the following working definition of serious mental illness: “a diagnosable mental disorder characterized by severe alterations in thinking, mood, or impaired behavior associated with distress and/or impaired functioning; primarily inclusive of major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder, panic disorder, and post-traumatic stress disorder, but may include a personality disorder with significant functional impairments.”
As offered in previous monitoring reports:
1) SHP should ensure that all inmates with a serious mental illness have an active psychiatric diagnosis and then develop a specific intervention tailored to that diagnosis. The Special Needs Treatment Plans policy (No. J-G-01) should also be revised.
SCP’s Special Needs Treatment Plans policy (No. J-G-01)

Provision B.1.c Status Discussion

Ensure adequate on-site psychiatric coverage for prisoners’ serious mental health needs and ensure that psychiatrists see such prisoners in a timely manner.
Partial Compliance
As indicated in prior monitoring reports, the psychiatrist was previously providing four (4) or eight (8) hours of on-site services per month. In September 2013, those hours were allegedly increased to 16 hours per month. However, during the Independent Consultant’s most recent on-site assessment, it was determined that the psychiatrist was still only the devoting approximately 8 hours of on-site services per month. This continues to be problematic.
However, at the conclusion of the on-site visit, and with the intervention of both the RCDF Administrator and Sheriff, authorization for funding an additional 8 hours of on-site psychiatric services per month time was granted. As such, beginning in May 2014, on-site psychiatric services will hopefully be increased to 16 hours per month, and fulfilled by the current psychiatrist and a colleague. This provision will obviously need to be monitored again during the next site visit.
In addition, the standard of care requires that inmates admitted into a jail or prison facility who have a current prescription for psychotropic medication, and appear stable, should be seen by a psychiatrist within 5 to 10 business days. Those inmates with a current prescription for psychotropic medication who appear unstable, should be seen by the psychiatrist in less than 5 business

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days. In emergent cases, the inmate should either be seen immediately by the psychiatrist or transported to the emergency room.

Recommendations

According to data reported to the Independent Consultant on a monthly basis, there were approximately 67 inmates in the RCDF with prescriptions for psychotropic medication in March 2014. In addition, according to a recent audit by the SHP Vice President of Operations, almost 50% (i.e., 33) of inmates with current prescriptions for psychotropic medication had not been seen by the psychiatrist as of April 30, 2014. This is very problematic and hopefully will be corrected in the next few months with the recent increase in on-site psychiatric services to 16 hours per month.
None

Evidentiary Basis

Monthly Reporting Data by the RCDF Administrator, March 2014. Internal Mental health Program Audit by the SHP Vice President of Operations, April 2014.

Provision B.1.d
Status Discussion

Ensure that prisoners with chronic mental illness are placed on a chronic mental health list for follow-up every 30, 60, or 90 days, as clinically appropriate. Prisoners with chronic mental illnesses shall not be required to submit a request for mental health services in order to receive such services at regular intervals.
Partial Compliance
With the hiring of a QMHP in October 2013, inmates with chronic mental illness are more likely to be seen on a timely basis that 30, 60, and 90-day intervals. The QMHP has assumed responsibility for maintaining the SHP Nursing Chronic Disease Flowsheet and Chronic Illness Tracking Log to identify and manage inmates with chronic and serious mental illness.
In addition, the SHP Vice President of Operations and MTA informed the Independent Consultant during the recent on-site assessment that that a “Mental Health Chronic Care Log” has been developed and currently utilized as a tracking tool.
Finally, the standard of care requires that a psychiatrist should assess each inmate on psychotropic medication at least every 90 days or sooner if clinically indicated (e.g., a change in medication and/or change to a higher level of care). A recent audit indicated that there were at least 12 inmates who were seriously mentally ill and on psychotropic medication that had not seen the psychiatrist in over 90 days of RCDF confinement. This is problematic.
Regularly scheduled appointments with the QMHP and psychiatrist for those inmates with serious mental illness will be examined again during the next

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Recommendations
Evidentiary Basis

on-site visit.
As offered in previous monitoring reports:
1) As offered in Provision B.1.b above, SCP’s Special Needs Treatment Plans policy (No. J-G-01) should be revised to include more narrative on treatment planning for inmates with chronic and serious mental illness, to include the frequency of follow-up assessments and the parameters and array of components of treatment planning. The policy should also explain use of the SHP Nursing Chronic Disease Flowsheet and Chronic Illness Tracking Log forms.
Monthly Reporting Data by the RCDF Administrator, March 2014. Internal Mental health Program Audit by the SHP Vice President of Operations, April 2014. Discussion with QMHP and psychiatrist.

Provision B.1.e
Status Discussion

Ensure timely and appropriate therapy, counseling, and other mental health programs for all prisoners with serious mental illness. This includes adequate space for treatment, an adequate number of QMHPs to provide treatment, access to licensed in-patient psychiatric care when clinically appropriate, and an adequate array of structured therapeutic programming.
Partial Compliance
Structured therapeutic programming for inmates with serious mental illness, to include both individual and group therapy, was previously either very limited or not occurring at all. When offered, individual therapy is provided by either the QMHP or psychiatrist. Both clinicians assess inmates with serious mental illness in the privacy of the QMHP’s office (unless they are on suicide precautions where they are seen by the QMHP in the booking area).

Recommendations
Evidentiary Basis

Access to licensed in-patient psychiatric care was available following assessment and referral of the SHP psychiatrist, as well as following triage by a Mobile Crisis clinician from Centerstone Mental Health Services.
As offered in previous monitoring reports:
1) RCDF and SHP officials should work collaboratively in creating reasonable structured therapeutic programming for inmates with serious mental illness.
Observation and discussion with QMHP and psychiatrist.

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Provision B.1.f Status Discussion
Recommendations

Ensure an adequate array of crisis services to appropriately manage the psychiatric emergencies that occur among prisoners. Crisis services shall not be limited to administrative segregation or observation status. Prisoners shall have access to appropriate licensed in-patient psychiatric care.
Partial Compliance
As offered during the other on-site sites, although SHP’s Basic Mental Health Services policy (No. J-G-04) briefly addressed crisis services to manage psychiatric emergencies (e.g., “crisis intervention is to be initiated if patient is a threat to themselves and others”), the current policy was very vague as to a specific protocol that was to be initiated during a psychiatric emergency. Inmates in crisis were put on either Suicide Precautions or Medical Observation status, as well as the Restraint Chair on a limited basis (see provision B.4.a below). Access to licensed in-patient psychiatric care was available following assessment and referral of the SHP psychiatrist, as well as following triage by a Mobile Crisis clinician from Centerstone Mental Health Services.
As offered in previous monitoring reports:
1) SHP’s Basic Mental Health Services policy (No. J-G-04) should either be revised or a new policy developed that addresses the array of crisis services available to manage psychiatric emergencies.

Evidentiary Basis

Provision B.1.g
Status Discussion

Ensure that the Jail’s QMHPs or QMS maintain a log of prisoners receiving mental health services, which shall include both those prisoners who receive counseling and those who receive medication. The log shall be updated every time a prisoner receives mental health services. The log shall include each prisoner’s name, diagnosis or complaint, and next scheduled appointment. Each clinician shall have ready access to a current log listing any prescribed medication and dosages for prisoners on psychotropic medications.
Substantial Compliance
As previously discussed, the QMHP has assumed responsibility for maintaining the SHP Nursing Chronic Disease Flowsheet and Chronic Illness Tracking Log to identify and manage inmates with chronic and serious mental illness. In addition, as recommended in the previous monitoring report, each intervention with an inmate is now documented as a progress note in the

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inmate’s medical chart. As such, this provision is moved to Substantial Compliance.
Recommendations

Evidentiary Basis

Review of medical charts.

Provision B.2.a Status Discussion
Recommendations
Evidentiary Basis

Training: Ensure that all mental health staff performing mental health assessments receive comprehensive training concerning the policies, procedures, and practices for the delivery of mental health services, including the screening, assessment, and referral processes.
Partial Compliance
Although hired in October 2013, the QMHP has not received any additional mental health training other than that provided by the SHP Vice President of Operations. The Independent Consultant was informed during the recent onsite visit that future training would include instruction in the new DSM-5 Diagnostic and Statistical Manual of Mental Disorders, ideally from a local workshop within the state of Tennessee. The Independent Consultant also suggested that the QMHP attend the up-coming Correctional Mental Health Care Conference in Denver, CO on July 20-21, 2014 sponsored by the National Commission on Correctional Health Care.
1) Provide verification to the Independent Consultant that any appropriate training occurred.
Discussion with the QMHP and SHP Vice President of Operations.

Provision B.2.b Status Discussion

Ensure that all nurses performing health screenings receive comprehensive training concerning the policies, procedures, and practices for the mental health screening process.
Partial Compliance
As discussed in previous monitoring reports, the MTA trained all nursing staff regarding completion of the Mental Health Survey form in April 2013. However, since nursing staff have only recently (i.e., April 2014) been required to complete the Mental Health Survey form on all inmates within 14 days of RCDF confinement, the adequacy of such training cannot be critiqued

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Recommendations

without review of completed screening forms. This provision will be fully audited during the next on-site visit.
None

Evidentiary Basis

Review of medical charts during next on-site visit.

Provision B.2.c
Status Discussion
Recommendations

Randomly test five percent of relevant staff on an annual basis to determine their knowledge of the policies, procedures, and practices for the mental health screening, assessment, and referral processes. The testing instrument and policies shall be approved by the United States. The results of these assessments shall be evaluated to determine the need for changes in training practices. The review and conclusions will be documented and provided to the IC, the County, and the United States.
Partial Compliance
The requirements of this provision were previously misunderstood. A posttest was developed and administered to all correctional staff receiving suicide prevention training. Although an admirable practice, this provision requires the random testing of 5% of all correctional, medical, and mental health personnel on the RCDF/SHP mental health program. A post-test of five questions was developed by the SHP Vice President of Operations and approved by the Independent Consultant during the most recent on-site visit. The post-test will be given to 5 percent of all staff in the near future.
None

Evidentiary Basis

Discussion with the SHP Vice President of Operations and RCDF Administrator.

Provision B.2.d

Develop and implement written training protocols in the area of mental health for correctional staff, including an introductory training provided to new hires, which will include training on basic mental health information (e.g., recognizing mental illness, specific problematic behaviors, additional areas of concern); identification, timely referral, and proper supervision of prisoners with serious mental health needs; appropriate responses to behavior symptomatic of mental illness; suicide prevention; and an annual refresher training on relevant topics. The training will be conducted by a QMHP. The County will document and track training and attendance by staff, who must attend the training provided for in this provision in order to continue their employment.

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Status Discussion

Partial Compliance
The Independent Consultant was informed that mental health clinicians from Centerstone Mental Health Services conducted a 2-hour mental health training for correctional staff at the RCDF in September 2013. (A similar training, utilizing a 65-slide PowerPoint presentation entitled “Mental Illness 101,” was done in October 2011. The Independent Consultant reviewed the curriculum and found that it reasonably reflected the requirements of this provision.)

Recommendations

Substantial compliance with this provision can be achieved by ensuring that the above described mental health training (or similar training) is provided to correctional staff on an annual basis. A completion rate of 90% should be obtained.
1) Provide evidence (from participant list) of the total number of correctional staff that received the September 2013 suicide prevention training, as well as a schedule of training for remaining staff.

2) Although not required by this provision, it is also recommended that all nursing staff completed this annual mental health training.

Evidentiary Basis

Provision B.3.a

Psychotropic Medication Management: The County shall ensure the accurate administration of psychotropic medication and maintenance of medication records. At a minimum, the County shall:

Status Discussion
Recommendations

Ensure that prisoners have proper diagnoses made by a psychiatrist, psychologist or medical doctor for each psychotropic medication they receive.
Partial Compliance
The Independent Consultant’s initial review of selected records in late February 2013 found that each health care chart had a Medication Administration Record (MAR) that accurately reflected administration of psychotropic medication(s). However, not all of the selected records contained a psychiatric diagnosis associated with the psychotropic medication. The SHP Vice President of Operations informed the Independent Consultant during the recent on-site visit that the current mental health diagnosis would now be contained on the MAR of each inmate. This provision will be more fully audited during the next on-site visit.
As offered in previous monitoring reports:

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Evidentiary Basis

32
1) The QMHP should confer with the SHP psychiatrist and/or other provider of the current psychotropic medication to ensure that a current psychiatric diagnosis is documented in the chart (e.g., in the MAR). Review of medical charts.

Provision B.3.b

Ensure a medication continuity system so that incoming prisoners receive psychotropic medications for serious mental health needs in a timely manner, as medically appropriate.

Status Discussion
Recommendations

Partial Compliance
As previously offered by SHP, once an inmate’s psychotropic medication(s) are verified and ordered from the pharmacy, they are delivered and dispensed within 24 hours. This practice could not be confirmed by the Independent Consultant during the recent on-site visit and will be reviewed with the MTA during the next on-site visit.
As offered in previous monitoring reports:

Evidentiary Basis

1) As also discussed in Provision C.2 below, SHP should develop a quality improvement process by which timeliness of verification and dispensing of psychotropic medication can be audited on a regular basis. As discussed during recent on-site visit, SHP should begin auditing this provision on a monthly basis and, if 100% compliance is achieved, quarterly auditing can begin.
Discussion with the SHP Vice President of Operations and MTA.

Provision B.3.c
Status Discussion

Ensure that prescriptions for psychotropic medications are reviewed by a psychiatrist or other qualified prescriber with mental health experience and training on a regular, timely basis to assess whether each prisoner’s prescribed regimen continues to be appropriate and effective for his or her condition. Whenever a psychotropic medication is discontinued, added, or changed, the County will ensure that the psychiatrist or other qualified prescriber making such changes contemporaneously documents the reason for such change in the prisoner’s health record.
Partial Compliance
As discussed above in B.1.c, the standard of care is for the psychiatrist to assess inmates on psychotropic medication at a minimum of every 90 days, unless more frequent assessment is clinically indicated. To date, the

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Recommendations

psychiatrist has not been able to assess all inmates receiving psychotropic medication at 90-day intervals prior to medication renewal. This is very problematic and hopefully will be corrected in the next few months with the recent increase in on-site psychiatric services to 16 hours per month.
None

Evidentiary Basis

Discussion with psychiatrist, SHP Vice President of Operations, and MTA.

Provision B.3.d

Ensure that individuals receiving psychotropic medication are adequately monitored for potential negative side-effects of such medications.

Status Discussion
Recommendations

Partial Compliance
According to SHP, current monitoring is accomplished by reviewing mental health sick call requests and the chronic care list to ensure identification of any potential negative side-effects of such medications. This practice could not be confirmed by the Independent Consultant during the recent on-site visit and will be reviewed during the next on-site visit.
None

Evidentiary Basis

Provision B.3.e Status Discussion
Recommendations

Ensure that one unified health record is maintained for each prisoner that includes complete records for both physical and mental health and a complete list of medications the prisoner is taking. The County will also ensure that such unified health records are available to all medical and mental health staff who are necessary to facilitate continuity of care.
Substantial Compliance
The Independent Consultant previously confirmed that one unified health record was maintained for each inmate in the RCDF. The unified chart includes both medical and mental health records, as well as a MAR when applicable. The unified chart was well-maintained by an SHP medical records clerk. All medical and mental health personnel had easy access to the chart. This provision remains in Substantial Compliance.
None

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Evidentiary Basis

Provision B.4.a

Use of Restraints: The County shall prevent the unnecessary or excessive use of restraints on prisoners with mental illness or requiring suicide precautions. At a minimum, the County shall:

Status Discussion
Recommendations

Develop and maintain comprehensive policies and procedures for the use of restraints for prisoners with mental illness in accordance with generally accepted standards of care.
Partial Compliance
To date, the RCDF does not have a policy on use of restraints. The RCDF Administrator drafted a policy and it was subsequently reviewed by SHP officials. The draft policy was recently revised and approved by the Independent Consultant in May 2014. The policy should be implemented in the near future.
None

Evidentiary Basis

Provision B.4.b
Status Discussion
Recommendations

Ensure that a QMHP by preference, and if not available, a QMS provides written approval prior to the use of restraints on prisoners suffering from mental illness or requiring suicide precautions. The QMHP or QMS shall document the basis for and duration of the use of restraints and the performance and results of welfare checks on such restrained prisoners. The parties acknowledge that there may be situations which arise of immediate nature where such prior written approval is not practical for the safety of the inmate, other inmates or the facility staff. In such cases, written approval shall be obtained as soon as practicable and the same documentation obtained.
Partial Compliance
See discussion above.
The recently approved restraint policy has not yet been implemented, and this provision will be fully audited during the next on-site visit.
None

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Evidentiary Basis

Provision B.4.c

Ensure that restrained mental health prisoners are monitored at least every 15 minutes by a Correctional Officer and further monitored by a Qualified Medical Staff to assess their physical condition every 2 hours.

Status Discussion
Recommendations

Substantial Compliance
As found during previous on-site assessments, the Independent Consultant reviewed incident reports on the use of the Restraint Chair in 38 cases in 2012, and 4 cases in 2013. The reports indicated that restrained inmates were observed by correctional officers at 15 minute intervals and seen by nursing staff at least every two hours. This provision remains in Substantial Compliance.
None

Evidentiary Basis

Provision B.5.a
Status Discussion

Mental Health Staffing: The County shall ensure that the Jail’s mental health staffing is sufficient to provide adequate care for prisoners’ serious mental health needs, fulfill constitutional mandates and the terms of this Agreement, and allow for the adequate operation of the Jail, consistent with constitutional standards.
Partial Compliance
A QMHP was only recently hired in October 2013 and on-site psychiatric services are scheduled to be increased to 16 hours per month in the near future. As such, the critical issue as to whether or not the RCDF has sufficient mental health staffing to address the provisions in this Settlement Agreement will be determined during subsequent on-site visits.

Recommendations

Evidentiary Basis

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Provision B.5.b Status Discussion
Recommendations

The County will ensure that all persons providing mental health treatment meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure.
Substantial Compliance
The SHP psychiatrist is appropriately licensed and board-certified in psychiatry. The QMHP is currently licensed as a Licensed Master Social Worker by the State of Tennessee, Department of Health, Division of Health Licensure and Regulation. This provision is moved to Substantial Compliance.
None

Evidentiary Basis

Provision B.6.a Status Discussion
Recommendations
Evidentiary Basis

Release and Transfer: RCDF shall notify a QMS prior to the release or transfer of a prisoner with mental health needs from RCDF custody as soon as information relating to his or her release or transfer becomes available.
Partial Compliance
As observed during both the current and previous assessments, although both RCDF and SHP officials stated that correctional officers notify medical staff when inmates are released from custody, it was said not to occur on a consistent practice. In addition, the RCDF does not have a policy that address release and transfer of inmates with serious mental illness.
1) RCDF officials should develop a policy on discharge planning that is similar to SHP’s Policy J-E-13 (Discharge Planning). However, the RCDF policy should outline specific procedures that correctional staff will follow to notify medical personnel of an inmate’s pending release or transfer from the RCDF.
Discussion with RCDF and SHP officials.

Provision B.6.b

When a QMS is notified of the release or transfer of a prisoner with mental health needs, the QMS shall prepare and send with the transferring or released prisoner a summary detailing major mental health concerns and listing current medications and dosages, as well as medication history while at RCDF, in order to ensure continuity of care.

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Status Discussion
Recommendations

Partial Compliance
As offered in previous monitoring reports, an inmate’s current Medication Administration Record and Admission Data/History and Physical Form are forwarded to transferring agency’s upon the inmate’s release. Although SHP policy also requires completion of a Medical Information Transfer Form, the form had not been utilized until recently. According to SHP officials, an inmate being released from RCDF custody and on psychotropic medication will be given a copy of their MAR that will contain the current diagnosis. This provision will be audited again during the next on-site visit to ensure that both the Medical Information Transfer Form and MAR are provided upon discharge.
None

Evidentiary Basis

Discussion with the SHP Vice President of Operations and MTA.

Provision B.6.c
Status Discussion

RCDF shall provide released prisoners with a three day supply of appropriate prescription medication. RCDF shall also provide released prisoners with the contact information for local mental health crisis services and schedule if requested an appointment with a mental health provider in the community and/or will offer to schedule the initial appointment. RCDF shall supply sufficient medication for the period of transit for prisoners who are being transferred to another correctional facility or other institution not to exceed a three day supply.
Partial Compliance
As offered in previous monitoring reports, all inmates on medication at the time of their discharge from the RCDF were provided with a 3 to 5 day supply of medication. However, with regard to the release of inmates who have a serious mental illness, medical staff were not providing appointments or contact information for local community mental health providers, including Centerstone Mental Health Services/Mobile Crisis.
During the site visit in October 2013, the RCDF Administrator provided the Independent Consultant with a “Information Packet” containing the contact information of various community resources in the Springfield and Robertson County areas that is said to be given to inmates upon discharge. However, it was not clear whether or not the QMHP or nursing staff were offering to schedule an initial appointment with a local community mental health provider. This provision will be more fully audited during the next on-site visit.

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Recommendations None Evidentiary Basis
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C. QUALITY IMPROVEMENT AND RISK MANAGEMENT
The County will develop, implement, and maintain a system to ensure that trends and incidents involving restraint use, psychotropic medications, and avoidable suicides and self-injurious behavior are identified and corrected in a timely manner.

Provision C.1 Status Discussion
Recommendations

Within 90 days of the Effective Date, the County shall develop and implement written Quality Improvement policies and procedures adequate to identify and address serious deficiencies in prisoner suicide prevention and mental health care.
Partial Compliance
As offered in previous monitoring reports, the RCDF and SHP did not have any policies or procedures regarding quality improvement for suicide prevention and the provision of mental health services.
1) RCDF and SHP should develop and implement quality improvement policies or procedures for suicide prevention and the provision of mental health services.

Evidentiary Basis

Provision C.2

Within 90 days of the Effective Date, the County will implement monthly quality assurance mechanisms at the individual and system levels to prevent or minimize harm to prisoners. These quality assurance mechanisms shall track and analyze patterns and trends regarding levels of risk for suicide and self-injurious behavior, restraint and psychotropic medication use and, more generally, the provision of mental health care at RCDF. Each monthly report shall include:
(1) relevant aggregate data, including:
i. number of incidents related to self-harming behavior, including suicide gestures, attempts, or completed suicides, and any purposeful self-injurious act or attempted act that inflicted harm requiring medical attention or likely would have if completed;
ii. all uses of restraints of prisoners with mental illness, including instances of self-injurious behavior while restrained, use of restraints on a prisoner on three or more occasions in a 30-day period, and single uses of restraints exceeding one hour in duration;
iii. number of prisoners prescribed psychotropic medications;

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iv. number of prisoners prescribed two or more psychotropic medications;
v. the number of prisoners who report having participated in general mental health/therapy counseling;
vi. the number of prisoners who have received one-on-one treatment from the psychiatrist;
vii. the time elapsed between prisoners’ requests for mental health services and the provision of services by a QMHP or QMS;
viii. a list of prisoners with chronic mental illnesses, including the dates prisoners were treated by a QMHP or QMS;
ix. number of individuals with mental illness who return to RCDF within 30-60 days.
(2) an assessment of trends and interventions, including:
i. trends and/or the patterns regarding the self-harm data (i.e., the location and shift during which the majority of self-harm occurred; circumstances surrounding the discovery of the self-harm; the structures, objects, or instruments used to execute the self-harm, prisoners frequently engaged in self-harm);
ii. whether prisoners at risk of self-harm are being appropriately identified for care;
iii. whether incidents of self-harm are increasing or decreasing;
iv. the severity of incidents of self-harm; v. whether restraints are being appropriately used against
prisoners with mental illness; vi. whether prisoners are receiving appropriate and
adequate mental health counseling and therapy; vii. the timeliness of mental health services provided; viii. referrals to outside care; ix. whether prisoners with chronic mental illnesses are
receiving mental health services at regular intervals without requesting such services; x. staff counseling and discipline for violating psychotropic medication policies or restraint use polices; and xi. the effectiveness of interventions undertaken in response to identified trends from previous months.
(3) Based on these monthly assessments, the County shall recommend and implement changes to policies and
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procedures.

Status Discussion

(4) The Jail shall ensure that all relevant facts and circumstances surrounding serious suicide attempts and completed suicides are investigated and reviewed by a multidisciplinary team, consisting of medical, mental health, and corrections staff . This team shall identify any areas in which staff performance could be improved or jail procedures that need to be adjusted to improve the ability to protect prisoners from self-harm. All reviews shall be documented and shall include the team’s findings, concerns, recommendations and remedial actions.
Partial Compliance
According to the SHP Vice President of Operations and MTA, the Daily Report of Mental Health/Suicide Services form utilized to track aggregate data on the provision of various mental health services has been reactivated. In addition, the RCDF Administrator has consistently forwarded QA management data, which includes the above SHP data, to the Independent Consultant on a monthly basis since August 2013.

Recommendations

Finally, the Independent Consultant previously reviewed summaries of a few serious suicide attempts that occurred over the past several months. Consistent with this provision, the incidents resulted in a morbidity review by representatives of the corrections, medical, and mental health departments. At the suggestion of the Independent Consultant, the reviews were to have included: 1) review circumstances surrounding incident; 2) review procedures relevant to incident; 3) review relevant training received by staff; 4) review pertinent health care services/reports of victim; 5) review possible precipitating factors (i.e., circumstances which may have caused victim to attempt/commit suicide); and 6) recommendations, if any, for change in policy, training, physical plant, health care services, and operational procedures. To date, the reviews have begun to be structured to include the above inquiry, although documentation appeared limited regarding the goal of the inquiry and recommended corrective actions. The process remains a work in progress.
As offered in previous monitoring reports:
1) The Daily Report of Mental Health/Suicide Services form should be revised to also include the “number of inmates on psychiatric observation status.” The form should be consistently forwarded to the Independent Consultant on a monthly basis along with RCDF’s QA management data.

2) To assist in expediting achievement of substantial compliance with each provision of this Settlement Agreement, it is strongly recommended that RCDF and SHP officials formally meet on at least a monthly basis regarding the recommendations contained within this report and provide a monthly

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Evidentiary Basis

42
report to the Independent Consultant regarding status of compliance with each provision. Review of monthly QA management data for January through March 2014.
Review of the Daily Report of Mental Health/Suicide Services forms for January through March 2014.

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SUICIDE RISK ASSESSMENT

INMATE’S NAME:__________________________________________________I.D. NUMBER:____________

(Last)

(First)

(M.I.)

DOB:__________ AGE:___ SEX:___ INITIAL ASSESSMENT:___ REASSESSMENT:_____ DATE:______

SUICIDE PRECAUTIONS DURING PRIOR CONFINEMENT: YES___ (When:_____________) NO______

REASON FOR REFERRAL:___________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

SUICIDE RISK INDICATORS (Check all that apply):

Suicide Attempt____

Suicide Ideation/Gesture____

Self‐Mutilation____

Depressed_____

Agitated_____

Mood Change_____

Hostile/Aggressive____

Sleep Problems_____

Recent Loss_______

Lethargy_____

Excessive Weight Gain/Loss____ Isolation/Withdrawal_____

Giving Away Possessions_____

Intoxicated____

Hopeless/Helpless______

Afraid/Fearful____

Bizarre Behavior (Explain Above)___ Other (Explain Above)___

TYPE OF THREAT/ATTEMPT: Hanging_____Cutting____Jumping____Ingestion___Overdose___Other____

PROTECTIVE FACTORS (Check all that apply):

Identifies reason to live/not commit suicide_____

Future orientation/plans for future_______

Family Support__________

Children at home____________

Religious/spiritual/cultural beliefs________

Spousal support____________

Interpersonal social support_________

Insight into problems_________

Exercises regularly_________

Job or school assignment______

Positive coping skills/conflict resolution skills________ Active and motivated in mental health treatment_____

PREVIOUS PSYCHIATRIC/SUICIDE HISTORY:________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

CURRENT MEDICATIONS:________________________________________________________________________ _____________________________________________________________________________________________

ASSESSMENT OF LETHALITY: Low (1)____________ Medium (2)_____________ High (3)_____________

DIAGNOSIS: Axis I:______________________________________________________________________________________ Axis II:_____________________________________________________________________________________ Axis III:_____________________________________________________________________________________ Axis IV:____________________________________________________________________________________ Axis V (GAF):________________________________________________________________________________

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44

FINDINGS/RECOMMENDATIONS:__________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

TREATMENT PLAN (Describe circumstances in which risk for suicide is likely to recur; specific strategies/actions patient and clinician will take if suicidal thoughts do occur; include frequency of continued contact, referrals, etc.) ____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________________________________

ACTIONS:

Suicide Precautions Authorized:

Yes________

No_____

Level: CLOSE (Physical checks at staggered intervals not to exceed every 15 minutes)___ CONSTANT (1:1 Continuous, uninterrupted observation)_____ OTHER (Specify)_________________________________

Medical Restraints: Yes________

No_____

Safety Smock: Yes________

No_____

Items Allowed (Check): Clothing___Undergarments___Blankets___Mattress___Pillow____

Reading Materials____Toiletries___Other____________________

Shower: Yes________

No_____

Visits: Yes________

No_____

Telephone Cells: Yes________

No_____

Housing Assignment:_______________________________________________

Transfer Recommendation:_______________________________________________

Other Referrals/Recommendations:_______________________________________________

SIGNATURE/TITLE: ________________________________________________TIME:___________________
(Qualified Mental Health Professional)

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 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF TENNESSEE

UNITED STATES OF AMERICA,

)

)

PLAINTIFF,

)

)

v.

)

)

ROBERTSON COUNTY;

)

HOWARD BRADLEY, COUNTY MAYOR,

)

in his official capacity; ROBERTSON COUNTY )

COMMISSIONERS, in their official capacity; )

BILL HOLT, ROBERTSON COUNTY SHERIFF, )

in his official capacity;

)

)

DEFENDANTS.

)

__________________________________________)

CIVIL ACTION NO: 3:13-cv-00392

COMPLIANCE REPORT PLAINTIFF, THE UNITED STATES OF AMERICA, hereby files the Ninth and Final Compliance Report.

Respectfully submitted,

/s/ William G. Maddox WILLIAM G. MADDOX Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave, NW Washington, D.C. 20530 (202) 514-6255
1

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Settlement Agreement Between the United States Department of Justice and Robertson County, Tennessee
9th and Final Monitoring Report
Submitted by:
Lindsay M. Hayes, Independent Consultant
January 30, 2018 (revised final)
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Introduction
In October 2010, the United States Department of Justice (USDOJ)’s Civil Rights Division (Special Litigation Section) conducted an investigation regarding alleged inadequate conditions of confinement within the Robertson County Detention Facility (RCDF) in Springfield Tennessee. The investigation resulted in a Findings Letter issued on August 26, 2011 alleging that the “RCDF’s mental health practices place prisoners at a substantial and unreasonable risk of serious harm. Shortly thereafter, the USDOJ and Robertson County began to negotiate a settlement agreement that eventually was finalized and became effective upon the signature of United States District Court Judge Kevin H. Sharp on April 30, 2013. According to the Settlement Agreement, “From the beginning, and continuing through the United States’ investigation of conditions of confinement at RCDF, Defendants have acted expeditiously to begin addressing concerns the United States has raised with respect to conditions at RCDF, including concerns related to the provision of mental health care. This Agreement memorializes the actions that Defendants will implement to address the United States’ findings related to mental health care.”
Even prior to the effective date of the Agreement, Robertson County officials expressed a strong desire to begin complying with provisions of the Agreement and requested that this writer, jointly chosen by the parties to be the Independent Consultant, conduct an on-site baseline assessment to determine the current level of compliance. That assessment was conducted in late February 2013 and resulted in the 1st Monitoring Report dated April 30, 2013. A second abbreviated site visit was conducted on October 30, 2013, resulting in the 2nd Monitoring Report dated January 28, 2014. Seven (7) subsequent site visits have been conducted to date.
Monitoring Compliance with the Settlement Agreement
There are 48 provisions to this Settlement Agreement, including 21 for Suicide Prevention, 25 for Mental Health Treatment, and 2 for Quality Improvement and Risk Management. Pursuant to the Agreement, the following definitions are utilized to measure compliance with each provision:
Substantial Compliance indicates that defendants have achieved compliance with most or all components of the relevant provision of the Agreement for both the quantitative (i.e., 90% performance measure) and qualitative (i.e., consistent with the larger purpose of the Agreement) measures.
Partial Compliance indicates that compliance has been achieved on some of the components of the relevant provision of the Agreement, but significant work remains.
Non-Compliance indicates that most or all of the components of the Agreement provision have not yet been met.
According to the Agreement, “the Court shall retain jurisdiction of this action for all purposes until the County has achieved substantial compliance with each provision of the Agreement, provides
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3

constitutional mental health care to prisoners, and has maintained substantial compliance and provided constitutional mental health care for a period of one year.”
This report is formatted to present each provision, followed by the provision’s current status or rating (substantial, partial, or non-compliance) as determined by the Independent Consultant, a discussion section which provides justification for each rating, recommendations offered to raise each status to substantial compliance, and the evidentiary basis utilized in monitoring each provision.

Ninth Site Visit

The Independent Consultant conducted the 9th and final on-site visit to the Robertson County Detention Facility (RCDF) on September 28-29, 2017. The site visit included an initial meeting with the RCDF Administrator. In addition, numerous medical charts of inmates on the suicide precautions and chronic care lists for serious mental illness from June thru September 2017 were reviewed, as well as monthly RCDF compliance reports. Finally, a debriefing was held during the afternoon of September 29, 2017 that included the Sheriff, Chief Deputy, County Attorney, USDOJ attorney, RCDF Administrator, SHP Chief of Clinical Services, Medical Team Administrator, Qualified Mental Health Professional, and Psychiatrist.
The abbreviated 8th Monitoring Report (dated June 5, 2017) confirmed an earlier finding during the 7th Monitoring Report (dated December 31, 2016) that all 48 provisions were in Substantial Compliance. This 9th Monitoring Report, as well as the 8th Monitoring Report, confirmed that these 48 provisions sustained Substantial Compliance. The sustained provisions are shown in the table below.

Substantive Area
Suicide Prevention Mental Health Quality Improvement TOTAL

Total Provisions
21 25 2 48

Sustained and Substantial Compliance
# %
21 100%
25 100%
2 100%
48 100%

Partial Compliance

# %

-

-

-

-

-

-

-

-

NonCompliance

# %

-

-

-

-

-

-

-

-

As detailed in this report, as well as raised during previous monitoring tours, although all 48 provisions continue to remain in sustained Substantial Compliance, for two of the provisions (A.1h dealing with timely psychiatric referrals, and A.1.n dealing with adequate treatment planning for inmates released from suicide precautions) though constitutional, RCDF should continue to improve and sustain these provisions remain problematic. In addition, a third issue relating to inmates placed on suicide precautions during a prior RCDF confinement and readmitted to the facility and not always being referred to a QMHP was found during this most recent assessment, and has been resolved through a corrective action plan.

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4
It was noteworthy that Substantial Compliance was achieved in many of the mental health provisions of this Settlement Agreement because psychiatric hours were increased to 32 hours per month.
Conclusion
During the exit meeting on September 29, 2017, the County again assured the Independent Consultant and USDOJ attorney that they were committed to maintaining the 32-hour per month psychiatric coverage well beyond the successful resolution of this Settlement Agreement. In addition, due to the concern regarding continuing supervision of the lone QMHP assigned to the RCDF by Southern Health Partners (SHP), the SHP President informed the RCDF Administrator that:
“Providing additional support, resources, guidance and supervision will be our responsibility, one which we take seriously. We feel our program at Robertson County is a flagship, one that we would like to use in training other staff members as to quality practices. Upon hiring of additional QMHPs we will ask for on-site training at the facility to be completed so that they can further provide support to the QMHP when needed. Also, the SHP Mental Health Director is staying with the company and will continue to have oversite and assist the QMHP at the Robertson County Detention Facility.” As noted above, the Agreement requires “the Court shall retain jurisdiction of this action for all purposes until the County has achieved substantial compliance with each provision of the Agreement, provides constitutional mental health care to prisoners, and has maintained substantial compliance and provided constitutional mental health care for a period of one year.” It is this Independent Consultant’s opinion that, although the three issues noted above and contained in this report have not been ideally resolved, Robertson County has maintained Substantial Compliance with all of the 48 provisions and has operated a substantially adequate mental health care system for a sufficient period of time to warrant completion of this Settlement Agreement.
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5

THE SETTLEMENT AGREEMENT: Substantive Provisions

The County shall take all actions necessary to comply with the substantive provisions of this Agreement listed below. These provisions are intended to ensure that prisoners with mental illness or at risk of suicide receive proper treatment and do not experience unnecessary suffering or harm while incarcerated. The failure to provide necessary treatment not only harms prisoners, but affects public safety if prisoners’ mental health deteriorates during incarceration. Accordingly, the County shall ensure constitutionally adequate intake, assessment, treatment, and monitoring of prisoners with mental health needs or at risk for self-injurious behavior.
A. SUICIDE PREVENTION
The County shall protect the safety of prisoners at risk for self-injurious behavior or suicide by providing timely and adequate access to Qualified Mental Health Professionals, including giving priority access to individuals most at risk of harm and who otherwise meet the criteria for being at high risk for suicide.

Provision A.1
Status Discussion

Policies: The County shall implement comprehensive policies and protocols to ensure that prisoners at risk of self harm are identified, protected, and treated in a manner consistent with the Constitution. The County shall continuously track and analyze prisoners’ risk of self harm and implement measures to protect prisoners by reducing or eliminating the risk of harm. At a minimum, the policies and protocols shall:
Substantial Compliance
This provision is interpreted as a “catch-all” provision for all suicide prevention-related provisions, therefore, this provision cannot come into substantial compliance until all of the provisions under Suicide Prevention come into substantial compliance.
Following several draft revisions, the Southern Health Partners’ (SHP) suicide prevention policy for the RCDF (No. J-G-05) was finalized on March 17, 2014. As discussed in previous reports, the SHP policy needed to be slightly revised based upon the requirements of the Settlement Agreement.
In early January 2014, following several efforts by RCDF officials to develop an adequate suicide prevention policy and in an effort to expedite the process, the Independent Consultant (IC) developed the policy based upon earlier drafts. The revised policy was forwarded back to RCDF officials and also finalized on March 17, 2014.
Because all suicide prevention-related provisions are in Substantial Compliance, this provision was previously moved to Substantial Compliance.

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6
Recommendations
Evidentiary Basis

Provision A.1.a
Status Discussion

Ensure that all prisoners are appropriately screened for risk of self harm using an appropriately validated screening instrument. At a minimum, the screening instrument should include inquiry regarding the following:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as the death of a family member or
close friend; (5) history of suicidal behavior by family members and close
friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court,
transferring agency, or similar individuals regarding the prisoner’s potential suicide risk; (8) medication history; and (9) risk of withdrawal from drugs or alcohol, including whether the prisoner is under the influence of drugs or alcohol, the amounts taken, the date of last dose and history of withdrawal symptoms.
Substantial Compliance
The RCDF Intake Screening form administered by booking officers was revised to include inquiry regarding “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” (see above). In addition, an “Arresting Officer’s Questionnaire” was created to solicit information regarding a detainee’s mental status and potential for suicide risk upon admission into the RCDF. Further, booking officers are said to now utilize the “alert screen” of RCDF’s jail management system “XJail” software to determine if the newly admitted detainee was on suicide precautions during a prior RCDF confinement.
Finally, a critical issue to the appropriate screening of incoming detainees to identify the risk of suicide is the ability to provide reasonable privacy and confidentiality during the intake screening process. (Inmates cannot be expected to affirmatively respond to sensitive medical and mental health inquiries if reasonable privacy is not provided.)

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7

As a result of the 1st Monitoring Report findings, the RCDF Administrator reconfigured the booking area so that the intake screening process is now conducted away from the booking counter and located next to the fingerprint machine on the back wall. Such a change better ensures confidentiality and privacy.

The IC observed the intake process during a previous on-site assessment and verified that all of the above changes were made. As such, this provision was previously moved to Substantial Compliance.

However, as noted in the Introduction of this report, the IC observed a disturbing practice during the most recent monitoring visit in September 2017. The IC reviewed 12 cases of inmates placed on suicide precautions during a prior RCDF confinement and subsequently readmitted into the facility. In 10 of those cases, the booking officer incorrectly marked “no” on the Intake Screening form for the designated question regarding prior suicide precautions in the RCDF. The deficiency was brought to the attention of the RCDF Administrator who subsequently issued the following corrective action on October 26, 2017:

Recommendations

1) The RCDF has requested a report from its jail management system (JMS) provider (Southern Software) of all inmates previously placed on suicide precautions in order to update and present accurate data for use by booking officers;
2) A report will be generated for all inmates placed on suicide precautions in order to ensure that their names are placed in the JMS;
3) The Intake Screening form has been slightly revised to ensure that all booking officers independently verify an inmate’s previous placement on suicide precautions, rather than allowing the inmate’s self-report such information;
4) Prior to an inmate’s housing placement, all prior incident reports will be reviewed to verify any placement on suicide precautions;
5) A new check sheet has been developed that requires a booking officer to verify alerts within the JMS; and
6) Any inmate flagged on the JMS for a prior alert will initially be placed on psychiatric observation status until they can be seen by a QMHP.
The above six-point corrective action of October 26, 2017 appears reasonable and should be monitored by the RCDF’s Continuous Quality Improvement program, see Provisions C1-3.

Evidentiary Basis

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8

Provision A.1.b
Status Discussion

Ensure that all prisoners are screened by Qualified Medical Staff upon arrival to RCDF, but no later than within 24 hours, to identify the prisoner’s risk for suicide or self-injurious behavior. If a prisoner will be discharged in less than 24 hours, Qualified Medical Staff should perform a screening prior to the prisoner’s release.
Substantial Compliance
According to SHP officials, a previous deficiency of health care staff not routinely completing the Suicide Prevention Screening Guidelines form on all new detainees was previously corrected. Currently, each new detainee is required to be screened by either a nurse or QMHP within 24 hours of admission.

The IC previously reviewed medical charts of newly admitted inmates in April 2014 and verified that Suicide Prevention Screening Guidelines forms were completed by nursing staff on a timely basis. As such, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision A.1.c Status
Discussion

Classify prisoners based on the results of the screening factors as low, moderate, or high risk.
Substantial Compliance
Both the RCDF and SHP’s suicide prevention policies have been revised to include the following three levels of observation:
Level 1 requires constant observation for those inmates identified as being at high risk for suicide based upon “an overt attempt of a serious nature and have stated they will continue to attempt. These persons may also present psychotic symptoms and are deemed an immediate danger to themselves or others.”
Level 2 requires close observation at 15 minute intervals and can be said to be reserved for inmates identified as being at moderate risk for suicide based upon “presenting suicidal intention or have made a suicide threat or have made a suicide gesture or plan. These persons are not psychotic.”

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9 Level 3 requires psychiatric observation at 30-minute intervals and can be said to be reserved for inmates “who were not presenting suicidal intent or plan, but may have a history of severe to moderate mental illness and require observation and possibly medical stabilization before being moved into a housing unit.” As such, this provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis
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Provision A.1.d
Status Discussion

10
Ensure that prisoners are protected from identified risks for suicide or self-injurious behavior commensurate with their level of risk by:
(1) Ensuring that any prisoner classified as high risk is searched and monitored with constant supervision until the prisoner is transferred to a QMHP for assessment. Constant supervision means in-person observation of the prisoner on a continuous, uninterrupted basis. Other aids, e.g., closed-circuit television, can be used as a supplement to, but never as a substitute for, such observation. If RCDF cannot provide continuous observation, the prisoner should be transferred to an appropriate mental health facility.
(2) Ensuring that any prisoner classified as moderate risk is searched and monitored with close supervision until the prisoner is transferred to a QMHP for assessment. Close supervision requires staff to observe prisoners at staggered intervals not to exceed every 15 minutes.
(3) Ensuring that any prisoner classified as low risk is searched and monitored until the prisoner is transferred to a QMHP for assessment. Prisoners classified as low risk shall be observed by staff at staggered intervals not to exceed every 30 minutes.
(4) Ensuring that a QMHP conducts appropriate mental health assessments within the following periods from the initial screen:
i. 14 days, or sooner, if medically necessary, for prisoners classified as low risk;
ii. 48 hours, or sooner, if medically necessary, for prisoners classified as moderate risk; and
iii. immediately, but no later than two hours from the time the QMHP comes on duty at RCDF, for prisoners classified as high risk. If a prisoner classified at high risk is set to be released prior to a QMHP arriving on duty at RCDF, RCDF shall call the local mobile crisis unit for an on-site assessment prior to release.
Substantial Compliance
Similar to the provision above (A.1.c), this provision had previously remained in partial compliance because the RCDF and SHP suicide prevention policies were in need of revision and the QMHP had not been hired until October 2013. In addition, this provision required a protocol pertaining to the assessment of inmates on suicide precautions prior to their release from custody. Because

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11
both policies have since been revised and the QMHP was previously found to be fully acclimated into the program, this provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision A.1.e
Status Discussion

Appropriate mental health assessments include an assessment of the following factors:
(1) Whether the suicide risk screening indicates low, moderate or high risk;
(2) Any suicide attempt in the past; (3) Any suicidal ideations, with intent/plan within the past 30
days; (4) Any command hallucinations to harm self within the past 30
days; (5) Any combination of the following:
i. Suicidal ideations within the past year with or without intent/plan;
ii. Suicidal gestures (current and/or within past year); iii. One or more of the following diagnoses:
a. Bipolar Disorder, Depression b. Major Depression with or without Psychotic
Features c. Schizophrenia d. Schizoaffective Disorder e. Any diagnosis within the Pervasive
Developmental Disorder Spectrum f. Any other factor(s) determined by the
Interdisciplinary Team as contributing to suicide risk (e.g. recent loss, family history of suicide, etc.)
(6) Any history of self-injurious behavior resulting in injury requiring medical attention within the past year.
Substantial Compliance
As detailed in the previous report, pursuant to SHP policy, two instruments were available as mental health assessments: a Mental Health Survey and a

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12
Psychiatric Nursing Initial Assessment form. In practice at the RCDF, however, the Mental Health Survey was previously rarely utilized. Upon initial referral, the QMHP often completed a Psychiatric Nursing Initial Assessment. The form listed most of the required factors listed within this provision, although they were not specifically identified.
Substantial compliance could only be achieved with slight revision of the Psychiatric Nursing Initial Assessment form to include specific reference to the required factors referenced in this provision. During a previous site visit, the IC reviewed the new Psychiatric Nursing Assessment (revised from the Psychiatric Nursing Initial Assessment form in May 2014). The form included more in-depth inquiry regarding suicide/self-injurious history, mental health history (including diagnoses), and mental status examination.
This provision was previously moved to Substantial Compliance.
It should be noted, however, that SHP recently changed the name of the “Psychiatric Nursing Assessment” to “Psychiatric Assessment.” Such a name change was inappropriate because the form is completed by the QMHP, not the psychiatrist, and the name of the form closely resembles the name of the psychiatrist’s “Initial Psychiatric Assessment” form. Based upon the IC’s previous recommendation, the form was subsequently renamed a “Mental Health Assessment.”
Recommendations
Evidentiary Basis

Provision A.1.f
Status Discussion

Ensure that QMHPs perform an appropriate mental health assessment following any adverse triggering event while a prisoner remains in RCDF custody, including any of the following:
(1) Any suicide attempt; (2) Any suicidal ideation, with or without a plan; or (3) Any aggression to self resulting in major injury.
Substantial Compliance
The QMHP was hired in October 2013 and a previous review of medical charts indicated assessments were conducted following any of the above listed triggering events. This provision was previously moved to Substantial Compliance.

Recommendations

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13

Evidentiary Basis

Provision A.1.g
Status Discussion

Ensure that QMHPs, as part of the prisoner’s Interdisciplinary Team, maintain a risk profile for each individual based on the assessment factors identified above and develop and implement interventions to minimize the risk of harm to each individual.
Substantial Compliance
With the hiring of a QMHP in October 2013, the RCDF now has an “interdisciplinary team” comprised of the Medical Team Administrator (MTA), RCDF Administrator, and Security Captain that meets on a minimum weekly basis to discuss inmates on suicide precaution, as well as other inmates requiring special handling. As such, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision A.1.h
Status Discussion

Ensure adequate and timely treatment for prisoners, whose assessments reveal mental illness and/or suicidal ideation, including timely and appropriate referrals for specialty care and visits with QMHPs, as clinically appropriate.
Substantial Compliance
With the hiring of a QMHP in October 2013, as well as increase in the number of psychiatric hours, inmates identified as either mentally ill and/or suicidal are now much more likely to receive timely assessments.
Due to continued deficiencies found in this provision, as previously described in the 6th Monitoring Report, Southern Health Partners notified the IC on May 11, 2016 that they had created the following corrective action plan for this provision:
Patients entering the facility with diagnosed mental illness with an active prescription verified and restarted will be placed on the Psychiatrist list immediately. If the patient is stable on their medications, and there are no emergent needs, the following procedure will be adhered to:

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14
1. Patient will be placed on the QMHP log and seen by the QMHP within 14 days. The Psychiatric assessment will be completed at this time.
2. Patient will be placed on the Psychiatrist log, and seen by the Psychiatrist within 30 days (The medical staff will denote why the person is placed on the list (i.e. John Doe, psych meds continued, new assessment needed). The initial Psychiatric Consult will be completed at this time.
If the patient entering the facility has a diagnosed mental illness, and they have no active medication prescription or the prescription cannot be verified:
1. The patient will be placed on the QMHP log and seen within 5 days. The Psychiatric assessment will be completed at this time.
2. The patient will be placed on the Psychiatrist log and seen within 14 days. The initial Psychiatric Consult will be completed at this time.
If the patient entering the facility has an emergent mental health need identified by operations staff or medical staff.
3. The patient will see QMHP on his/her next working day (if they are not in the facility at the time the need was determined)
4. The patient will see the Psychiatrist the next time the Psychiatrist is in the facility (if they are not in the facility at the time the need was determined).
As a result of the above corrective action, Southern Health Partners has made steady improvement in the area of timely referrals for inmates who present as suicidal and/or screened positive for mental illness. Sample review of 12 medical charts of inmates placed on suicide precautions during June through December 2016 found that all received timely assessments by the QMHP. In addition, a sample review of 38 medical charts of inmates who screened positive for mental illness found that almost 90 percent (34 of 38) received timely referrals to the psychiatrist.
This provision was moved to Provisional Substantial Compliance in January 2017 because, although there has been steady improvement and the County reached the 90 percent threshold, there were concerns in a few of the reviewed charts in which the QMHP did not make timely referrals to the psychiatrists. In the 8th Monitoring Report, the IC reviewed 43 medical charts and found that
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15

timely assessments (both initial and/or follow-up QMHP and psychiatric) were provided in 93 percent (40 of 43) of the cases. In the most recent review, conducted on September 28, 2017, sufficiently maintained his level of compliance, i.e., a review of 36 cases found that timely assessments were provided in 89 percent (32 of 36) of the cases.

Recommendations
Evidentiary Basis

Thus, this provision is moved to sustained compliance because of its sustained sufficient level of compliance and, as stated in the Introduction, SHP leadership has agreed to provide continuing supervision to ensure timely assessment by the QMHP and psychiatric providers.
SHP leadership should provide continuing supervision to ensure timely assessment by the QMHP and psychiatric providers.
Review of 36 medical charts of inmates who screened positive for mental illness during June through September 2017.

Provision A.1.i
Status Discussion

Ensure appropriate levels of supervision, as defined above, of actively suicidal prisoners and prisoners with lower levels of risk. Correctional officers shall document their checks in a format that does not have preprinted times and staff shall document their visual verification of the prisoner’s welfare accurately and completely. A supervisor shall conduct and document a review of all documents related to this provision before the end of the shift during which it occurred to ensure compliance with policy and this Agreement.
Substantial Compliance
A previous concern that various observation forms were utilized by correctional officers to verify observation of an inmate on suicide precautions has been corrected with current use of only the SHP’s “Observation Cell Record” form. As verified by the IC during a prior site visit, as well as confirmed during a recent site visit, the forms are now reviewed and signed by a RCDF supervisor each shift. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

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Provision A.1.j
Status Discussion

16
Set forth the conditions of the watch, including allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a QMHP, except under emergency circumstances.
Substantial Compliance
This provision is interpreted to include not only the policy, procedures, and practices regarding allowable clothing, property, and utensils afforded inmates placed on suicide precautions, but (as noted above, “consistent with generally accepted correctional standards of care”) also the location in which they are housed and the expectation that they will be housed in cells that are “suicide resistant.”
Suicidal inmates are placed in several locations within the RCDF: 1) inmates requiring Level 1 constant observation or Level 2 close observation are placed in either Cell No. 5 or Cell No. 6 in the medical unit; 2) inmates requiring Level 2 close observation are placed in any of the nine (9) booking cells. In addition, inmates requiring Level 3 psychiatric observation are placed in one of the four (4) observation/isolation cells.
During the initial site visit in late February 2013, the IC inspected each of these cell areas and found that the ceiling ventilation grates in all of the booking cells, as well as the observation/isolation cells, contained holes with a diameter greater than the industry standard of 3/16 per inch. Ventilation grates with this diameter allow for an inmate to weave a piece of clothing or other material through the grate hole and utilize the vent as an anchoring device in a hanging attempt. Within the medical unit, the designated cells contained double bunks in which the metal frames also served as potential anchoring devices in a hanging attempt, as well as contained bunk holes that could be easily be utilized as an anchoring device.
Following issuance of the 1st Monitoring Report in April 2013, the RCDF Administrator embarked upon a program to retrofit cells that were designated for suicide precautions. The result was removal of double bunks in the medical unit, covering of bunk holes, and replacement of ceiling ventilation grates. Various photographs of the renovation project were subsequently sent to the IC for review. Inspection of the photographs found that although bunk holes had been covered from the bunks, there still appeared to be a significant gap between the bunk frame and the wall that could be utilized as an anchoring point in a suicide attempt by hanging. In addition, although the holes in the new ventilation grates appeared to be smaller in diameter, it was difficult to ensure that the holes were the industry standard of 3/16 per inch or smaller in diameter from review of the photographs. On September 15, 2013, an inmate on Level 2 suicide precautions was able to weave a piece of his sheet through the

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17
ventilation grate in his cell. As a result, the RCDF Administrator ordered that the ventilation grates be replaced again.
During the IC’s 3rd Monitoring visit, the renovation project was inspected once again with the RCDF Administrator and personnel from the Robertson County Maintenance Department. The inspection found that Cell No. 5 or Cell No. 6 in the Medical Unit still contained a gap between the bed and wall, as well as ventilation grates with holes that were larger than 3/16 inch diameter that could (and have been) utilized as an anchoring point in a suicide attempt by hanging. In addition, inspection of the nine (9) Booking cells found that although one ceiling ventilation grate in each cell had been replaced with a grate of 3/16 inch diameter, the second grate in each cell remained dangerous and needs to be replaced.
During the IC’s on-site monitoring visit in February 2015, the nine (9) Booking cells and Cell No. 5 or Cell No. 6 in the Medical Unit were again inspected and found to be suicide-resistant. The ventilation grates in both the Booking cells and the Medical Unit were retrofitted with a grate of 3/16 inch diameter, and the gap between the bed and the wall in the Medical Unit cells was covered. As such, this provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision A.1.k
Status Discussion

Ensure that a QMHP or QMS, not including a licensed practical nurse, regularly, but no less than once per day, reassesses prisoners on suicide precautions to determine whether the level of precaution or supervision should be raised or lowered. It is expected this reassessment will be made on-site and in person on Monday through Friday, and will be made by a QMHP or QMS by telephone communication with the assistance of a LPN on the weekends. These reassessments shall be documented and recorded in the prisoner’s medical chart.
Substantial Compliance
With the hiring of a QMHP in October 2013, inmates on suicide precautions are now much more likely to receive daily assessments during the work week. In addition, review of medical charts during several recent monitoring periods found that nursing staff have greatly improved documenting their weekend check-ins of suicidal inmates.

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Due to continued deficiencies found in this provision, as previously described in the 6th Monitoring Report, SHP notified the IC on May 11, 2016 that they had created the following corrective action plan for this provision:
The QMHP will:
1. Complete the Suicide Risk Assessment at his/her initial assessment of the patient on Suicide Precautions.
2. If the patient is released from suicide observation at this time, this will serve as the only assessment of the patient by the QMHP while on observation.
3. If the patient is continued on suicide precautions, the QMHP will conduct an initial SRA and a reassessment SRA prior to release from suicide precautions.
4. If the patient is kept on suicide precautions more than 2 days, QMHP will complete the Mental Health Clinical Contact Monitoring Form to document continued reassessments until the patient is discontinued from suicide precautions.
As a result of the above corrective action, SHP made steady improvement in the area of timely assessments and reassessments referrals for inmates on suicide precautions. Sample review of 12 medical charts of inmates placed on suicide precautions during June through December 2016 found that all received timely assessments by the QMHP, and all inmates were reassessed on a daily basis, including weekends by nursing staff. As such, this provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision A.1.l
Status

Ensure that all mental health care staff within the Jail have access to critical information for prisoners on suicide precautions (e.g., progress notes from all treating clinicians). Following each assessment, mental health care staff shall provide correctional staff with pertinent and relevant information regarding a prisoner on suicide precautions to the extent that it affects the correctional staff’s duties and responsibilities for supervising prisoners on suicide precautions.
Substantial Compliance

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Discussion

With the hiring of a QMHP in October 2013, the QMHP and psychiatrist continue to communicate and collaborate on individual cases, as well as provide correctional personnel with appropriate information as needed. As such, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision A.1.m
Status Discussion

Ensure that only a QMHP may promote, demote, or terminate a prisoner’s suicide precaution level or status. LPNs and correctional officers may only modify suicide precautions or remove prisoners from suicide watch upon the documented order of a QMHP.
Substantial Compliance
Review of medical charts during previous assessments indicated that only a QMHP has been upgrading, downgrading, and discharging inmates from suicide precautions. Pursuant to both RCDF and SHP policy, nursing and correctional personnel can initiate suicide precautions pending an assessment by a QMHP. As such, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision A.1.n
Status
Discussion

Ensure that all prisoners discharged from suicide precautions receive a follow-up assessment within eight days, in accordance with a treatment plan developed by a QMHP.
Substantial Compliance
This provision specifically requires an assessment within 8 days following discharge from suicide precautions, as well as development of a treatment plan.
The SHP suicide prevention policy (J-G-05) exceeds this provision’s requirements by requiring a QMHP to conduct follow-up assessments of inmates discharged from suicide precautions (and were on such precautions for more than 24 hours) at intervals of 7 days, 14 days, 1 month, and then periodically until discharge from custody. A “SHP Suicide Watch Tracking Log” is utilized to manage this follow-up schedule.

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In addition, pursuant to the SHP suicide prevention policy, “The treatment plan will describe signs, symptoms, and the circumstances in which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the patient or medical staff can take if suicidal thoughts do occur. This treatment plan is to be documented in the patient’s medical record accordingly.”
The QMHP has consistently provided a high level of compliance with followup assessments for inmates released from suicide precautions. Treatment planning, however, was chronically problematic. Due to this deficiency, as previously described in the 6th Monitoring Report, Southern Health Partners notified the IC on May 11, 2016 that they had created the following corrective action plan to address treatment planning:
The QMHP will:
1. Follow up with patients (who were on suicide precautions more than 24 hours) as established in the SHP policy (J-G-05).
2. Complete a treatment plan on patients who were on suicide precautions longer than 24 hours. (Please see Treatment Plan Attached). This form will be used with the SRA at the time of release from suicidal precautions.
As a result of the above corrective action, SHP has made steady improvement in the area of timely assessments and reassessments referrals for inmates on suicide precautions. Sample review of 12 medical charts of inmates placed on suicide precautions during June through December 2016 found that all had treatment plans contained on a new SHP form entitled “Treatment Plan Suicide Precautions Release.” Although all of the treatment plans listed specific goals, objectives, and interventions to reduce and/or avoid recurrence of the inmate suicidal ideation, not all of the plans were as specific as they should have been. In addition, although group therapy was recommended in most treatment plans, there was no documentation to suggest that these inmates were enrolled in any of the RCDF’s current group therapy classes. Because of the improvement in treatment planning templates for suicidal inmates, this provision was moved to Substantial Compliance in January 2017.
The most recent review, conducted on September 28, 2017, did not find substantial improvement, i.e., a review of seven (7) cases of inmates placed on suicide precautions continue to find safety plans that needed improvement in most of the cases.
Given the Independent Consultant’s discussions with RCDF leadership concerning this issue, as well as the level of technical assistance rendered onsite, coupled with SHP leadership agreeing to provide continuing supervision
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Recommendations

of the QMHP to ensure adequate development of safety planning in appropriate cases, this provision is moved to sustained compliance.
SHP leadership should provide continuing supervision of the QMHP to ensure that treatment plans for inmates discharged from suicide precautions contain individualized, realistic, and measurable strategies to reduce the recurrence of suicidal ideation.

Evidentiary Basis
Provision A.2.a
Status Discussion

Review of seven (7) medical charts of inmates placed on suicide precautions during June through September 2017.
Training: The County shall ensure that all staff have the adequate knowledge, skill, and ability to address the needs of prisoners at risk for suicide. Within 180 days of the Effective Date, the County will institute a suicide prevention training program. The County shall review and revise its current suicide prevention training curriculum to include the following topics:
(1) suicide prevention policies and procedures (as revised consistent with this Agreement);
(2) analysis of facility environments and why they may contribute to suicidal behavior;
(3) potential predisposing factors to suicide; (4) high-risk suicide periods; (5) warning signs and symptoms of suicidal behavior; (6) case studies of recent suicides and serious suicide attempts; (7) mock demonstrations regarding the proper response to a
suicide attempt; and (8) the proper use of emergency equipment.
Substantial Compliance
A SHP consultant previously developed a suicide prevention curriculum entitled “Suicide Training: Inside the Bars.” The PowerPoint curriculum, 72 slides in length, contained the following topics:
• Why are we doing this? • Constitutional responsibility to address suicide • What the research says – What experience says • Myths – Barriers to prevention & how to change it • Causal factors: environment, events, individual stressors, mental
illness/SA • Suicide requires intent, means and opportunity • Components to good prevention • Overview of WCD and SHP policy • Details of policy

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• Management options – in house, out of house • QPR and Debriefing
The curriculum was quite good and consistent with the required training topics within this Agreement.
The IC received verification that correctional and health care staff was trained on the suicide prevention curriculum on November 19 and November 26, 2013, resulting in approximately 95 percent of required staff trained. As such, this provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision A.2.b Status
Discussion

Ensure that all correctional, medical, and mental health staff are trained on the suicide screening instrument.
Substantial Compliance
The IC received verification that correctional and health care staff was trained on the suicide prevention screening forms on April 4 and April 9, 2014, resulting in approximately 99 percent of required staff trained. As such, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision A.2.c
Status Discussion

Ensure that a minimum of four hours of in-service suicide prevention training is completed annually by all correctional, medical, and mental health staff, to include training on updated policies, procedures, and techniques.
Substantial Compliance
Annual suicide prevention training was initiated in September 2014, with four workshops held on September 3, September 4, September 15, and September 16. The QMHP was the instructor for most of the workshops. The IC previously reviewed the lesson plan for the 4-hour annual suicide prevention training and found it to be comprehensive. To date, all correctional staff, and all medical

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staff, has completed the annual suicide prevention training. This provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision A.2.d

Ensure that correctional staff is trained in observing prisoners on suicide watch and step-down unit status.

Status Discussion

Substantial Compliance
This provision appears redundant with Provision A.2.a. and because Substantial Compliance has been achieved with completion of the initial 4-hour suicide prevention training described in Provision A.2.a., this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision A.2.e

Ensure that all correctional staff are certified in cardiopulmonary resuscitation (“CPR”).

Status Discussion

Substantial Compliance
The RCDC Administrator previously informed the IC that most correctional staff received CPR training on November 19 and November 26, 2013, resulting in approximately 90 percent of required staff trained. (The MTA had previously reported, and training records reflected, that all medical staff were currently certified in CPR.) CPR cards were received in March 2014. According to the RCDF training director, CPR training occurs every two years and is again due to commence in 2015. According to the training director, approximately 90100 percent of custody staff are always CPR certified. This provision was previously moved to Substantial Compliance.

Recommendations

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Evidentiary Basis

Provision A.2.f
Status Discussion

Ensure that an emergency response bag that includes appropriate equipment, including a first aid kit and emergency rescue tool, shall be in close proximity to all housing units. All staff coming into regular contact with prisoners shall know the location of this emergency response bag and be trained to use its contents.
Substantial Compliance
First aid kits, automated external defibrillators (AED), and emergency rescue tools were previously found in each housing unit tower inspected by the IC. First aid kits included microshields and similar equipment utilized for rescue breathing. In addition, the medical unit had an emergency response bag that includes portable oxygen and an AED.

In regard to a previous recommendation to establish an emergency medical code system, RCDF and SHP officials decided not to establish a code system, but rather revise the current protocol so that all first responders now specifically announce the nature of the emergency, including medical equipment required. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

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B. MENTAL HEALTH TREATMENT
The County shall ensure that prisoners suffering from mental illness receive treatment appropriate to their condition and adequate to prevent unnecessary suffering or risk of harm. Proper treatment will also assist prisoners in successfully reentering the community upon release. To achieve this outcome, the County shall provide sufficient staffing to meet the demands for timely access to QMHPs and/or QMS and ensure that qualified staff perform comprehensive assessments, provide comprehensive multidisciplinary treatment planning and medication management, and monitor medication side effects.

Provision B.1
Status Discussion

Policies: The County shall implement comprehensive policies and protocols to ensure that RCDF delivers mental health services that include an array of services. These policies and protocols must also provide for necessary and appropriate mental health staff; require a treatment plan for prisoners with serious mental illness; and contain mechanisms sufficient to measure whether care is being provided in a manner consistent with the Constitution. At a minimum, the policies and protocols shall:
Substantial Compliance
This provision is interpreted as a “catch-all” provision for all mental health treatment-related provisions, therefore, this provision cannot come into substantial compliance until all of the provisions under Mental Health Treatment come into substantial compliance.

The current assessment found that SHP had appropriately revised several policies regarding the provision of mental health services, including the Basic Mental Health Services (J-G-04) and Special Needs Treatment Plans (J-G-01), revised May 11, 2016. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.1.a Status Discussion

Ensure that all prisoners are appropriately screened for mental illness using an appropriately validated screening instrument.
Substantial Compliance As indicated in previous monitoring reports, this provision requires that all RCDF inmates are to be screened utilizing an appropriately validated screening instrument. The provision does not address the time frame by which the

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screening is to be completed and what entity is responsible (corrections, medical, or mental health) for the screening. In addition, the IC is not aware of any validated screening instrument for mental illness in operation in any correctional facility throughout the country.
National correctional standards (e.g., the National Commission on Correctional Health Care) require that initial mental health screening include a structured interview with inquiries into the following areas:
• psychiatric hospitalization and out-patient treatment • suicidal behavior and suicidal ideation • violent behavior • victimization • special education placement • cerebral trauma or seizures • sex offenses • psychotropic medications • drug or alcohol abuse • orientation to person, place, and time • emotional response to incarceration • screening for intellectual functioning (i.e., mental retardation,
developmental disability, and learning disability
National correctional standards require that the initial mental health screening be completed on all inmates within 14 days of admission into the facility.
Currently, all inmates entering the RCDF receive Medical Screening from a booking officer. The form contains some inquiry regarding suicide risk and mental health history, but not all of the above described areas are addressed. In addition, SHP utilizes a “Medical Staff Receiving Screening form,” but this instrument is not appropriate for this provision for two reasons: 1) the form is not currently utilized for all inmates, it is only utilize on inmates referred to medical staff from the booking officer’s Medical Screening form; and 2) the form is deficient in its very limited mental health inquiry.
According to SCP’s Mental Health Policy (No. J-E-05), “all inmate patients with positive screening for mental health upon intake will receive a mental health evaluation. The post-admission evaluation will be performed within 14 days of intake.” This policy was defective because it assumed that the inmate had received initial mental health screening from an adequate screening instrument. As found in previous on-site monitoring tours, because the screening forms utilized in the RCDF (i.e., the Medical Screening form administered by booking staff and the Medical Staff Receiving Screening Form) did not address all of the required areas, proper screening for mental illness was not being done.
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However, SCP did have a screening instrument entitled “Mental Health Survey” that was appropriate for use as an initial mental health screening form, but was previously not being utilized on a regular basis. As stated in the 3rd Monitoring Report, the IC informed the parties that substantial compliance with this provision could be obtained if medical staff administered the Mental Health Survey form to all inmates in the RCDF within 14 days of admission. Positive responses to the mental health survey form would then result in a referral to the QMHP or psychiatrist for completion of a mental health evaluation. Currently, either the “Psychiatric Nursing Assessment” or the “Initial Psychiatric Assessment” forms could be utilized completion of a mental health evaluation, although the “Psychiatric Nursing Assessment” could not be utilized as a suicide risk assessment form. The Mental Health Survey form was reactivated in April 2014.
As detailed in a previous monitoring report, several medical charts were reviewed and each contained a Mental Health Survey form that had been completed in a timely fashion (i.e., within 14 days of admission). As such, this provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision B.1.b Status Discussion

Ensure that treatment plans adequately address prisoners’ serious mental health needs and that the plans contain interventions specifically tailored to the prisoners’ diagnoses and problems.
Substantial Compliance
As previously indicated, unless instructed otherwise by the parties, the IC has been utilizing the following working definition of serious mental illness: “A diagnosable mental disorder characterized by severe alterations in thinking, mood, or impaired behavior associated with distress and/or impaired functioning; primarily inclusive of major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder, panic disorder, and post-traumatic stress disorder, but may include a personality disorder with significant functional impairments.”
SHP’s Special Needs Treatment Plans Policy (No. J-G-01) has undergone numerous revisions in order to become compliant with the Settlement Agreement. It was most recently revised on May 11, 2016 and includes a revised list of serious mental health disorders that require a treatment plan:

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• schizophrenia • paranoid with other psychotic disorders • bipolar disorders (hypomania, manic, depressive, and mixed) • major depressive disorder (single episode or recurrent) • schizoaffective disorder (bipolar or depressive0 • pervasive developmental disorders • obsessive-compulsive disorders • depression in childhood and adolescence • panic disorder • post-traumatic stress disorders (acute, chronic, or with delayed onset) • bulimia nervosa • anorexia nervosa
• In addition, substance abuse disorders, adjustment disorders, and personality disorders (borderline and antisocial)
In addition, the SHP policy now includes the requirement for: 1) narrative requiring all inmates with a serious mental illness have an active psychiatric diagnosis and then develop a specific intervention tailored to that diagnosis, 2) a working definition/listing of serious mental illness diagnoses, and 3) treatment planning definitional narrative from the National Commission on Correctional Health Care’s “Patients with Special Health Needs” (Standard JG-02).
During this 7th monitoring visit, sample review of 38 medical charts of inmates who screened positive for mental illness found that almost 90 percent (34 of 38) were seen by both the QMHP and psychiatrist, and treatment plans were subsequently developed.
Because of the improvement in treatment planning for inmates with serious mental illness, this provision was previously moved to Substantial Compliance. However, similar to Provision A.1.n (regarding treatment planning for suicidal inmates) the QMHP needs to demonstrate better consistency in this area.
Recommendations
Evidentiary Basis
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Provision B.1.c Status Discussion

29
Ensure adequate on-site psychiatric coverage for prisoners’ serious mental health needs and ensure that psychiatrists see such prisoners in a timely manner.
Substantial Compliance
As indicated in prior monitoring reports, the psychiatrist was originally providing four (4) or eight (8) hours of on-site services per month. In September 2013, those hours were allegedly increased to 16 hours per month. However, during the IC’s 3rd on-site monitoring visit, it was determined that the psychiatrist was still only devoting approximately 8 hours of on-site services per month. However, at the conclusion of that visit, and with the intervention of both the RCDF Administrator and Sheriff, authorization for funding an additional 8 hours of on-site psychiatric services per month time was granted. As such, beginning in mid-June 2014, on-site psychiatric services was increased to 16 hours per month, and fulfilled by the current psychiatrist and a colleague.
The standard of care requires that inmates identified with a serious mental illness and in need of psychotropic medication should be seen by a psychiatrist no more than 14 days from identification of the mental illness (which normally occurs during the intake screening process), unless the current behavior indicates the need for an emergent or urgent assessment. In addition, a newly arrived inmate with serious mental illness that has a current prescription for psychotropic medication that can be verified and timely dispensed (i.e., within 24 to 72 hours), should be seen within 30 days unless the behavior indicates the need for an emergent or urgent assessment. Finally, all inmates receiving psychotropic medication should be seen by a psychiatrist at least every 90 days, or sooner if a change in medication is indicated and/or a different level of care is warranted.
Although the increase in psychiatric coverage to 16 hours per month has resulted in a significant increase in the number of psychiatric contacts with inmates, the IC’s previous reviews of medical charts continued to find problems with timely initial psychiatric assessments. The following recommendation was included within the 4th Monitoring Report: “SHP data captured on the monthly Daily Report of Mental Health Services should include the total number of new inmates that were identified during the month as exhibiting serious mental illness and in need of psychotropic medication, and then whether they were seen on a timely basis (either within 14 days or 30 days, unless the behavior indicated an urgent or emergent referral).” In response, SHP subsequently notified the IC on May 5, 2015 that “The monthly reporting statistic sheet has been altered to include new patients receiving psychotropic medications.”
During the IC’s May 2016 review of 8 medical charts of inmates identified as seriously mentally ill continued to indicate problems with timely psychiatric

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assessment, only 2 of 8 reviewed cases (25%) resulted in a psychiatric assessment. This was a very disappointing finding and resulted in continued Partial Compliance with this provision.

As a result of this continued efficiency, the IC was informed during a teleconference call on July 11, 2016 that several SHP staffing changes were approved by the County: 1) the number of psychiatric hours was increased from 16 to 32 per month; 2) a new “mental health clerk” position was funded at 30 hours per week; and 3) a “medical compliance officer” position was established at 36 hours per week.

In addition, according to other SHP data, over 70 inmates per month are prescribed psychotropic medication in the RCDF. However, although SHP data captured on the Daily Report of Mental Health Services was recently revised pursuant to the IC’s recommendation to include both “new patient” contacts and “chronic care” contacts by the psychiatrist(s), the data did not indicate whether the contacts were timely. As previously offered, because this provision measures the timeliness of psychiatric contacts, this SHP data would be more helpful if it included the total number of inmates that were identified during the month as exhibiting serious mental illness and in need of psychotropic medication, and then whether they were seen on a timely basis (either within 14 days or 30 days, unless the behavior indicated an urgent or emergent referral).

Recommendations

As a result of the above corrective action, SHP has made steady improvement in the area of timely referrals to, and assessments initiated by, the psychiatrists. During this 7th monitoring visit, sample review of 38 medical charts of inmates who screened positive for mental illness found that almost 90 percent (34 of 38) received timely referrals to the psychiatrist. This provision was previously moved to Substantial Compliance. It was noteworthy that Substantial Compliance was achieved because psychiatric hours were increased to 32 hours per month.
The County and SHP should continue to ensure that psychiatric hours are maintained at a minimum of 32 hours per month.

Evidentiary Basis

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Provision B.1.d
Status Discussion

Ensure that prisoners with chronic mental illness are placed on a chronic mental health list for follow-up every 30, 60, or 90 days, as clinically appropriate. Prisoners with chronic mental illnesses shall not be required to submit a request for mental health services in order to receive such services at regular intervals.
Substantial Compliance
With the hiring of a QMHP in October 2013, inmates with chronic mental illness are more likely to be seen on a timely basis that 30, 60, and 90-day intervals. The QMHP has assumed responsibility for maintaining the SHP Nursing Chronic Disease Flowsheet and Chronic Illness Tracking Log to identify and manage inmates with chronic and serious mental illness.

During the 3rd Monitoring visit, a “Mental Health Chronic Care Clinic Log” had been developed and utilized as a tracking tool. According to the IC’s review of several months of data, documents, it would appear that almost all inmates on the Mental Health Chronic Care Clinic Log were seen by the QMHP on a monthly basis. Because this provision does not include a requirement to assess the quality of assessment or treatment planning, and simply requires regularly scheduled contact with the QMHP, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.1.e
Status Discussion

Ensure timely and appropriate therapy, counseling, and other mental health programs for all prisoners with serious mental illness. This includes adequate space for treatment, an adequate number of QMHPs to provide treatment, access to licensed in-patient psychiatric care when clinically appropriate, and an adequate array of structured therapeutic programming.
Substantial Compliance
Structured therapeutic programming for inmates with serious mental illness, to include both individual and group therapy, was previously either very limited or not occurring at all. When offered, individual therapy was provided by only the QMHP or psychiatrist. Both clinicians assess inmates with serious mental illness in the privacy of the QMHP’s office (unless they are on suicide precautions where they are seen by the QMHP in the booking area).
Beginning in September 2014, the County agreed to hire a licensed professional counselor (LPC) through SHP to provide 10 hours of weekly group therapy

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treatment. At that time, the LPC has reportedly provided the 14-week Anger Management group to over 36 inmates. Priority was given to inmates with serious mental illness. Previous preliminary plans were to offer a Life Skills group in the future.
Access to licensed in-patient psychiatric care remained available following assessment and referral of the SHP psychiatrist, as well as following triage by a Mobile crisis clinician from Centerstone Mental Health Services. SHP revised its Basic Mental Health Services policy (J-G-04) to include reference to a fulltime QMHP, on-site psychiatric coverage, and a list of emergency treatment services (i.e., Mobile Crisis Services, Northcrest Medical Center Emergency Department, and Middle Tennessee Mental Health Institute).
During a previous on-site monitoring visit, the IC requested a listing of all inmates with mental serious mental illness that had participated in the anger management program. In addition, because offering only one therapeutic program (i.e., “anger management”) did not represent an “adequate array of structured therapeutic programming,” the IC recommended that the SHP psychiatrist and QMHP confer and discuss the types of therapeutic programming that would be most appropriate for RCDF inmates with serious mental illness. It was agreed by the parties during the debrief meeting on September 9, 2015 that SHP officials will then develop a plan and schedule for delivering such programming within the current 40-hour per month allotment for therapeutic programming and submit it to the IC by December 1, 2015.
The SHP corrective action plan dated May 11, 2016 included a revised Basic Mental Health Services policy (J-G-04) listing the following treatment services offered to inmates with a serious mental illness on a case-by-case basis:
• Suicide Monitoring and Follow-up • Psychiatric Assessment by the QMHP • Discharge Planning as indicated • Treatment Planning (as indicated in the Psychiatric Assessment) • Initial Psychiatry Consult • Ongoing Psychiatry monitoring as determined in the initial consult • Medication Management/monitoring • Individual Psychotherapy • Group Psychotherapy (to include the following groups; however, not
limited to)  Managing Stress and Anxiety  Breathing Exercises  Understanding Bi-Polar and Managing your illness  Sleep Management  Anger Management  Natural ways to control impulses
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 Parenting Skills  Coping with incarceration  Effects of various drugs  Schizophrenia (ADL enhancement skills)
SHP notified the IC on May 31, 2016 that it had consulted with its group facilitator and proposed rotating the following groups every three months: 1) anger management, 2) coping with stress and anxiety, and 3) life skills. The IC responded to SHP that, based upon an uncertain average length of stay within the RCDF, it was unknown as to whether inmates with a serious mental illness could be offered all three groups during their confinement. As a result, the IC suggested that SHP explore the possibility of scheduling these three groups on a rotating three-week basis (i.e., a different group each week). As a result, SHP agreed to the revised group schedule.
During this 7th on-site monitoring visit, the IC was informed that the original group facilitator had resigned their position effective August 23, 2016. A new facilitator was subsequently hired and groups were restarted on October 11, 2016. Despite the loss of group therapy treatment for approximately seven (7) weeks, SHP has shown steady improvement with this provision during the last two months. The following treatment modules are now offered to inmates with serious mental illness at the RCDF:
• The Right Frame of Mind/Acceptance of Mental Health Disorders/Coping with Incarceration
• Anger Awareness/Dysfunctional Thinking/Conflict Resolution • Managing Stress and Anxiety/Mindfulness/Calming
Techniques
These three groups continue to be rotated on a three-week basis (i.e., a different group each week). Groups run between 60 and 90 minutes. The group facilitator is on-site for approximately 10 hours per week (Monday and Tuesday).
Since these group therapy sessions were initiated on June 20, 2016, approximately 350 inmates have participated, with most involved with multiple group sessions. Review of attendance sheets over the course of several months found only one area of concern, i.e., approximately 15 percent of inmates assigned to the program refused to participate, and an unknown, but large number of assigned inmates could not participate in subsequent sessions because they were released from custody.
During the most recent on-site visit, the IC had an opportunity to converse with the group facilitator on September 28, 2017 and determined that group participation has increased based upon several corrective actions, including a
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change of schedules and custody personnel proactively encouraging inmate participation. This provision was previously moved to Substantial Compliance.
Recommendations

Evidentiary Basis

Interview with group facilitator on September 28, 2017.

Provision B.1.f
Status Discussion

Ensure an adequate array of crisis services to appropriately manage the psychiatric emergencies that occur among prisoners. Crisis services shall not be limited to administrative segregation or observation status. Prisoners shall have access to appropriate licensed in-patient psychiatric care.
Substantial Compliance
As offered during the other on-site sites, although SHP Basic Mental Health Services policy (No. J-G-04) briefly addressed crisis services to manage psychiatric emergencies (e.g., “crisis intervention is to be initiated if patient is a threat to themselves and others”), the policy was very vague as to a specific protocol that was to be initiated during a psychiatric emergency. Inmates in crisis were put on either Suicide Precautions or Medical Observation status, as well as the Restraint Chair on a limited basis (see provision B.4.a below). Access to licensed in-patient psychiatric care was available following assessment and referral of the SHP psychiatrist, as well as following triage by a Mobile crisis clinician from Centerstone Mental Health Services.

SHP previously revised its Basic Mental Health Services Policy (No. J-G-04) to list its emergency treatment services (i.e., Mobile Crisis Services, Northcrest Medical Center Emergency Department, and Middle Tennessee Mental Health Institute). This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

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Provision B.1.g
Status Discussion

Ensure that the Jail’s QMHPs or QMS maintain a log of prisoners receiving mental health services, which shall include both those prisoners who receive counseling and those who receive medication. The log shall be updated every time a prisoner receives mental health services. The log shall include each prisoner’s name, diagnosis or complaint, and next scheduled appointment. Each clinician shall have ready access to a current log listing any prescribed medication and dosages for prisoners on psychotropic medications.
Substantial Compliance
As previously discussed, the QMHP assumed responsibility for maintaining the SHP Nursing Chronic Disease Flowsheet and Mental Health Chronic Care Clinic Log to identify and manage inmates with chronic and serious mental illness. In addition, as recommended in a previous monitoring report, each intervention with an inmate is now documented as a progress note in the inmate’s medical chart. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.2.a
Status Discussion

Training: Ensure that all mental health staff performing mental health assessments receive comprehensive training concerning the policies, procedures, and practices for the delivery of mental health services, including the screening, assessment, and referral processes.
Substantial Compliance
Although hired in October 2013, the QMHP has not received any additional mental health training other than that provided by the SHP Vice President of Operations. The IC was informed during several prior monitoring on-site visits that future training would include instruction in the new DSM-5 Diagnostic and Statistical Manual of Mental Disorders, as well as attendance at a Correctional Mental Health Care Conference sponsored by the National Commission on Correctional Health Care. Because such training had not occurred as of February 2015, the date of the last on-site monitoring, the IC again recommended verification that the QMHP has received instruction on the new DSM-5 Diagnostic and Statistical Manual of Mental Disorders, as well as attended workshops at the NCCHC’s Spring Conference on Correctional Health Care in April 2015. In response, SHP notified the IC that the “QMHP completed training at the NCCHC conference in New Orleans in April 2015. Please see attached class roster those attended by QMHP.”

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While on-site during the 4th Monitoring visit, the IC conversed with the QMHP who verified that she has received, and begun to review, the new DSM-5 Diagnostic and Statistical Manual of Mental Disorders, as well as Lippincott’s Manual of Psychiatric Nursing Care Plans, which contains 52 treatment plans addressing the most commonly encountered behaviors of serious mental illness. In addition, the QMHP attended the NCCHC conference in April 2015 and participated in approximately 11 workshops.
This provision was previously moved to Substantial Compliance based upon the agreement that the QMHP would be scheduled to attend future NCCHC conferences on an annual basis, with the costs to be shared by both the County and SHP.
Recommendations
Evidentiary Basis

Provision B.2.b Status Discussion

Ensure that all nurses performing health screenings receive comprehensive training concerning the policies, procedures, and practices for the mental health screening process.
Substantial Compliance
As discussed in previous monitoring reports, the MTA trained all nursing staff regarding completion of the Mental Health Survey form in April 2013, but the form was rarely utilized. In 2014, however, Mental Health Survey form was reactivated and now required to be completed on all inmates within 14 days of RCDF confinement.

In addition, all nursing staff, as well as most correctional staff received a 2hour annual mental health workshop on September 3, September 4, and September 15, 2014. Most of the workshops were conducted by the QMHP. The IC previously reviewed the lesson plan and found it to be adequate. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

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Provision B.2.c
Status Discussion

Randomly test five percent of relevant staff on an annual basis to determine their knowledge of the policies, procedures, and practices for the mental health screening, assessment, and referral processes. The testing instrument and policies shall be approved by the United States. The results of these assessments shall be evaluated to determine the need for changes in training practices. The review and conclusions will be documented and provided to the IC, the County, and the United States.
Substantial Compliance
Previously, a post-test was developed and administered to all correctional staff receiving suicide prevention training. The SHP Vice President of Operations subsequently developed a post-test of five questions related to policies and procedures on suicide prevention and mental health services. The IC approved the post-test during a previous on-site visit. The post-test was administered to all SHP personnel in April 2014, as well as to all correctional staff in September 2014. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.2.d
Status Discussion

Develop and implement written training protocols in the area of mental health for correctional staff, including an introductory training provided to new hires, which will include training on basic mental health information (e.g., recognizing mental illness, specific problematic behaviors, additional areas of concern); identification, timely referral, and proper supervision of prisoners with serious mental health needs; appropriate responses to behavior symptomatic of mental illness; suicide prevention; and an annual refresher training on relevant topics. The training will be conducted by a QMHP. The County will document and track training and attendance by staff, who must attend the training provided for in this provision in order to continue their employment.
Substantial Compliance
As discussed in B.2.b above, most correctional staff received a 2-hour annual mental health workshop on September 3, September 4, and September 15, 2014. Most of the workshops were conducted by the QMHP. The IC reviewed the lesson plan, previously developed by Centerstone Mental Health Services and including a 65-slide PowerPoint presentation entitled “Mental Illness 101,”

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and found that it reasonably reflected the requirements of this provision. This provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision B.3.a

Psychotropic Medication Management: The County shall ensure the accurate administration of psychotropic medication and maintenance of medication records. At a minimum, the County shall:

Status Discussion

Ensure that prisoners have proper diagnoses made by a psychiatrist, psychologist or medical doctor for each psychotropic medication they receive.
Substantial Compliance
During the IC’s initial review of selected records in late February 2013, each health care chart had a Medication Administration Record (MAR) that accurately reflected administration of psychotropic medication(s). However, as required by this provision, not all of the selected records contained a psychiatric diagnosis associated with the psychotropic medication. It was the IC’s recollection during the 3rd Monitoring visit that the SHP Vice President of Operations stated the current mental health diagnosis would be contained on the MAR of each inmate. However, when the IC began to review a sample of MARs during a recent previous visit, it was found that diagnoses were not contained on the forms. A subsequent discussion with both the SHP Vice President of Operations and MTA determined that they were under the impression that the diagnoses would be contained in the psychiatric note and/or IPA section of the medical chart, as originally envisioned. Due to this misunderstanding, this provision could not be adequately audited during the February 2015 on-site visit.

The 4th Monitoring Report contained two recommendations for SHP to continue auditing medical charts to ensure that current psychiatric diagnoses were in the chart, preferably in the MAR. In response, SHP notified the IC on May 5, 2015 that “the diagnosis is being written on the MAR at the present time and please see attached audit to include those with diagnosis as well.”

Following review of numerous medical charts during previous monitoring audits, this provision was previously moved to Substantial Compliance.

Recommendations

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Evidentiary Basis

Provision B.3.b Status Discussion

Ensure a medication continuity system so that incoming prisoners receive psychotropic medications for serious mental health needs in a timely manner, as medically appropriate.
Substantial Compliance
As previously offered by SHP, once an inmate’s psychotropic medication(s) are verified and ordered from the pharmacy, they are delivered and dispensed within 24 hours. This practice could not be confirmed by the IC during the a previous on-site monitoring visit and, therefore, the 4th Monitoring Report recommended that “SHP should develop a quality improvement process by which timeliness of verification and dispensing of psychotropic medication can be audited on a regular basis. As discussed in the 5th Monitoring Report, SHP should begin auditing this provision on a monthly basis and, if 100% compliance is achieved, quarterly auditing can begin.” SHP did not respond to this recommendation.

Despite the above concern, sample review of 38 medical charts of inmates who screened positive for mental illness and were subsequently seen by the psychiatrist during this 7th on-site monitoring visit found that almost 90 percent received timely verification and dispensing of psychotropic medication. A comparable number of medical charts were again reviewed in September 2017. This provision was previously moved to Substantial Compliance. It was noteworthy that Substantial Compliance was achieved because psychiatric hours were increased to 32 hours per month.
Recommendations

Evidentiary Basis

Review of 36 medical charts of inmates who screened positive for mental illness during June through September 2017.

Provision B.3.c

Ensure that prescriptions for psychotropic medications are reviewed by a psychiatrist or other qualified prescriber with mental health experience and training on a regular, timely basis to assess whether each prisoner’s prescribed regimen continues to be appropriate and effective for his or her condition. Whenever a psychotropic medication is discontinued, added, or changed, the County will ensure that the psychiatrist or other

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40
qualified prescriber making such changes contemporaneously documents the reason for such change in the prisoner’s health record.
Substantial Compliance
As discussed above in B.1.c, the standard of care is for the psychiatrist to assess inmates on psychotropic medication at a minimum of every 90 days, unless more frequent assessment is clinically indicated. SHP had previously not been able to provide the IC with sufficient documentation to indicate that psychiatrists are assessing all inmates on psychotropic medication at intervals that did not exceed 90 days. For example, although SHP maintains a Mental Health Chronic Care Clinic Log that tracks the number of inmates on psychotropic medications, whether they are on one or multiple medications, and the dates seen by a mental health provider. The log, however, does not distinguish between contacts by the QMHP versus contacts by a psychiatrist. Therefore, the Mental Health Chronic Care Clinic Log cannot be utilized to verify whether a psychiatrist is seeing all inmates on psychotropic medications at intervals that do not exceed 90 days.
Southern Health Partners notified the IC on May 11, 2016 that they had created the following corrective action plan for this provision:
1. Psychiatrist and/or Medical Provider will document any changes to psychotropic medications of the Chronic Care Psychiatry Monitoring Form.
2. If a patient puts a sick call in or refuses (3 documented refusals) to take their psychotropic medications, medical staff and/or QMHP will document the refusal on an SHP Refusal Form and the patient is placed on the psychiatrist log for an immediate consult with the patient. They are not to make any changes to medications unless they have an order to do so.
3. The Chronic Care log has been reviewed and meets current criterion under this provision. The log must be updated each time there are changes to the patient’s diagnosis or complaint and/or medication. Each mental health contact and Psychiatry contact will be documented on the form.
Sample review of 38 medical charts of inmates who screened positive for mental illness during this 7th on-site monitoring visit found that almost 90 percent had their psychotropic medications reviewed by the psychiatrists in a timely fashion. A comparable number of medical charts were also reviewed in September 2017. As such, this provision was previously moved to Substantial Compliance. It was noteworthy that Substantial Compliance was achieved because psychiatric hours were increased to 32 hours per month.

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Recommendations

Evidentiary Basis

Review of 36 medical charts of inmates who screened positive for mental illness during June through September 2017.

Provision B.3.d

Ensure that individuals receiving psychotropic medication are adequately monitored for potential negative side-effects of such medications.

Status Discussion

Substantial Compliance
According to SHP, current monitoring is accomplished by reviewing Health Care Sick Call Requests and QMHP contacts through the Mental Health Chronic Care Clinic Log to ensure identification of any potential negative sideeffects of such medications. This practice was confirmed by the IC during the February 2015 on-site monitoring visit. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.3.e
Status Discussion

Ensure that one unified health record is maintained for each prisoner that includes complete records for both physical and mental health and a complete list of medications the prisoner is taking. The County will also ensure that such unified health records are available to all medical and mental health staff who are necessary to facilitate continuity of care.
Substantial Compliance
The IC previously confirmed that one unified health record was maintained for each inmate in the RCDF. The unified chart includes both medical and mental health records, as well as a MAR when applicable. The unified chart was wellmaintained by an SHP medical records clerk. All medical and mental health personnel had easy access to the chart. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

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Provision B.4.a

Use of Restraints: The County shall prevent the unnecessary or excessive use of restraints on prisoners with mental illness or requiring suicide precautions. At a minimum, the County shall:

Status Discussion

Develop and maintain comprehensive policies and procedures for the use of restraints for prisoners with mental illness in accordance with generally accepted standards of care.
Substantial Compliance
The RCDF Administrator drafted the “Use of Clinically-Ordered Restraints for Inmates with Serious Mental Illness” policy (No. 8.03.R1). The policy was rewritten and approved by the IC in May 2014. The policy was implemented on June 10, 2014. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.4.b
Status Discussion

Ensure that a QMHP by preference, and if not available, a QMS provides written approval prior to the use of restraints on prisoners suffering from mental illness or requiring suicide precautions. The QMHP or QMS shall document the basis for and duration of the use of restraints and the performance and results of welfare checks on such restrained prisoners. The parties acknowledge that there may be situations which arise of immediate nature where such prior written approval is not practical for the safety of the inmate, other inmates or the facility staff. In such cases, written approval shall be obtained as soon as practicable and the same documentation obtained.
Substantial Compliance
The IC previously reviewed documentation regarding the use of the Restraint Chair. In each incident, the use of restraint did not exceed 60 minutes. Practices were found to be consistent with the RCDF “Use of Clinically-Ordered Restraints for Inmates with Serious Mental Illness” policy (No. 8.03.R1). This provision was previously moved to Substantial Compliance.

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Recommendations
Evidentiary Basis

Provision B.4.c

Ensure that restrained mental health prisoners are monitored at least every 15 minutes by a Correctional Officer and further monitored by a Qualified Medical Staff to assess their physical condition every 2 hours.

Status Discussion

Substantial Compliance
As found during previous on-site assessments, restrained inmates were observed by correctional officers at 15 minute intervals and seen by nursing staff at least every two hours. In addition, as shown above in Provision B.4.b, correctional staff continue to observe inmates confined in the restraint chair at 15-minute intervals. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.5.a
Status Discussion

Mental Health Staffing: The County shall ensure that the Jail’s mental health staffing is sufficient to provide adequate care for prisoners’ serious mental health needs, fulfill constitutional mandates and the terms of this Agreement, and allow for the adequate operation of the Jail, consistent with constitutional standards.
Substantial Compliance
The QMHP was hired in October 2013 and provides 40 hours of on-site mental health services. On-site psychiatric services were increased to 16 hours per month in mid-June 2014. Because several mental health provisions remained in partial compliance, the critical issue as to whether or not the RCDF has sufficient mental health staffing to address the provisions had been a continuing source of discussion throughout this Settlement Agreement.
As a result of numerous provisions remaining in Partial Compliance, the IC was informed during a teleconference call on July 11, 2016 that several SHP staffing changes were approved by the County: 1) the number of psychiatric hours was increased from 16 to 32 per month; 2) a new “mental health clerk”

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position was funded at 30 hours per week; and 3) a “medical compliance officer” position was established at 36 hours per week. This provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision B.5.b
Status Discussion

The County will ensure that all persons providing mental health treatment meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure.
Substantial Compliance
The SHP psychiatrists are appropriately licensed and board-certified in psychiatry. The QMHP is currently licensed as a Licensed Master Social Worker by the State of Tennessee, Department of Health, Division of Health Licensure and Regulation. This provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision B.6.a
Status Discussion

Release and Transfer: RCDF shall notify a QMS prior to the release or transfer of a prisoner with mental health needs from RCDF custody as soon as information relating to his or her release or transfer becomes available.
Substantial Compliance
Although both RCDF and SHP officials previously informed the IC that correctional officers notify medical staff when inmates are released from custody, the notification did not always occur on a consistent basis because of the lack of an appropriate RCDF policy.
The RCDF Administrator subsequently drafted the “Inmate Release and Transfer” policy (No. 4.04). The policy was revised and approved by the IC, and was implemented on December 1, 2014. This RCDF policy is consistent

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with SHP Policy J-E-13 (Discharge Planning). This provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis

Provision B.6.b
Status Discussion

When a QMS is notified of the release or transfer of a prisoner with mental health needs, the QMS shall prepare and send with the transferring or released prisoner a summary detailing major mental health concerns and listing current medications and dosages, as well as medication history while at RCDF, in order to ensure continuity of care.
Substantial Compliance
As offered in previous monitoring reports, an inmate’s current Medication Administration Record (MAR) and Admission Data/History and Physical Form are forwarded to transferring agency’s upon the inmate’s release. Although SHP policy also requires completion of a Medical Information Transfer Form, the form had historically not been utilized. Instead, because many inmates are transported to/from the Tennessee Department of Correction, SHP staff utilize the “Tennessee Department of Correction Health Status/Transfer Summary” form. As such, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis Provision B.6.c
Status Discussion

RCDF shall provide released prisoners with a three day supply of appropriate prescription medication. RCDF shall also provide released prisoners with the contact information for local mental health crisis services and schedule if requested an appointment with a mental health provider in the community and/or will offer to schedule the initial appointment. RCDF shall supply sufficient medication for the period of transit for prisoners who are being transferred to another correctional facility or other institution not to exceed a three day supply.
Substantial Compliance
As offered in previous monitoring reports, all inmates on medication at the time of their discharge from the RCDF were provided with a 3-5 day supply of medication. However, with regard to the release of inmates who have a serious mental illness, medical staff were not providing appointments or contact

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46 information for local community mental health providers, including Centerstone Mental Health Services/Mobile Crisis. During a previous site visit, the RCDF Administrator provided the IC with a “Information Packet” containing the contact information of various community resources in the Springfield and Robertson County areas that is said to be given to inmates upon discharge. As discussed in Provision B.6.a above, the RCDF “Inmate Release and Transfer” policy (No. 4.04) became effective on December 1, 2014. The policy requires that inmates on psychotropic medication will receive a sufficient supply (approximately 3-5 days worth of medication) upon discharge, as well as an offer from the QMHP to schedule an appointment with the appropriate community mental health provider. This provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis
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C. QUALITY IMPROVEMENT AND RISK MANAGEMENT
The County will develop, implement, and maintain a system to ensure that trends and incidents involving restraint use, psychotropic medications, and avoidable suicides and self-injurious behavior are identified and corrected in a timely manner.

Provision C.1
Status Discussion

Within 90 days of the Effective Date, the County shall develop and implement written Quality Improvement policies and procedures adequate to identify and address serious deficiencies in prisoner suicide prevention and mental health care.
Substantial Compliance
As offered in previous monitoring reports, the RCDF and SHP did not have any policies or procedures regarding quality improvement for suicide prevention and the provision of mental health services, or any policies and procedures that were consistent with the requirements of this Settlement Agreement. Since the 3rd Monitoring visit, both RCDF and SHP have developed policies and procedures regarding quality improvement for suicide prevention and the provision of mental health services, including: 1) RCDF “Continuous Quality Improvement Program - Mental Health Care/Suicide Prevention” policy (No. 11.06), effective October 20, 2014; 2) RCDF “Quality Improvement of Inmate Mental Health Care” policy (No. 11.03-AR1), effective October 8, 2014, revised January 6, 2015; and SHP “Quality Improvement Program policy (No. J-A-06), undated. The IC reviewed and approved these policies. As such, this provision was previously moved to Substantial Compliance.

Recommendations

Evidentiary Basis

Provision C.2

Within 90 days of the Effective Date, the County will implement monthly quality assurance mechanisms at the individual and system levels to prevent or minimize harm to prisoners. These quality assurance mechanisms shall track and analyze patterns and trends regarding levels of risk for suicide and self-injurious behavior, restraint and psychotropic medication use and, more generally, the provision of mental health care at RCDF. Each monthly report shall include:
(1) relevant aggregate data, including:
i. number of incidents related to self-harming behavior, including suicide gestures, attempts, or completed suicides, and any purposeful self-injurious act or

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attempted act that inflicted harm requiring medical attention or likely would have if completed; ii. all uses of restraints of prisoners with mental illness, including instances of self-injurious behavior while restrained, use of restraints on a prisoner on three or more occasions in a 30-day period, and single uses of restraints exceeding one hour in duration; iii. number of prisoners prescribed psychotropic medications; iv. number of prisoners prescribed two or more psychotropic medications; v. the number of prisoners who report having participated in general mental health/therapy counseling; vi. the number of prisoners who have received one-on-one treatment from the psychiatrist; vii. the time elapsed between prisoners’ requests for mental health services and the provision of services by a QMHP or QMS; viii. a list of prisoners with chronic mental illnesses, including the dates prisoners were treated by a QMHP or QMS; ix. number of individuals with mental illness who return to RCDF within 30-60 days.
(2) an assessment of trends and interventions, including:
i. trends and/or the patterns regarding the self-harm data (i.e., the location and shift during which the majority of self-harm occurred; circumstances surrounding the discovery of the self-harm; the structures, objects, or instruments used to execute the self-harm, prisoners frequently engaged in self-harm);
ii. whether prisoners at risk of self-harm are being appropriately identified for care;
iii. whether incidents of self-harm are increasing or decreasing;
iv. the severity of incidents of self-harm; v. whether restraints are being appropriately used against
prisoners with mental illness; vi. whether prisoners are receiving appropriate and
adequate mental health counseling and therapy; vii. the timeliness of mental health services provided; viii. referrals to outside care;
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ix. whether prisoners with chronic mental illnesses are receiving mental health services at regular intervals without requesting such services;
x. staff counseling and discipline for violating psychotropic medication policies or restraint use polices; and
xi. the effectiveness of interventions undertaken in response to identified trends from previous months.
(3) Based on these monthly assessments, the County shall recommend and implement changes to policies and procedures.
(4) The Jail shall ensure that all relevant facts and circumstances surrounding serious suicide attempts and completed suicides are investigated and reviewed by a multidisciplinary team, consisting of medical, mental health, and corrections staff . This team shall identify any areas in which staff performance could be improved or jail procedures that need to be adjusted to improve the ability to protect prisoners from self-harm. All reviews shall be documented and shall include the team’s findings, concerns, recommendations and remedial actions.
Substantial Compliance
According to the SHP Vice President of Operations (now Chief of Clinical Services) and MTA, the Daily Report of Mental Health/Suicide Services form utilized to track aggregate data on the provision of various mental health services was previously reactivated. In addition, the RCDF Administrator has consistently forwarded QA management data, which includes the above SHP data, to the Independent Consultant on a monthly basis since August 2013.
In addition, although RCDF and SHP officials formally met on at least a monthly basis regarding the recommendations contained within this report they did not routinely provide a monthly report to the IC regarding status of compliance with those remaining provisions in Partial Compliance.
As a result of this deficiency, SHP notified the IC on May 11, 2016 that they had created the following corrective action plan for this provision:
Effective May 2016, there will be a monthly mental health staffing held on the 4th Thursday of every month. Participants are to include at a minimum:
QMHP Group Provider MTA

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Compliance Nurse Mental Health Coordinator (may be remote attendance depending on schedule)
Correctional Staff or County Administrator (depending on availability) Medical Provider (if available) Psychiatrist (if available) Unit Clerk (Document meeting agenda)
Purpose of Meeting, but not limited to the following:
Discuss specific treatment issues regarding a patient(s) Treatment Progress/Concerns Medical concerns Group updates Any other clinical issues Review of QA data Discharge Planning Corporate or County concerns
Meeting agendas and notes will be typed and placed in a binder for review by IC, SHP Corporate office, and at the discretion of the County Administrator.
During this 7th on-site monitoring visit, the IC reviewed the monthly meeting minutes of the RCDF Mental Health Staff Meetings from June 29 through December 13, 2016. Meeting participants regularly included the SHP Chief of Clinical Services, SHP Mental Health Coordinator, MTA, QMHP, Medical Compliance Officer, Group Facilitator, and RCDF Administrator.
Finally, in addition to the SHP’s “Daily Report of Mental Health/Suicide Services - Monthly Report,” SHP had previously developed (in May 2016) both a “Suicide Precautions Monitoring Tool” and a “MAR/Medication/QMHP/Psychiatrist Assessment Monitoring Tool” to track compliance with this Settlement Agreement on a monthly basis. The utilization of these three (3) forms now equips the County with quality assurance tools to measure compliance with the Settlement Agreement. This provision was previously moved to Substantial Compliance.
Recommendations
Evidentiary Basis
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