Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_90-cv-00520/USCOURTS-caed-2_90-cv-00520-863/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 42:1983 Prisoner Civil Rights

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UNITED STATES DISTRICT COURT 

FOR THE EASTERN DISTRICT OF CALIFORNIA 

RALPH COLEMAN, et al., 

Plaintiffs, 

v. 

EDMUND G. BROWN, JR., et al., 

Defendants. 

No. 2:90-cv-0520 KJM DB P 

ORDER 

In an order filed August 9, 2016, the court once again outlined “seven general 

goals” that remain for defendants to achieve compliance with the Constitution and thereby the 

end of federal court oversight. ECF No. 5477 at 2-3 (quoting ECF No. 4124 at 85).1

 One of the 

necessary goals is full implementation of defendants’ staffing plans. See, e.g, ECF No. 4539 at 

24 (citing ECF No. 4232 at 5 n.3). The California Department of Corrections and Rehabilitation 

(CDCR) defendants filed their mental health staffing plan on September 30, 2009. ECF 

No. 3693. The Department of State Hospitals (DSH) defendants are under court order to 

implement their staffing plan, to do so “in coordination with CDCR’s development of its own 

 1

 All references to page numbers are to the page number assigned by the court’s Electronic 

Case Filing (ECF) system located at the top of the page. 

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mental staffing plan, and within the context of the . . . meet-and-confer process with the Coleman

parties,” as well as to provide the Special Master with monthly updates on implementation of 

their staffing plan. ECF No. 5573 at 3. 

Mental health staffing is now before the court on a report from the Special Master 

on the status of implementation of CDCR’s staffing plan. ECF No. 5564. For the reasons set 

forth in this order, the court will issue specific direction to the parties to guide resolution of 

outstanding issues related to mental health staffing, to ensure coordination between the DSH and 

CDCR defendants in resolution of any outstanding issues related to implementation of the DSH 

defendants’ staffing plan. The court’s direction is intended to move the staffing component of 

compliance from its present posture to full and complete remediation, including, if necessary, 

through issuance of an enforcement order. 

I. BACKGROUND 

In 1995, the court found that California’s prison system was “significantly and 

chronically understaffed in the area of mental health care services.” Coleman v. Wilson, 

912 F. Supp. 1282, 1307 (E.D. Cal. 1995). At that time, the evidence showed that defendants 

were “understaffed in the range of some three hundred members deemed necessary to deliver 

adequate care to mentally ill inmates; this number is higher when the vacancy rate in authorized 

positions is considered.” Id. at 1318. One defendant “acknowledged serious problems with 

recruitment and retention of psychiatrists and psychologists” at prison institutions, and attributed 

the problems “to non-competitive salaries, undesirable geographical locations and clientele, and 

inadequate incentives.” Id. Evidence at trial showed defendants had “‘known [about and 

repeatedly acknowledged] the serious problem with understaffing at least since . . . 1985.’” Id. at 

1315 n.47 (quoting Findings and Recommendations filed June 6, 1994, at 75-76). 

The constitutional deficiencies identified at trial have plagued efforts to remediate 

constitutionally inadequate mental health staffing levels for more than twenty years. This history 

and the extensive remedial efforts undertaken in an effort to address inadequate mental health 

staffing levels are set out in detail in the Special Master’s report. See ECF No. 5564 at 2-6. 

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Since 2002, defendants have been under a court order to limit to ten percent the 

vacancy rate among psychiatrists, psychologists and social workers, including contractors. Id. at 

3 & n.2 (citing ECF No. 1383 at 4). Since 2010, necessary mental health staffing levels have 

been determined by staffing ratios contained in a staffing plan developed by defendants in 

response to an order filed June 18, 2009, as part of a coordinated effort to plan for, develop and 

activate mental health beds sufficient to meet short-term, intermediate and long-range need. See

ECF No. 3613, passim. The staffing plan (hereafter 2009 Staffing Plan) was filed September 30, 

2009, ECF No. 3693, and approved by the Special Master on March 4, 2010. See ECF No. 5564 

at 31-32. The plan provides staffing ratios for the programs at each level of defendants’ Mental 

Health Services Delivery System (MHSDS) and other ancillary programs. See ECF No. 3693 at 

12-33. These ratios are expressed as one mental health staff person per x number of inmate 

patients. See id. 

 On January 4, 2010, the court gave final approval to most parts of defendants’ 

long-range mental health bed plan. ECF No. 3761. In relevant part, the court ordered full 

activation of mental health care units in a new prison health care facility at Stockton2 by the end 

of 2013. Id. at 4. In 2014, defendants came to the court seeking, inter alia, relief from the 2013 

deadline on the ground that “difficulties with recruitment and retention of staff psychiatrists are 

preventing the opening of five remaining mental health units.” ECF No. 5116 at 2. In granting 

the requested extension, the court signaled its agreement “with defendants’ judgment that they 

should not house seriously mentally ill inmates in hospital units unless those units are sufficiently 

and adequately staffed.” Id. at 6. In addition, defendants agreed to conduct a review of their 

then-current salary schedule for psychiatrists to determine whether that schedule was 

“competitive both within California and nationally” and they were ordered to file the results of 

that review. Id. at 7, 12. On March 24, 2014, defendants reported to the court that the salaries for 

prison psychiatrists were “‘within the range of comparable private and public sector salaries for 

 2

 The facility is referred to in the order as “[d]efendants’ proposed Consolidated Care 

Center.” ECF No. 3761 at 4. It is now known as the California Health Care Facility (CHCF). 

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psychiatrists within California and nationally’ and they ha[d] the authority to ‘offer newly hired 

psychiatrists salaries in excess of the minimum starting salary in the State pay scale range.’” ECF 

No. 5171 at 2-3 (quoting ECF No. 5123 at 3). 

 On June 19, 2014, the court issued an order requiring defendants to 

revisit and, as appropriate, revise their existing mental health 

staffing plan in order to resolve the ongoing problem of mental 

health staffing shortages and come into compliance with the 

requirements of th[e] court’s June 13, 2002 order (ECF No. 1383) 

concerning maximum mental health staff vacancy. 

ECF No. 5171 at 4. Defendants were ordered to report to the court on the results of that review 

by September 12, 2014. Id. 

 As the Special Master reports: 

 After receiving an extension of time, defendants filed their 

“Report on Review of Mental Health Staffing” on February 2, 

2015, in which they conceded that the vacancy rate among 

psychiatry positions, including the use of contract staff, was nearly 

20 percent. ECF No. 5269 at 6. As a remedy for staffing deficits for 

both psychiatrists and psychologists, defendants proposed a fourpronged approach, which included: 

1. The creation of a psychiatric medical assistant classification to 

perform clerical tasks currently performed by psychiatry staff. 

2. The expansion of their psychologist internship program and 

reactivation of a fellowship program for psychiatrists. 

3. Offering differential pay for civil service psychiatrists and 

increasing contract rates for contract psychiatrists to work in hard to 

recruit locations. 

4. Continuing the recently expanded telepsychiatry program. 

Id. at 6-10. 

ECF No. 5564 at 4-5. In their report, defendants represented that CDCR would “not change any 

staffing ratios for psychiatrists” “[u]ntil the effectiveness” of the new psychiatric medical 

assistant (PMA) classification could “be established.” ECF No. 5269 at 7. In objections to the 

defendants’ report, plaintiffs expressed concern that defendants’ “clear goal” in developing the 

PMA classification was to use those positions “to justify a unilateral reduction in the total number 

of allocated psychiatry positions systemwide.” ECF No. 5281 at 3. 

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 On May 18, 2015, the court ordered defendants to move forward with the four 

proposals made in their report. ECF No. 5307 at 6. Crediting the “serious questions” raised by 

plaintiffs “about a reduction in psychiatry positions once the new PMA positions are established 

and filled”, the court required defendants to “seek the approval of the Special Master and leave of 

court before making any changes to the staffing ratios under which the mental health program is 

currently operating.” Id. at 5, 6. The court also ordered the Special Master to report to the court 

on the status of defendants’ implementation of their four proposals and to make “such 

recommendations as may be necessary to address any ongoing mental health staffing 

deficiencies.” Id. at 6. The court was clear then, as it is now, that it is time to “finally and fully” 

remedy the problem of inadequate staffing that have “plagued the remedial phase of this litigation 

since its inception” more than twenty years ago. Id. at 5. 

 The Special Master’s report required by the court’s May 18, 2015 order was 

included in his Twenty-Sixth Round Monitoring Report. See ECF No. 5439 at 28 (citing ECF 

No. 5377). In its order on the Twenty-Sixth Round Report, the court discussed the staffing 

recommendations: 

 With respect to staffing, the Special Master recommends that 

(1) defendants be required to provide him with monthly updates on 

the implementation of their staffing plan and that they be required 

to meet with the Special Master monthly “to discuss and consider 

strategies and initiatives, including but not limited to potential 

clustering of higher-acuity mentally ill inmates at those institutions 

where it has been shown that mental health can be more readily 

attracted and retained, all to resolve the problem of mental health 

staffing in CDCR prisons in a thorough and lasting way;” (2) that 

he be ordered to file a stand-alone report on the status of mental 

health staffing and defendants’ implementation of their plan within 

120 days; and (3) that defendants be directed to complete and 

implement the new peer review process. ECF No. 5439 at 141-42. 

ECF No. 5477 at 5. The court went on to pointedly lay out its expectations: 

In making the foregoing recommendations, the Special Master 

demonstrates more patience than this court would accept absent his 

long experience and strenuous efforts in this remedial process. The 

Twenty-Sixth Round Monitoring Report describes in great detail 

the “long and tortured” history of “CDCR’s struggle to implement a 

viable staffing plan for the provision of adequate mental health 

treatment” and the absence of improvement in the “[c]hronic 

understaffing of CDCR mental health positions” and the 

“stagnat[ion]” of “CDCR’s implementation of its most recent 

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mental health staffing plan.” ECF No. 5439 at 16, 22-43. The 

Special Master reports that “[v]acancies in the key mental health 

clinical disciplines of psychiatry and psychology remained 

problematic and were nearly unchanged from rates in 1998. . . .” Id.

at 16 (emphasis added). 

Several factors appear to be at work in defendants’ failed efforts to 

hire and retain sufficient numbers of mental health staff, including 

but not limited to the geographic locations in which defendants 

continue to house significant numbers of seriously mentally ill 

inmates. The ongoing rise in the numbers of mentally ill inmates in 

California’s prisons, see ECF No. 5439 at 134-135, compounds 

defendants’ difficulties, as staffing levels are based on inmate/staff 

ratios, see, e.g., ECF No. 5269 at 6. Defendants have reported to 

the court that “its pay for psychiatrists is competitive with other 

private and public employers.” ECF No. 5269 at 9. As of February 

2015, they planned to nonetheless pursue “differential pay” for 

psychiatrists working in “hard-to recruit” institutions. Id. It is not 

at all clear to this court that additional pay will solve this 

deepseated problem and the court can no longer sanction the 

continued pursuit of remedial strategies that have not worked in the 

past. While the court will adopt the Special Master’s 

recommendation, it will give defendants four more months to work 

with him to devise a meaningful strategy that will, finally, mean 

mentally ill inmates are located in institutions that are adequately 

staffed with mental health staff competent to meet their treatment 

needs. To be clear: the court expects more than a mere plan. The 

court requires that the report from the Special Master demonstrate 

clear action in accordance with planned steps and a measurable 

timeline by which those steps will be completed. 

ECF No. 5477 at 5-6. 

 The staffing report currently before the court, ECF No. 5564, is the one required 

by the August 9, 2016 order. The parties have responded, extensively, to the report. On 

March 30, 2017, plaintiffs filed objections, ECF No. 5590, and defendants filed a response, ECF 

No. 5591. On April 13, 2017, defendants filed evidentiary objections and a motion to strike a 

declaration filed with plaintiffs’ objections, ECF No. 5600, and a reply to plaintiffs’ objections, 

ECF No. 5601. Plaintiffs also filed evidentiary objections, ECF No. 5602, and a reply to 

defendants’ response, ECF No. 5603. On April 21, 2017, plaintiffs filed a response to 

defendants’ motion to strike. ECF No. 5611. On April 27, 2017, defendants filed a response to 

plaintiffs’ evidentiary objections, ECF No. 5612, and more evidentiary objections and a motion to 

strike a second declaration, ECF No. 5613. On May 4, 2017, plaintiffs filed a response to the 

second motion to strike. ECF No. 5614. 

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II. SPECIAL MASTER’S REPORT AND RECOMMENDATIONS 

The Special Master reports on the results of a series of workgroup meetings he has 

held to focus on staffing with members of his staff, plaintiffs’ counsel, defendants’ counsel and 

representatives of the CDCR defendants. ECF No. 5564 at 7. The workgroup met for the first 

time in June 2016 and continued to meet for seven months. Id. Discussions centered on the four 

proposals contained in defendants’ February 2, 2015 plan as well as a number of other proposals 

“including, cash for on-call compensation for all clinicians, dual appointments, psychiatric nurse 

practitioners, utilization management, establishing a mental health academy for new mental 

health staff, salary increases for psychiatrists and clustering.” Id. The Special Master reports that 

“[d]uring the course of the meet and confer process, it was determined that certain staffing 

proposals were complex and thus required additional time to plan and bring into fruition.” Id. 

For that reason, the Special Master sought and received a sixty day extension of time to file his 

stand-alone staffing report. Id.; ECF Nos. 5523, 5530. 

The proposals discussed by the workgroup resulted in an updated staffing plan 

presented by defendants to the Special Master on January 10, 2017. ECF No. 5564 at 8 & Ex. B. 

This staffing plan includes the following elements as remedial measures: 

 Use of medical assistants to assist psychiatrists 

 Internship and Fellowship programs 

 Increased pay rates for contract psychiatrists 

 Telepsychiatry 

 Cash for on-call compensation for all clinicians 

 Dual appointments at additional institutions 

 Psychiatric Nurse Practitioners 

 Utilization Management 

 Proposition 57 

 Establishment of a Mental Health Academy 

 Salary increases for psychiatrists 

 Bed planning (clustering) 

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Id. 

 The Special Master reports on each element of the latest plan and recommends the 

court adopt it in part and reject it in part. Id. Specifically, the Special Master recommends 

 That the Court enter an order directing defendants to proceed 

with the implementation of their staffing plan proposals related to 

medical assistants, internship and fellowship programs, increased 

rates for contract psychiatrists, telepsychiatry, cash for on-call 

compensation, dual appointments, psychiatric nurse practitioners, 

utilization management relating to 3CMS inmates, Proposition 57, 

and the Mental Health Academy, which includes the above 

recommendations; 

 That the Court reject defendants’ staffing plan proposals on 

utilization management related to EOP inmates, salary increases for 

psychiatrists, and clustering, and that the Court enter an order that 

defendants be required to develop a supplemental plan to address 

those areas, which includes the above recommendations; and 

 That the Court enter an order directing the defendants and the 

Special Master to meet and confer every 90 days until the staffing 

plan is fully implemented, including plaintiffs as appropriate, to 

discuss the status of defendants’ implementation of the adopted 

staffing plan proposals as outlined in the recommendations above. 

Id. at 28-29. 

On August 28, 2017, the court approved a stipulation filed by the parties informing 

the court of their agreement on utilization management review for EOP inmates and that the EOP 

review is underway. See ECF No. 5668. The Special Master's recommendation that the court 

reject a prior proposal for EOP utilization management review is therefore moot, as are 

defendants' objections to that recommendation. 

III. BRIEFING OF THE PARTIES 

A. Plaintiffs’ Objections and Request for Additional Relief 

Plaintiffs’ principal objection to the Special Master’s report is that it does not go 

far enough in its recommendations concerning pay for psychiatrists. Plaintiffs seek additional 

orders requiring “targeted extra pay differentials for psychiatrists in hard-to-hire locations,” and 

requiring defendants “to complete and share a salary/compensation survey, in order to guide 

future pay and benefit increases designed to attract new hires and retain existing psychiatrists.” 

ECF No. 5590 at 7. Plaintiffs also contend defendants’ proposals concerning clustering and 

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telepsychiatry are inadequate to resolve the “severe” staffing shortages among psychiatrists. Id. 

at 23. Finally, plaintiffs ask the court to set a status conference “to devise a durable remedy to 

this entrenched problem.” Id. at 7. 

With their objections, plaintiffs present evidence of the vacancy rates in clinical 

positions in January 2017. Ex. E to Nolan Decl., ECF No. 5590-1 at 23.3 With limited 

exceptions, all of those vacancy rates exceeded ten percent, and the vacancy rates among chief 

psychologists and staff psychiatrists was almost thirty-three percent in each category. Id.

4

 

In reply, defendants contend (1) compensation for California’s prison psychiatrists 

is “among the highest in the nation”; and (2) they are providing constitutionally adequate mental 

health care at current staffing levels. ECF No. 5601 at 1-2. As they also discuss in their 

response to the Special Master’s report, defendants contend the 2009 staffing ratios are 

“outdated” and need to be revisited. Id. at 1. Defendants contend plaintiffs were part of the 

discussion that led to the current clustering plan and plaintiffs’ objections are “after the fact” and 

untimely. Id. at 9. 

B. Defendants’ Response 

Defendants object to the Special Master's concerns about the use of telepsychiatry 

and argue they should be allowed to fully implement their telepsychiatry program. ECF No. 5591 

at 5-9. Defendants also contend additional salary increases for psychiatrists are not warranted, id. 

at 11-13, and that they are adequately meeting patient needs even with existing vacancies, id. at 

13-15. Finally, they contend the Special Master “recently clarified” that his recommendation 

concerning clustering “is intended to move Coleman class members out of High Desert State 

Prison [(High Desert)] in particular”; defendants contend closing High Desert’s mental health 

 3

 Defendants object to, and move to strike, ¶¶ 14, 18, and 20-25 of the Nolan Declaration, 

and Exhibits D and F to that declaration. For purposes of this order, the court has relied on only 

¶ 9 of the Nolan Declaration and Exhibit E, authenticated by ¶ 9. Defendants’ motion to strike 

will be denied without prejudice and their other evidentiary objections will be disregarded. 

4

 In their brief, plaintiffs contend the evidence shows “the overall vacancy rate for staff 

psychiatrists in CDCR was 45.8%.” ECF No. 5590 at 5. This conclusion is not obvious from the 

cited evidence. 

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program “presents serious problems.” Id. at 16. More broadly, defendants contend requiring 

clustering would “violate the Prison Litigation Reform Act’s prohibition on orders requiring 

construction of prisons,” that “the recommendation is not supported by data or evidence,” and 

that “[d]efendants are concerned that further clustering of high-acuity patients may negatively 

impact care, particularly at prisons with more complex missions, and negatively impact the staff.” 

Id. at 16-17. 

In response, plaintiffs argue that “[d]efendants’ rejection of meaningful 

compensation increases for psychiatrists is overly fatalistic about solving the problem, and at 

odds with any common sense understanding of market forces and the laws of supply and 

demand.” ECF No. 5603 at 4. Plaintiffs add that “[t]he current nationwide psychiatrist shortage 

makes raising pay even more essential, not futile, as reflected in Defendants’ decision to increase 

compensation for registry psychiatrists and medical doctors in hard-to-hire locations.” Id. 

Plaintiffs contend defendants’ position on the use of telepsychiatry 

is at odds with professional standards, with their own telepsychiatry policy’s cautionary statements that on-site psychiatrists 

are preferred for higher levels of care, with this Court’s prior 

admonishment that “there may be class members not susceptible to 

this method of care,” and with their own statewide Chief 

Psychiatrist’s acknowledgement that he and his staff could not 

locate any good studies on the efficacy of tele-psychiatry in the 

prison context. 

Id. at 4-5. In addition, plaintiffs urge the court to reject defendants’ objection to the Special 

Master’s criticisms of defendants’ clustering plan, which plaintiffs contend “ignores and 

exacerbates the risks of operating high-acuity mental health programs at facilities that cannot 

recruit and retain clinical staff. . .” Id. at 5. 

IV. ANALYSIS 

The court begins by acknowledging the effort of the Special Master and the parties 

reflected in the latest series of meetings, planning and reporting. This effort has served to narrow 

and focus the issues that require resolution in order for defendants to meet their Eighth 

Amendment obligation to “employ mental health staff in ‘sufficient numbers to identify and treat 

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in an individualized manner those treatable inmates suffering from serious mental disorders.’” 

Coleman v. Wilson, 912 F. Supp. at 1306 (internal citation omitted). 

At the same time, the plan provided by defendants to the Special Master that forms 

the basis for his current report does not satisfy an important requirement of the August 9, 2016 

order: it does not include a timeline by which the steps outlined in the plan will be completed. 

Cf. ECF No. 5477 at 6 (“The court requires that the report from the Special Master demonstrate 

clear action in accordance with planned steps and a measurable timeline by which those steps will 

be completed.”). It is past time for defendants to complete the task of hiring sufficient mental 

health staff to come into compliance with the Eighth Amendment and orders of this court. For 

the reasons explained below, the court will provide defendants one year from now to come into 

compliance with the required staffing ratios and the court’s June 13, 2002 order. It will be for 

defendants, working under the guidance of the Special Master, to complete all steps necessary to 

meet that goal; many of those steps are included in the proposals discussed in the Special 

Master’s current report. 

Defendants also have not provided the Special Master with any substantive 

information on the proposal contained in their February 2, 2015 staffing plan to implement pay 

differentials for psychiatrists at “hard-to-recruit locations.” ECF No. 5564 at 12. The court 

clearly directed defendants in the August 9, 2016 order to work with the Special Master “to 

devise a meaningful strategy that will, finally, mean mentally ill inmates are located in 

institutions that are adequately staffed with mental health staff competent to meet their treatment 

needs.” ECF No. 5477 at 6. The court also directed that the Special Master’s report 

“demonstrate clear action in accordance with planned steps and a measureable timeline by which 

those steps will be completed.” Id. Yet the updated staffing plan defendants provided to the 

Special Master on January 10, 2017 “dropped any specific mention of pursuing pay differentials.” 

ECF No. 5564 at 14. Defendants instead simply informed the Special Master “that the pay 

differential would be handled through the collective bargaining process.” Id. at 14; see also id. at 

24. 

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 The failure to provide the Special Master with meaningful information necessary 

to full consideration of the role of psychiatrist salaries in remedying the ongoing constitutional 

violation in this action violates the spirit, if not the letter, of the court’s August 9, 2016 order. It 

also violates several paragraphs of the December 11, 1995 Order of Reference, ECF No. 640, 

requiring defendants and their staff to cooperate fully with the Special Master in the performance 

of his duties, including by responding to “requests for the compilation or communication of oral 

or written information” and to provide the Special Master with “unlimited access to the records, 

files and papers maintained by defendants” to the extent such access is related to the Special 

Master’s performance of his required duties. Id. at 5-6. 

It should not have to be said again: It is defendants’ responsibility to meet their 

constitutional obligations. To that end, they are required to continue working under the guidance 

of the Special Master to meet their responsibility, and the Special Master must have full and 

complete access to all information necessary for him to do his job. In the next year, defendants 

must work closely and in full cooperation with the Special Master in a focused effort to resolve 

all outstanding obstacles to achievement of constitutionally adequate levels of mental health 

staffing. Existing court orders in fact require this cooperation. 

Defendants also ask the court to revisit the existing staffing ratios for psychiatrists. 

See, e.g., ECF No. 5591 at 4. Defendants have not sought or obtained the approval of the Special 

Master for such a change, cf. ECF No. 5307 at 6, nor do they make a specific proposal for how 

those ratios should be changed. See ECF No. 5591, passim. Nonetheless, before addressing the 

parties’ objections to the Special Masters’ report on elements of defendants’ proposals for 

meeting their staffing obligations, the court addresses whether the staffing ratios for psychiatrists 

set in 2009 Staffing Plan should be revisited. 

A. Staffing Ratios 

In their response to the Special Master’s report, defendants contend “it is time to 

reevaluate the need and feasibility of the outdated staffing ratios from the 2009 staffing plan. . . .” 

ECF No. 5591 at 4. In spite of the broad language of defendants’ objection, its focus is on 

staffing ratios for psychiatrists. 

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Defendants acknowledge that their “average fill rate” for psychiatry positions for 

the last three years has been seventy-five percent, well below the ninety percent required by the 

June 13, 2002 order, ECF No. 1383. Id. Defendants attribute this lapse “in large part [to] the 

acute nationwide shortage of psychiatrists that exists today. . . exacerbated by the fact that a large 

portion of California’s board-certified psychiatrists are already employed by CDCR and . . . 

DSH.” Id. Defendants question whether the staffing ratios for psychiatrists contained in their 

2009 plan “can ever be realistically satisfied.” Id. at 13. They present evidence that CDCR and 

DSH “employ more psychiatrists combined than the number of psychiatrists working in all but 

ten states,” that “[i]n 2014 the 713 psychiatrists employed by DSH and CDCR represent nearly 

17.4 percent of California’s board certified psychiatrists and placed the two agencies as largest 

employer among all states in the Country” and that the salaries offered by the two agencies “are 

already among the highest in the nation.” Id. Defendants also contend they “are unaware of other 

health-care systems that require as rich a staffing level for psychiatrists as is mandated” by this 

court. Id. Finally, they argue generally that they are providing adequate mental health care to 

class members in spite of the ongoing staffing vacancies. Id. at 13-15. To support this 

contention, defendants present (1) evidence of “systemic, statewide compliance with [their] 

medication-administration measure total[ing] ninety-six percent over the past twelve months; and 

(2) evidence that eleven institutions with staffing vacancy rates above ten percent nonetheless 

“achieved greater than ninety percent compliance rate for psychiatry services.” Id. at 14 (citing 

Tebrock Decl. ¶¶ 8, 11 & Exs. 1, 2). 

 Plaintiffs oppose the request to reevaluate the staffing ratios, and object to the 

evidence tendered by defendants in support of the request. ECF Nos. 5603 at 14-19; ECF No. 

5602 at 5-7. Plaintiffs contend “[t]he time for raising objections to the psychiatrist staffing ratios 

passed in 2015, when Defendants submitted their staffing plan in response to the Court’s 2014 

order directing them to review their 2009 staffing plan.” ECF No. 5603 at 14. Plaintiffs also 

observe that defendants have not sought approval of the Special Master to revise existing staffing 

ratios, as required by this court’s February 18, 2015 order. Id. at 15. Finally, plaintiffs present 

evidence to rebut defendants’ evidence, and they also point to findings from the Special Master’s 

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Twenty-Sixth Round Monitoring Report concerning harm to the plaintiff class from ongoing 

shortages among psychiatrists. Id. at 17-20. 

There are several flaws in defendants’ request. First, defendants have not 

presented either the Special Master or this court with a specific proposal for new staffing ratios. 

The court’s May 18, 2015 order was clear: any revision to existing staffing ratios requires 

approval of the Special Master. ECF No. 5307 at 6. That approval is a precondition to seeking 

leave from this court, also required, before changing any mental health staffing ratio. Id. 

Moreover, defendants face a heavy burden in attempting to persuade either the 

Special Master or this court that the staffing ratios for psychiatrists should be revisited. In 

January 2013, defendants moved to terminate this action. ECF No. 4275. In that motion, 

defendants made arguments concerning ongoing mental health staffing vacancies remarkably 

similar to those raised in their objections to the Special Master’s staffing report: they 

acknowledged the ongoing vacancies but contended the vacancies did “not ‘significantly impair 

the level of care being provided to inmates, and that “the clinical care itself places CDCR in the 

upper echelon of state prison mental health systems.”’” ECF No. 4539 at 54 (quoting ECF 

No. 4275-1 at 25 (quoting ECF No. 4275-5 at 1, 14 and citing ECF No. 4205 at 41)). In its 

April 5, 2013 order denying the termination motion, the court found that several necessary 

remedial goals, including “full implementation of defendants’ mental health staffing plan”, ECF 

No. 4232 at 5 n.3, “are tied to constitutional deficiencies described by the United States Supreme 

Court in its 2011 Opinion affirming the three-judge court’s population reduction order,” 

including: 

[u]nacceptably high staffing vacancy rates when measured against 

the state’s staffing formula, with expert testimony showing that the 

staffing need had been significantly underestimated. . . . Mental 

health staff “managing far larger caseloads than is appropriate or 

effective” and a prison psychiatrist reporting that they are “doing 

about 50% of what we should be doing to be effective. 

ECF No. 4539 at 25-26 (citing Brown v. Plata, 563 U.S. 493, 131 S. Ct. 1910, 1932 & n.5 

(2011)). 

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The April 5, 2013 order includes a ten page discussion of staffing. In relevant 

part, the court discussed the development of the 2009 Staffing Plan, as follows. 

In 2009, pursuant to this court’s June 18, 2009 order (ECF 

No. 3613), defendants developed a staffing allocation plan (ECF 

No. 3693) (2009 Staffing Plan). Defendants’ 2009 Staffing Plan 

sets forth how defendants’ mental health delivery system is to be 

staffed. See Declaration of Diana Toche, filed January 7, 2013 

(“Decl. Toche”) (ECF No. 4275-3) ¶ 6. The 2009 Staffing Plan is 

driven by ratios of clinical and support staff to inmate population at 

each level of the mental health care delivery system. See 2009 

Staffing Plan (ECF No. 3693), passim. Defendants’ experts opine 

that the 2009 Staffing Plan “will provide adequate resources to 

meet the mental health needs of inmates in a reasonable manner and 

within the standard of care.” Clinical Exp. Rpt. (ECF No. 4275-5) 

at 14. That opinion comports with defendants’ representation to the 

California Legislature that full implementation of that plan was 

necessary. 

 Prior to development of defendants’ 2009 Staffing Plan, 

expert testimony showed that the state had underestimated its 

mental health staffing needs. See Brown v. Plata, 131 S. Ct. at 

1932 n.5. After submitting the 2009 Staffing Plan to this court, 

defendants, at the end of 2009, submitted a budget change proposal 

to the California Legislature to “fully implement” the staffing 

model described in the 2009 Staffing Plan. Exhibit K to 

Declaration of Jane E. Kahn in Support of Plaintiffs’ Response to 

Defendants’ Motion to Strike or Modify Portions of the TwentyFifth Round Monitoring Report of the Special Master, filed 

February 11, 2013 (Ex. K to Decl. Kahn) (ECF No. 4325) at 93. 

The budget change proposal described the critical flaws in 

defendants’ prior staffing model, and represented that the 2009 

Staffing Plan identifies appropriate staffing levels to meet 

constitutional standards. . . .” Id. at 95. 

ECF No. 4539 at 54-55 (emphasis added). In a footnote, the court observed that the budget 

change proposal also asserted that the 2009 Staffing Plan “would allow defendants to ‘provide the 

quantity and quality of Resources needed to achieve compliance with policies and procedures 

contained in the . . . Revised Program Guide’ and was ‘consistent with models for program 

staffing in similarly situated models in other states.’ Ex. K to Decl. Kahn at 98.” Id. at 55 n.46. 

///// 

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///// 

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 Finally, the court held that “[e]ven if it were proper for defendants to back away 

from the 2009 Staffing Plan,” defendants had not proved they could “meet their constitutional 

obligations with the existing levels of staffing vacancies.” Id. at 61. As the court summarized, 

evidence cited by the United States Supreme Court showed that a 

previous staffing plan was inadequate. Defendants represented to 

the state legislature that the 2009 Staff Plan would meet their 

constitutional obligations. As described in the text, defendants have 

failed to show how they can meet their constitutional obligations by 

retreating from the current plan. 

Id. at 61 n.47. 

The April 5, 2013 order established a number of matters relevant to the issues now 

before the court. First, the 2009 Staffing Plan was developed to remedy previous staffing levels 

described as constitutionally deficient by the United States Supreme Court. Second, defendants 

represented to the California Legislature at least that the staffing levels in the 2009 Staffing Plan 

were “appropriate” and necessary to meet constitutional standards.5 Third, defendants were not 

meeting their constitutional obligations at the vacancy levels that existed at the time the 

termination motion was filed. Finally, in the 2009 Staffing Plan and the Budget Change Proposal 

cited in the 2013 order, defendants represented to this court and to the California Legislature that 

staffing levels in other jurisdictions were considered in developing the 2009 Staffing Plan, and 

that the 2009 Staffing Plan “was ‘consistent with models for program staffing in similarly situated 

models in other states.’ Ex. K to Decl. Kahn at 98.” Id. at 55 n.46; see also ECF No. 3693 at, 

e.g., 8. In view of this record and the findings accompanying the 2013 order, defendants may 

wish to reconsider their representation that they “are unaware of other health-care systems that 

 5

 The 2009 Staffing Plan contains a footnote in which defendants stated they did not 

“concede that all of the programs and/or staffing identified in the Plan are required by the 

Coleman Court” nor that “the proposed staffing and services are constitutionally required,” nor 

that the “Plan would satisfy the Prison Litigation Reform Act’s requirements that prospective 

relief be narrowly drawn, extend no further than necessary to correct the alleged violation of the 

federal right, and be the least intrusive means necessary to correct the alleged violation.” ECF 

No. 3693 at 7 n.1. This disclaimer notwithstanding, the Staffing Plan was developed in response 

to a court order to “resolve all outstanding staffing allocation issues” to remedy an ongoing 

constitutional violation. ECF No. 3613 at 2. 

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require as rich a staffing level for psychiatrists as is mandated” by this court, particularly given 

their express reliance on staffing levels in other jurisdictions as an aid to development of the 2009 

Staffing Plan. 

Defendants do not even mention the April 5, 2013 order or its discussion of 

staffing in their objections. Under the law of the case doctrine “a court is generally precluded 

from reconsidering an issue that has already been decided by the same court, or a higher court in 

the identical case.” Thomas v. Bible, 983 F.2d 152, 154 (9th Cir. 1993) (citing Milgard 

Tempering, Inc. v. Selas Corp. of America, 902 F.2d 703, 715 (9th Cir.1990)). 

The doctrine is not a limitation on a tribunal’s power, but rather a 

guide to discretion. Arizona v. California, 460 U.S. 605, 618, 

103 S.Ct. 1382, 1391, 75 L.Ed.2d 318 (1983). A court may have 

discretion to depart from the law of the case where: 1) the first 

decision was clearly erroneous; 2) an intervening change in the law 

has occurred; 3) the evidence on remand is substantially different; 

4) other changed circumstances exist; or 5) a manifest injustice 

would otherwise result. Failure to apply the doctrine of the law of 

the case absent one of the requisite conditions constitutes an abuse 

of discretion. Thomas v. Bible, 983 F.2d at 155. 

United States v. Alexander, 106 F.3d 874, 876 (9th Cir. 1997). Defendants have not even begun 

to meet their burden of showing why the conclusions of the April 5, 2013 order, listed above, 

should be revisited. 

Defendants’ burden is compounded by the fact that for most programs the 2009 

Staffing Plan increased the caseload for prison psychiatrists. Specifically, the 2009 Staffing Plan 

revised then-existing staffing ratios for prison psychiatrists as follows: 

Department From To 

Correctional Clinical Case Management Services –

General Population (CCCMS-GP) Staff Psychiatrist 1:315 1:280 

CCCMS – Reception Center (RC) Intake and 

Screening; Staff Psychiatrist -- 1:33 

CCCMS-RC Treatment 

Staff Psychiatrist 1:301 1:200 

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CCCMS – Administrative Segregation Unit (ASU) 

and Condemned Unit 

Staff Psychiatrist 

1:98 1:125 

CCCMS—Segregated Housing Unit (SHU)

Staff Psychiatrist 1:149 1:200 

Enhanced Outpatient Program (EOP) – GP

Staff Psychiatrist 1:99 1:120 

EOP – RC 

Staff Psychiatrist 1:99 1:120 

EOP – ASU and Condemned Unit

Staff Psychiatrist 1:58 1:64 

Psychiatric Services Unit (PSU)

Staff Psychiatrist 1:64 1:64 

Mental Health Crisis Bed (MHCB)

Clinical Psychologist 

Staff Psychiatrist 

Senior Psychiatrist, Supervisor 

1:6 

1:8 

1:133 

1.18:10 

2.5:25 

1:50 

Mental Health Outpatient Housing Unit (MH-OHU)

Staff Psychiatrist 

Senior Psychiatrist, Supervisor 

-- 

-- 

1:9 

1:150 

Desert Institutions 

Staff Psychiatrist .4/institution .5/institution 

ECF No. 3693 at 12-24. With the exception of certain programs at the CCCMS level of care, the 

2009 Staffing Plan increased the number of inmate-patients per staff psychiatrist.6 The 2009 

Staffing Plan was a comprehensive reworking of all mental health staffing ratios, and included 

creation of a few new positions. See ECF No. 3693 at 12-33. The fact that the 2009 Staffing Plan 

increased most psychiatrist/inmate-patient ratios does not compel a conclusion that constitutional 

deficiencies in prior staffing ratios remained uncured by the ratios in the 2009 Staffing Plan. At 

the same time, however, defendants have a heavy burden going forward to justify further 

increases in these ratios. 

 6

 The new ratios also decreased the caseload for senior psychiatrist supervisors in MHCB 

units. 

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Defendants’ heavy burden is even further compounded by the fact that, as 

plaintiffs point out, in 2014 defendants were ordered to “revisit and, as appropriate, revise their 

existing mental health staffing plan to resolve the ongoing problem of mental health staffing 

shortages and come into compliance” with the June 13, 2002 order, ECF No. 1383. ECF No. 

5171 at 4. Defendants completed their review and filed a report on February 2, 2015. ECF 

No. 5269. The proposals in defendants’ report focused on increasing retention of psychiatrists by 

creating a new psychiatric medical assistant (PMA) classification, assisting with both recruitment 

and retention through internships, fellowships and differential pay and increased contract rates in 

“hard-to-recruit institutions,” ECF No. 5269 at 9, as well as increased use of tele-psychiatry. Id. 

at 9-10. After completion of the thorough review required by the 2014 order, defendants did not 

come to the court requesting a change in the psychiatrist staffing ratios: they proposed additional 

steps to meet the requirements of those ratios. 

Defendants’ request now can only be construed as a request to increase the 

existing caseload of prison psychiatrists. For all of the foregoing reasons, there is scant evidence 

in the record to suggest this change would advance remediation of the Eighth Amendment 

violation in this case; rather, there is strong evidence that such a change would slow progress 

toward the end of federal court oversight. 

Defendants have signaled to the Special Master that once the PMA program is 

implemented across all institutions “it may be necessary to review and, if appropriate, modify the 

ratios in the 2009 staffing plan.” ECF No. 5564 at 40. At this point, the court is skeptical that 

full implementation of the PMA program will justify increasing the caseload of prison 

psychiatrists. Defendants have consistently represented that the PMA program is intended to 

improve recruitment and retention of psychiatrists, not to support an increase in their caseload, 

which would seem at cross-purposes with retention efforts. See ECF No. 5269 at 7; ECF No. 

5564 at 40. At the same time, the court will not preclude defendants from raising with the Special 

Master the issue of whether full implementation of the PMA program supports a change in the 

staffing ratios for psychiatrists. However, that issue must be raised, if at all, so that it can be 

resolved by the Special Master and presented to the court within the time frame set in this order 

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for resolution of all outstanding issues related to mental health staffing and achievement of 

adequate mental health staffing levels. 

The court now turns to the Special Master’s recommendations concerning specific 

elements of defendants’ plan to which one or both parties have objected or responded, noting 

there are no objections to several of the proposals or the Special Master’s recommendations. 

B. Telepsychiatry 

In its February 2015 staffing plan, defendants proposed “the continuance of a 

statewide tele-psychiatry program.” ECF No. 5269 at 6. At that time, the CDCR defendants 

were using tele-psychiatry at nine institutions and had twenty-eight staff psychiatrists working out 

of three satellite offices, twenty-six full-time and two half-time. Id. at 9 & n.2. Approximately 

eighteen of the twenty-eight had been hired in the nine month period that preceded the report. Id. 

At that time, the CDCR defendants indicated it was their “preference to use on-site psychiatry 

whenever possible” and, therefore, “when an institution is able to fill a position for an on-site 

psychiatrist, the tele-psychiatrist is moved elsewhere in favor of the on-site doctor.” Id. at 9-10. 

The CDCR defendants represented that “[t]ele-psychiatrists are able to treat patients at all levels 

of care at institutions where recruitment is more difficult or temporary staffing shortages require 

relief.” Id. at 10. 

Plaintiffs objected “to the alleged absence of ‘adequate policies and procedures 

governing the appropriate use of telepsychiatry.’” ECF No. 5307 at 3 (quoting ECF No. 5281 at 

7). In its May 18, 2015 order, the court observed that defendants “apparently are broadening their 

reliance on telepsychiatry while the development of positions and procedures for this method of 

care, and assessment of its adequacy, is ongoing” and that “[t]his is troubling, particularly 

because there may be class members not susceptible to this method of care.” Id. at 5. 

The Special Master reports that “[b]y January 2017, the telepsychiatry staff had 

grown to 48 providing services to 18 institutions with an intended expansion to 100 working in 

three locations.” ECF No. 5564 at 15. Full expansion will require new office space which will 

not be completed until next year. Id. Plaintiffs raised several objections to the proposed 

expansion with the Special Master. Id. 

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The Special Master reports that he and his experts agree that “telepsychiatry is a 

viable method for the delivery of mental health services”, id. at 16, and he recommends “the 

continued expansion of the telepsychiatry program”, id. at 17, with the following caveats: 

 “Telepsychiatry should serve as a supplement for on-site psychiatry, not as a 

substitute and should only be utilized when institutions are unable to recruit 

psychiatrists to work on-site.” 

 CDCR should be required to continue its recruitment effort at all institutions. 

 “The convenience of telepsychiatry should . . . not serve as a reason to allow 

on-site psychiatrists to migrate to the comfort of remote off-site offices. It 

cannot be emphasized enough that telepsychiatry should not replace on-site 

psychiatry.” 

 Telepsychiatry should not be a “frontline approach” for psychiatric services 

“for inmates with the most intensive or emergent needs.” 

o For CCCMS level of care, telepsychiatry “is an appropriate option with 

the requirement that the telepsychiatrist work on-site at least twice per 

year at the designated institutions and more frequently if feasible.” 

o While not recommending permanent use of telepsychiatry at the EOP 

level of care due to inadequate assessment of its efficacy, the Special 

Master does recommend “that a psychiatrist be on-site at least quarterly 

to treat EOP inmates, given the frequency of psychiatric contacts 

required by the Program Guide.” 

o Telepsychiatry is not appropriate for the MHCB level of care except 

“as a last resort or in emergency situations when an on-site psychiatrist 

is not available.” 

ECF No. 5564 at 15-17 (emphasis added). 

Defendants object to the Special Master’s recommendations concerning limitations 

on the use of telepsychiatry for inmates at EOP and higher levels of care. ECF No. 5591 at 5-9. 

They present a declaration from Michael Golding, M.D., Chief Psychiatrist for CDCR, in support 

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of their objections to the recommended parameters, ECF No. 5591-1, which they contend 

supports a finding that telepsychiatry is as effective as on-site psychiatric interactions “in most 

applications.” Id. at 6. 

Plaintiffs object to a substantial amount of Dr. Golding’s declaration. See ECF 

No. 5602. Significantly, plaintiffs note that Dr. Golding avers that he and his research team 

“were unable to locate any well-controlled studies evaluating telepyschiatry vs. onsite psychiatry 

within a prison setting.” ECF No. 5591-1, Golding Decl. ¶ 2. Dr. Golding instead reasons from 

“findings published from studies on telepsychiatry in other settings,” which he describes as 

“informative and corroborat[ing] its usefulness in providing mental health treatment to patients 

who need it.” Id. Plaintiffs object to this extrapolation on a number of grounds. Specifically, 

plaintiffs object to the latter as “expert opinions that cannot be offered in a Declaration submitted 

under Rule 601” and to Dr. Golding’s “sweeping assertions about the meaning of the studies as a 

whole . . . [as] outside the province of a lay witness” under Federal Rules of Evidence 701 and 

702. ECF No. 5602 at 3. Although it is not entirely clear, it appears plaintiffs’ Rule 601 

objection may be related to their contention that Dr. Golding’s table summarizing the studies on 

which he relied is without sufficient indicia of reliability and personal knowledge to support its 

admission and, therefore, that the opinions he offers are inadmissible. While the merits of 

plaintiffs’ objections are unclear, it makes no difference because the court gives the declaration 

little weight. 

Upon review, the court concludes the evidence tendered by defendants is 

insufficient to demonstrate that use of telepsychiatry is appropriate for all Coleman class 

members at every level of care in the MHSDS. In his Twenty-Sixth Round Monitoring Report, 

the Special Master reported to the court that “[t]elepsychiatry was first conceived almost two 

decades ago as a proposed remedy to alleviate the psychiatry staffing shortage. It is primarily an 

option for treatment of inmates at the 3CMS level of care and a less desirable option for inmates 

at higher levels of care.” ECF No. 5439 at 30. In their response to his report, defendants rely on 

the Special Master’s review of their telepsychiatry program in support of their argument that the 

program can and should be expanded. ECF No. 5591 at 8. The court is persuaded that the 

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Special Master’s monitoring of CDCR’s use of telepsychiatry and the conclusions of his experts 

concerning its efficacy for class members based on that monitoring is more relevant to a 

determination of the appropriate use of telepsychiatry for members of the plaintiff class than are 

the studies cited by Dr. Golding. 

Given the experience with telepsychiatry to date, the time has come for the 

adoption of an addendum to the Revised Program Guide that will govern the use of telepsychiatry 

and the extent to which telepsychiatrists may provide mental health services in place of on-site 

psychiatrists going forward. With one clarification, the recommendations of the Special Master 

will be adopted at this time. The clarification is to the first recommendation, confirming that 

telespsychiatry should serve as a supplement, rather than a substitute, for on-site psychiatry and 

should only be used when institutions are unable to recruit psychiatrists or have short-term 

vacancies that cannot be filled by contract psychiatrists. Moreover, it is important to note that 

this recommendation is qualified by the ones that follow concerning the use of telepsychiatry at 

specific levels of the MHSDS. 

These recommendations, as clarified, shall form the basis of the addendum to the 

Revised Program Guide, subject to modification as appropriate as a result of ongoing monitoring 

of defendants’ telepsychiatry program. The addendum to the Revised Program Guide shall be 

developed and finalized with the guidance of the Special Master and his experts, with input from 

plaintiffs’ counsel at the discretion of the Special Master. This task shall be completed on a 

timeframe set by the Special Master so that it can be implemented prior to the one year deadline 

set by this order. 

C. Salary Increases for Psychiatrists 

Defendants’ February 2, 2015 plan included proposals to increase pay for contract 

psychiatrists and differential pay for civil service psychiatrists at hard-to-recruit institutions. ECF 

No. 5269 at 9. As noted above, the Special Master reports that defendants “left out any specific 

mention” of differential pay for civil service psychiatrists in their January 10, 2017, updated 

staffing plan. ECF No. 5564 at 12. He also reports that “[t]hroughout the recent meet and confer 

process, defendants repeatedly asserted that the issue of salary increases was being addressed 

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through the collective bargaining process and they could provide no further information on the 

subject.” Id. at 24. A collective bargaining agreement was reached after the Special Master filed 

his report. See Ex. G to Decl. of Nolan, ECF No. 5590-1. At the time defendants’ objections 

were filed, the agreement was still “subject to union ratification and subsequent approval by the 

legislature.” ECF No. 5591 at 11 n.11. As a consequence of defendants’ meager and insufficient 

presentation to the Special Master, he found this aspect of their staffing plan “unacceptable” and 

not in line with “the Court’s stated directive that defendants present more than a ‘mere plan’ and 

‘demonstrate clear action in accordance with planned steps and a measurable timeline by which 

those steps will be completed.’” ECF No. 5564 at 25 (quoting ECF No. 5477 at 6). As a result, 

the Special Master recommends that the court decline to adopt defendants’ proposals with respect 

to psychiatrist pay and, instead, that defendants be required to develop a supplemental plan to 

address psychiatrist pay and to take the following recommended steps: 

 Include in the supplemental plan detailed information about 

the timing and the amount of the increase in contractor rates. 

 Defendants be required to monitor the effect of salary rate 

increases on the usage of registry hours in order to 

determine whether further rate increases are necessary to 

assist in the recruitment and retention of psychiatry registry 

staff and report to the Special Master on a quarterly basis. 

 Within 90 days, defendants be directed to inform the Special 

Master “of the results of final collective bargaining 

agreements with all categories of mental health and medical 

staff that impact the delivery of mental health services, with 

a focus on any changes in existing terms of collective 

bargaining agreements that may enhance or impede future 

recruitments in each category,” as required by the June 13, 

2002 order. ECF No. 1383 at 4. If the collective bargaining 

process remains ongoing, defendants should be required to 

develop a benchmark that can be adopted by the Court, or in 

the alternative, develop a salary survey for the Court to 

consider. 

Id. at 13, 26, 28. 

 Plaintiffs’ chief objection to the Special Master’s report is that it does not go far 

enough on the question of pay for psychiatrists. Plaintiffs seek an order requiring defendants to 

“significantly increase minimum psychiatrist salaries, offer the 15% recruitment and retention 

differential to psychiatrists on the same terms offered to physicians and surgeons, and devise a 

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long-term plan to address staffing shortages.” ECF No. 5590 at 26. Defendants contend higher 

salaries alone will not solve the problem and that plaintiffs’ “proposal is an unsustainable solution 

for providing long term care to mentally ill inmates housed in state prisons.” ECF No. 5601 at 2. 

Defendants contend they should, instead, “be allowed to implement their 2017 Staffing Plan and 

work with the Special Master to revisit the previously-ordered staffing ratios to determine if these 

ratios are feasible or even necessary.” Id. 

 It is clear from the Special Master’s report that he is of the view that revisiting the 

existing salary structure for psychiatrists would greatly aid achievement of a complete remedy. 

Plaintiffs agree but do not think his recommendation goes far enough. Defendants appear, in 

essence, to hedge their bets, hoping the other provisions of their staffing plan will close the 

vacancy gap and that the court will permit revisiting of the staffing ratios. For the reasons 

discussed below, the court declines to make any further specific orders governing psychiatrist 

pay. It is clear that defendants know that increasing pay for psychiatrists is an option available to 

them to comply with the orders of this court. What is apparently less clear, but will now be made 

explicit, is that defendants must, within the next year, organize and locate the programs in their 

MHSDS so that those programs are staffed according to the ratios in the 2009 Staffing Plan, 

absent a change to those ratios approved by the Special Master and this court within the next year, 

and the June 13, 2002 order. Increasing pay for psychiatrists may be one tool defendants use to 

achieve this requirement. It is up to them. 

D. Bed Planning (Clustering) 

In the August 9, 2016 order, the court directed defendants to meet and confer 

monthly with the Special Master to discuss, among other options, “potential clustering of higheracuity mentally ill inmates at those institutions where it has been shown that mental health staff 

can be more readily attracted and retained, all to resolve the continuing problem of mental health 

staffing in CDCR prisons in a thorough and lasting way.” ECF No. 5477 at 8-9. 

The clustering plan defendants presented to the Special Master expands EOP beds 

at all institutions with EOP programs, with the exception of Pelican Bay, “which was closed to 

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EOP inmates because it was a hard to recruit location.” ECF No. 5564 at 26. The Special Master 

reports that 

the EOP bed expansion plan as currently designed does not address 

the core of the Court’s order regarding clustering, which is to 

consider placing “higher-acuity mentally ill inmates at those 

institutions where it has been shown that mental health staff can be 

more readily attracted and retained.” ECF No. 5477 at 8. True 

clustering, for example, would be closing a hard-to-recruit 

institution such as High Desert State Prison to intake, and placing 

those MHSDS inmates in an institution that has the ability to recruit 

and retain mental health staff. At its core, all defendants’ plan does 

is dramatically expand EOP beds at a number of institutions that 

defendants themselves described as hard-to-recruit institutions in 

their February 2, 2015 staffing plan, particularly in psychiatry, 

which was discussed earlier. For example, the vacancy rates in 

November 2016 for both on-site and telepsychiatry for Kern Valley 

State Prison, California Substance Abuse Treatment Facility, 

California State Prison/Los Angeles County, and California State 

Prison, Corcoran were 54 percent, 46 percent, 47 percent, and 33 

percent respectively. [Footnote omitted.] The EOP clustering plan 

offered by defendants is inadequate; it does not resolve the issue of 

recruiting and retaining staff in its current iteration. 

Id. at 27-28. The Special Master recommends that defendants be required to develop, within 

ninety days, a clustering plan “that expressly demonstrates how defendants propose to recruit and 

retain mental health staff at each designated cluster institution in order to resolve the longstanding staffing problems in CDCR.” Id. at 28. 

The Special Master’s recommendation is sound, particularly given the longstanding problem of recruiting psychiatrists at several of the institutions defendants themselves 

have identified as locations where it is hard to recruit psychiatrists. Given the deadline the court 

will impose in this order, defendants are well-advised to take the Special Master’s 

recommendation and work closely with him to develop a more robust clustering plan than the one 

presented during the workgroup discussions that led to his current report. If defendants choose to 

cluster programs to comply with this order, they will be required to work with the Special Master 

as they refine their clustering plan. 

E. Conclusion 

Over the past two decades a sufficient number of orders have been issued to guide 

defendants in meeting their constitutional obligations, including the Eighth Amendment 

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obligation to hire mental health staff in sufficient numbers to treat the mentally ill inmate 

population. More than twenty years into the remedial phase of this action, the ways to meet this 

obligation have been the subject of numerous court orders as well as extensive planning efforts by 

defendants under the supervision of the Special Master and with input from plaintiffs. 

It is fundamental that “in cases challenging conditions of prison confinement, 

courts must strike a careful balance between identification of constitutional deficiencies and 

deference to the exercise of the wide discretion enjoyed by prison administrators in the discharge 

of their duties.” Coleman v. Wilson, 912 F. Supp. at 1301 (citing Toussaint v. McCarthy, 801 

F.2d 1080, 1086-87 (9th Cir. 1986)); see also Coleman v. Schwarzenegger, 922 F. Supp.2d 822, 

963-64 (E.D. Cal. and N.D. Cal. 2009) (“institution-by-institution approach to population 

reduction would interfere with the state’s management of its prisons more than a single 

systemwide cap. . .”). At this juncture, further orders requiring specific remedial measures would 

in a number of instances be redundant and, more importantly, would tip the balance unacceptably 

toward micromanagement and substitute this court’s judgment for that of prison administrators. 

The court has repeatedly identified the constitutional deficiencies in staffing and has issued 

several orders aimed at remedying the deficiencies. As with transfers to inpatient care, which the 

court is addressing separately, defendants have a wide range of options available to meet their 

constitutional obligations to hire sufficient numbers of prison psychiatrists. These include, but 

are not limited to, raising salaries and clustering programs in locations where psychiatrists can be 

more easily recruited. Defendants may use a combination of these options and others in a focused 

effort to finally remedy ongoing staffing shortages. If defendants’ optimism that Proposition 57 

will reduce the population of mentally ill inmates, that reduction also will aid in achieving 

compliance with required staffing levels. What defendants cannot do is continue to fail to meet 

their obligation to hire a sufficient number of psychiatrists to meet their constitutional obligations. 

It is no secret that the court recently issued an enforcement order intended to bring 

defendants into full and permanent compliance with Program Guide timelines for transfer to 

inpatient care. ECF No. 5610. More than a decade had passed since defendants were ordered to 

“‘immediately implement’” those timelines. ECF No. 5583 at 3 (quoting ECF No. 1773). When 

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the court reviewed the record concerning Program Guide timelines for transfer to inpatient care, it 

was clear that “defendants have sufficient options to allow them to comply now, fully and 

permanently,” with those timelines. ECF No. 5583 at 8. 

With respect to staffing, the stark reality of the record before this court is that 

defendants have for fifteen years been under orders to keep their mental health staff vacancy rate 

below ten percent. For most of that fifteen year period, and for several classifications of mental 

health staff, defendants have been in violation of that order. As is clear from the Special Master’s 

most recent report, defendants are still in violation of the court’s order, particularly with respect 

to psychiatrists. See ECF No. 5590-1 at 23. The long history of failure to hire a sufficient 

number of psychiatrists, combined with defendants’ position on the matters before the court on 

the Special Master’s report, raises a question about whether defendants will ever be able to hire 

sufficient staff to meet their constitutional obligations to members of the plaintiff class, as long as 

the size of the seriously mentally ill inmate population in California’s prison system remains at 

current levels or continues to grow. The time is now to resolve that question. 

This court is committed to bringing this action to a conclusion sooner rather than 

later, to achieve the long deferred requirements of constitutional compliance. See, e.g., ECF 

No. 5477 at 1-2. The Special Master’s report makes clear defendants must do more to address 

ongoing mental health staffing shortages, particularly among psychiatrists, in order to achieve 

long-overdue complete remediation. Defendants’ latest plan, presented to the Special Master in 

January 2017 and the subject of his current report, articulates some goals, but does not follow the 

court’s direction to develop a timeline by which all steps in the plan will be complete. Because 

defendants have not developed the timeline required by the August 9, 2016 order, the court will 

set a one year deadline by which all outstanding issues pertaining to achieving adequate mental 

health staffing levels must be resolved and the required staffing levels achieved. The court will 

set a status conference six months from now to hear from defendants on their progress. A second 

status conference will be set thirteen months from now to address, as necessary, any required 

enforcement orders and the time staffing levels must be maintained at court-ordered levels, under 

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court supervision, in order for the court to be satisfied the remedy has been achieved and is 

durable. 

Finally, as the court noted at the start of this order, the DSH defendants are 

currently required by a March 8, 2017 order to work on and implement their staffing plan, to do 

so “in coordination with CDCR’s development of its own mental staffing plan, and within the 

context of the same meet-and-confer process with the Coleman parties” and to provide to the 

Special Master monthly updates on implementation of their staffing plan. ECF No. 5573 at 3. 

The March 8, 2017 order giving rise to that requirement will be modified by this order to require 

DSH defendants to complete development and full implementation of their mental health staffing 

plan within the one year time frame set by this order. 

In accordance with the above, IT IS HEREBY ORDERED that: 

1. The findings in the Special Master's February 6, 2017 Report on the Status of 

 Mental Health Staffing and the Implementation of Defendants' Staffing Plan are 

 adopted in full. 

2. The recommendations of the Special Master are adopted, with modifications, as 

 follows: 

 a. Defendants shall report to the Special Master at such regular intervals as 

 he may set on the implementation of their staffing plan proposals related to 

 medical assistants, internship and fellowship programs, increased rates for 

 contract psychiatrists, telepsychiatry, cash for on-call compensation, dual 

 appointments, psychiatric nurse practitioners, utilization management 

 related to 3CMS inmates, utilization management related to EOP inmates, 

 Proposition 57, and the Mental Health Academy; and 

b. Defendants and the Special Master shall meet and confer not less than 

every 90 days for the next year, including plaintiffs as appropriate, to 

discuss the status of defendants’ progress toward compliance with this 

order. 

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3. Within one year from the date of this order, the CDCR defendants shall take all 

 steps necessary to come into complete compliance with the staffing ratios in their 

 2009 Staffing Plan and the maximum ten percent vacancy rate required by the 

 court's June 13, 2002 order. 

4. Under the guidance of the Special Master, defendants shall develop an 

 addendum to the Revised Program Guide to govern the use of telepsychiatry and 

 the extent to which telepsychiatrists may provide mental health services in place of 

 on-site psychiatrists. Telespsychiatry should serve as a supplement, rather than a 

 substitute, for on-site psychiatry and should only be used when institutions are 

 unable to recruit psychiatrists or have short-term vacancies that cannot be filled by 

 contract psychiatrists. The Special Master's recommendations concerning the use 

 of telepsychiatry, as clarified by this order, shall form the basis of that addendum, 

 subject to modification as appropriate as a result of ongoing monitoring of 

 defendants’ telepsychiatry program. The addendum shall be developed and 

 finalized with the guidance of the Special Master and his experts, and with input 

 from plaintiffs’ counsel at the discretion of the Special Master. The addendum 

 shall be completed on a timeframe to be set by the Special Master so that it can 

 be implemented prior to the deadline set in paragraph 2 of this order. 

5. Paragraph two of the court's March 8, 2017 order, ECF No. 5573, is amended 

 to require complete implementation of the DSH defendants' staffing plan within 

 one year from the date of this order. 

6. Defendants' April 13, 2017 motion to strike, ECF No. 5600, and defendants' 

 April 27, 2017 motion to strike, ECF No. 5613, are denied without prejudice. 

7. This matter is set for status conference on April 12, 2018 at 10:00 a.m., in 

Courtroom No. 3. Not later than fourteen days prior to the status conference, the 

parties shall file a joint status report addressing the CDCR defendants’ progress 

toward compliance with paragraph 3 of this order, including but not limited to the 

status of implementation of the PMA program, the status of the addendum to the 

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Revised Program Guide governing telepsychiatry, psychiatrist salaries, clustering 

and any other issues relevant to an understanding of defendants’ progress toward 

such compliance. The joint status report shall also address the DSH defendants’ 

progress toward compliance with paragraph 5 of this order. 

8. This matter is set for further status conference on October 11, 2018 at 10:00 

a.m., in Courtroom No. 3. Not later than thirty days prior to the status conference, 

the parties shall file a joint status report addressing, as necessary, issues pertaining 

to enforcement of this order and to durability of the staffing remedy. 

DATED: October 10, 2017. 

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