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June 13, 1996

The Honorable William L. Gordon

Presiding Judge, Superior Court

County of Santa Barbara

1100 Anacapa Street, 2nd Floor

Post Office Box 21107

Santa Barbara, California 93121-1107

RE: SANTA BARBARA COUNTY GRAND JURY 1995-96 INTERIM FINAL REPORT -- COUNTY AGREEMENT WITH PRISON HEALTH SERVICES, INC.

Dear Judge Gordon:

This is the required response to Santa Barbara County Grand Jury 1995-96 Interim Final Report -- County Agreement with Prison Health Services, Inc.

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None.

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Despite the overall improvement in the medical care, the Grand Jury found several deficiencies in the terms of the contract; it also found instances of non-compliance with the contract.

. PHS failed to provide a procedure manual and operation protocol for Santa Barbara County Jail, as defined in the contract's Exhibit A, Scope of Services, Section G. 1. until March 1996.

RESPONSE:

Although it is true PHS did not have an operational protocol or operational plan unique to the Santa Barbara County Jail, they did have a protocol which was written for their Alameda County Jail contract. It covered all the necessary issues related to the custody environment; however, was not specific to Santa Barbara. This has been modified and is now in place.

. The Grand Jury was told that nurse staffing levels, as defined in Exhibit A.1. of the contract, have not been adhered to.

RESPONSE:

On occasion there needs to be flexibility with work schedules. This is designed to benefit the operation and not intended to, but sometimes does, conflict with the contract. Staffing needs are based on workloads. Some minor scheduling modifications needed to be done during the initial contract phase. All were approved and monitored by the Jail Executive Staff. This did not allow for PHS to have fewer staff at any time, just when they were on duty. Also, Exhibit B-1 allows for 85% minimum level of staffing before there is a penalty assessed. During the course of the contract, staffing has not been below this level.

. Section II Scope of Services: on site services were to be provided at the Santa Maria Branch Jail. Such services are not being provided.

RESPONSE:

This is accurate. This has been clarified in the proposed amendments to the contract submitted to the Board of Supervisors.

. Special Terms and Conditions, as required by the contract's Exhibit C - Section D: "Accreditation - PHS shall attain within six (6) months and maintain accreditation by the California Medical Association (CMA) subject to compliance of applicable standards by the SBCSD. Failure to maintain accreditation will result in a $25,000 penalty." Accreditation was not accomplished within six months. During the course of this Grand Jury's investigation, a $25,000 penalty was assessed.

RESPONSE:

This is accurate.

. Exhibit A, Section B. 2. of the contract requires that "Health Assessment: Fourteen (14) day health appraisals shall be performed in accordance with CMA." Testimony and monthly reports indicate that this was not being done.

RESPONSE:

An independent monthly audit conducted by Dr. Edelstein of County Health Care Services shows that the majority of the fourteen (14) day evaluations have been performed. Exhibit B-1 establishes a 95% minimum level of compliance and establishes a $25 fine per inmate penalty. Our records indicate that PHS conducted 2,875 appraisals in the first 10 months of the contract. The Sheriff's Business and Finance Bureau is working together with Health Care Services and they have developed an accurate way of monitoring this area.

The Grand Jury also discovered that the following services required by the contract were not provided.

. Medical services to pregnant inmates received at the Santa Maria Branch Jail

. Medical service to work furlough inmates while housed in the Honor Farm

RESPONSE:

PHS does not have on-site staff at the Santa Maria Branch Jail which the original contract called for; however, they are in contact with jail staff on a regular basis. No inmates are housed in Santa Maria on a long-term basis. Any inmate with an immediate medical need is transported to the hospital. All others who require medical care are transported to the Main Jail as soon as possible.

The contract with PHS specifically exempted Work Furlough in the Average Daily Population (ADP). This has been addressed in the contract amendments adopted and approved by the Santa Barbara County Board of Supervisors.

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In the nine months since the county's agreement with PHS, there have been no official adjustments or amendments to the contract.

FINDINGS AND RECOMMENDATIONS

FINDING 1: The contract Santa Barbara County entered into with PHS on July 1, 1995 for medical services excluded mental health care.

RECOMMENDATION 1: The 1996-97 Grand Jury should conduct a study to determine the cost-effectiveness of the contract considering the separate costs of mental health care to the county.

RESPONSE:

None.

FINDING 2: The contract provides a scope of services that include the Santa Barbara Main Jail and the Santa Maria Branch Jail. It is not practical to have on-site services provided at the Branch Jail in Santa Maria.

RECOMMENDATION 2: Item II, Scope Of Services, should be amended in compliance with section XXIV of the contract to read that no on site services are to be provided at the Santa Maria Branch Jail. Such services should continue to be provided at nearby hospitals.

RESPONSE:

Submitted as part of the amendment to the agreement with PHS and approved by the Santa Barbara County Board of Supervisors as recommended by staff.

FINDING 3: The Grand Jury found that the nurse staffing level had been altered without an amendment to the contract.

RECOMMENDATION 3a: Staffing levels should not be altered without an amendment to the contract.

RESPONSE:

After initial phase of the contract and some minor adjustments, the staffing level was submitted along with other amendments to the Board for approval.

RECOMMENDATION 3b: The Jail Commander should regularly review the staffing plan to ensure quality assurance.

RESPONSE:

This is on an ongoing basis and discussed at the monthly review/audit meetings.

FINDING 4: In reviewing the Monthly Performance Standard Review Committee minutes, the Grand Jury noted that the mandatory 14-day health appraisals were not performed to the level required by the contract.

RECOMMENDATION 4: The Jail Commander or his representative(s) should continually monitor all requirements as set forth in Exhibit A, Scope Of Services, of the contract, and ensure the county is protected. This is for risk management purposes, as well as to ensure compliance with the contract.

RESPONSE:

County Health Care Services conducts monthly audits for compliance of performance standards. This now includes a computer printout which provides the medical staff with an up-to-date list of those who are in custody and due for the fourteen (14) day evaluation. This is then reviewed by Health Care Services and the Sheriff's Department Business and Financial Bureau and penalties assessed if warranted.

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FINDING 5: California Medical Association accreditation was not accomplished within six months of the commencement of the contract as required by Exhibit C, Section D of the contract. The Grand Jury found that the contract is ambiguous as to how often a penalty should be assessed.

RECOMMENDATION 5: The Jail Commander should require a 100% minimum level of attainment and maintenance of full CMA accreditation. The Jail Commander should enforce this by deducting additional penalties of $25,000 per month starting June 1996 until full compliance is met and maintained as is required by the contract.

RESPONSE:

This was also made part of the amendment to the contract approved by the Board of Supervisors and PHS. They should be held accountable for only those areas for which they are responsible and not those which are beyond their control. The amendment calls for the penalty to begin in July 1996. On June 13, 1996 we were advised we received a two (2) year accreditation by CMA.

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FINDING 6: The contract clearly states all pregnant inmates shall be examined within two hours of booking. There is no PHS staff on duty at the Santa Maria Branch Jail, which makes it impractical to provide this service.

RECOMMENDATION 6: The contract language should be changed by section XXIV of the contract to read: "Pregnant inmates who are received at Santa Maria Branch Jail shall be taken to a nearby hospital for examination and evaluation within two hours of booking."

RESPONSE:

The amendment to the contract which was agreed to and approved reads as follows: "Pregnant and Postpartum Inmates: Provisions shall be made to care for the special needs of pregnant and postpartum women. Required services include, but are not limited to: Intake health screening within two (2) hours of booking or upon transfer and admission to the MJ; development and use of the Pregnant Female Protocols by health care staff; referral and coordination with a methadone treatment program; perinatal education and counseling with established written agreements to assure the continuous availability of full range routine and emergency obstetrical services, as well as management of high risk conditions."

FINDING 7: The Jail Commander is the county's designated representative as the administrator of the contract.

RECOMMENDATION 7: The Jail Commander should perform necessary oversight to ensure the filing of all incident and medical reports for injuries and deaths in accordance with PHS's standard operating procedure. Copies of all incident reports should be sent to Risk Management.

RESPONSE:

This is on an ongoing basis. Those incidents requiring notification of Risk Management are completed and forwarded as required by Policy.

FINDING 8: Levels of service provided at the Santa Maria Branch Jail and staffing levels at the Main Jail were changed by PHS staff without officially amending the contract.

RECOMMENDATION 8: The Jail Commander should be assured that any changes to the contract are properly amended and signed off. This must be done before the changes are implemented.

RESPONSE:

Although the contract was not amended, PHS did not change the staffing level without the permission or knowledge of the Chief Deputy of Custody Operations. It was only after careful consideration and the determination that it was in the best interest of the inmates, did the Chief allow for the modification. Once the change took place and the situation was monitored for success did we recommend the change to the contract which went forward. There needed to be a period of adjustment to determine the needs and adjust the workload to have as little impact on the organization as possible.

Sincerely,

Jim Thomas

SHERIFF

JT:GT:jb

cc: Grand Jury Foreman


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