Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

1 
  

Review 
  of 
  Riverside 
  County 
  Jail 
  Medical 
  Services 
  
 
  
Scott 
  A. 
  Allen, 
  MD 
  
 
  
Introduction 
  
 
  
I 
  have 
  been 
  asked 
  jointly 
  by 
  counsel 
  representing 
  the 
  County 
  of 
  Riverside 
  and 
  
counsel 
  representing 
  plaintiffs 
  in 
  the 
  matter 
  of 
  Gray 
  v. 
  County 
  of 
  Riverside 
  to 
  
provide 
  an 
  independent 
  assessment 
  of 
  the 
  medical 
  care 
  provided 
  by 
  the 
  County 
  in 
  
its 
  jail 
  system 
  and 
  to 
  make 
  recommendations 
  as 
  indicated 
  as 
  part 
  of 
  an 
  alternative 
  
resolution 
  process. 
  
 
  
In 
  my 
  task, 
  I 
  am 
  pleased 
  to 
  report 
  that 
  I 
  received 
  the 
  full 
  cooperation 
  of 
  the 
  staff 
  of 
  
the 
  Riverside 
  County 
  Sheriff’s 
  Department 
  and 
  County 
  medical 
  staff, 
  both 
  in 
  
Corrections 
  Health 
  Service 
  and 
  at 
  the 
  Riverside 
  University 
  Medical 
  Center 
  (RUMC, 
  
formerly 
  Riverside 
  County 
  Regional 
  Medical 
  Center 
  or 
  RCRMC). 
   
  In 
  particular, 
  I 
  wish 
  
to 
  thank 
  Lieutenants 
  Maurice 
  LeClair 
  and 
  Hal 
  Reed, 
  as 
  well 
  as 
  Correctional 
  Health 
  
Services 
  (CHS) 
  Administrator 
  William 
  Wilson, 
  CHS 
  Medical 
  Director 
  Dr. 
  Victor 
  Laus 
  
and 
  RUMC 
  Medical 
  Director 
  Dr. 
  Arnold 
  Tabuenca, 
  as 
  well 
  as 
  nursing 
  supervisors 
  
Stillwell, 
  Reeves, 
  Adewunmi 
  and 
  Redler 
  for 
  their 
  flexibility 
  and 
  cooperation 
  during 
  
my 
  investigation. 
  
 
  
 
  
Expert 
  Qualifications 
  
 
  
I 
  am 
  a 
  physician 
  licensed 
  in 
  the 
  state 
  of 
  California. 
   
  I 
  am 
  board 
  certified 
  in 
  Internal 
  
Medicine 
  and 
  am 
  a 
  Fellow 
  of 
  the 
  American 
  College 
  of 
  Physicians. 
  I 
  am 
  a 
  Professor 
  of 
  
Clinical 
  Medicine 
  and 
  Associate 
  Dean 
  of 
  Academic 
  Affairs 
  at 
  the 
  University 
  of 
  
California 
  Riverside 
  School 
  of 
  Medicine. 
  
 
  
I 
  have 
  been 
  a 
  physician 
  since 
  1991. 
   
  I 
  have 
  worked 
  in 
  the 
  field 
  of 
  correctional 
  health 
  
care 
  for 
  the 
  past 
  17 
  years. 
   
  From 
  1997 
  to 
  2004, 
  I 
  was 
  a 
  full 
  time 
  correctional 
  
physician 
  for 
  the 
  Rhode 
  Island 
  Department 
  of 
  Corrections; 
  for 
  the 
  final 
  three 
  years 
  I 
  
served 
  as 
  the 
  State 
  Medical 
  Program 
  Director 
  for 
  the 
  department 
  where 
  I 
  oversaw 
  
all 
  medical 
  care 
  for 
  the 
  State 
  of 
  Rhode 
  Island 
  prisons 
  and 
  jails 
  for 
  both 
  men 
  and 
  
women, 
  including 
  medical, 
  psychiatric 
  and 
  dental 
  services. 
   
  From 
  2005 
  to 
  2011, 
  I 
  
worked 
  full 
  time 
  in 
  the 
  Eleanor 
  Slater 
  Hospital, 
  the 
  state 
  psychiatric 
  hospital, 
  on 
  
secured 
  units 
  caring 
  for 
  patients 
  that 
  included 
  both 
  sentenced 
  and 
  forensic 
  
populations. 
   
  I 
  am 
  a 
  member 
  of 
  the 
  Society 
  of 
  Correctional 
  Physicians 
  and 
  a 
  Fellow 
  
of 
  the 
  American 
  College 
  of 
  Physicians. 
  
 
  
I 
  have 
  written 
  and 
  published 
  over 
  twenty 
  peer-­‐reviewed 
  papers 
  in 
  academic 
  
journals 
  related 
  to 
  prison 
  health 
  care 
  and 
  am 
  on 
  the 
  editorial 
  board 
  of 
  the 
  
International 
  Journal 
  of 
  Prisoner 
  Health 
  Care. 
   
   
  I 
  have 
  served 
  as 
  an 
  independent 
  
expert 
  to 
  the 
  Federal 
  Court 
  on 
  standards 
  of 
  hepatitis 
  C 
  management 
  in 
  prisons, 
  and 
  
have 
  served 
  as 
  a 
  plaintiff’s 
  expert 
  in 
  a 
  number 
  correctional 
  health 
  cases. 
  I 
  have 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

2 
  

consulted 
  on 
  detention 
  health 
  issues 
  both 
  domestically 
  and 
  internationally 
  for 
  the 
  
Open 
  Society 
  Institute 
  and 
  the 
  International 
  Committee 
  of 
  the 
  Red 
  Cross 
  and 
  
domestically 
  for 
  the 
  Department 
  of 
  Homeland 
  Security 
  among 
  others. 
  I 
  have 
  worked 
  
with 
  the 
  Institute 
  of 
  Medicine 
  on 
  several 
  workshops 
  related 
  to 
  detainee 
  healthcare. 
   
  
I 
  co-­‐founded 
  and 
  am 
  co-­‐director 
  of 
  the 
  Center 
  for 
  Prisoner 
  Health 
  and 
  Human 
  Rights 
  
at 
  Brown 
  University 
  and 
  co-­‐investigator 
  for 
  the 
  University 
  of 
  California 
  Criminal 
  
Justice 
  and 
  Health 
  Care 
  Consortium. 
  
 
  
A 
  more 
  detailed 
  listing 
  of 
  my 
  experience 
  in 
  correctional 
  health 
  care, 
  my 
  
participation 
  in 
  the 
  development 
  of 
  national 
  correctional 
  policy 
  and 
  standards, 
  my 
  
experiences 
  as 
  a 
  consultant 
  and 
  expert 
  witness, 
  and 
  a 
  list 
  of 
  my 
  publications 
  are 
  
included 
  in 
  my 
  curriculum 
  vitae, 
  which 
  has 
  been 
  provided 
  to 
  counsel 
  for 
  the 
  
plaintiffs 
  and 
  the 
  County. 
  
 
  
I 
  am 
  familiar 
  with 
  the 
  degree 
  of 
  care 
  and 
  skill 
  ordinarily 
  exercised 
  by 
  members 
  of 
  
the 
  medical 
  and 
  behavioral 
  health 
  professions 
  involving 
  the 
  care 
  and 
  treatment 
  of 
  
inmates 
  and 
  pre-­‐trial 
  detainees 
  in 
  correctional 
  facilities. 
  
 
  
Standards 
  
 
  
While 
  it 
  is 
  understood 
  that 
  the 
  Riverside 
  County 
  Jail 
  is 
  not 
  currently 
  accredited 
  by 
  
the 
  National 
  Commission 
  on 
  Correctional 
  Health 
  Care 
  (NCCHC), 
  the 
  Standards 
  for 
  
Services 
  in 
  Jails 
  (2014 
  Ed.) 
  provides 
  a 
  useful 
  benchmark 
  for 
  minimum 
  standards 
  for 
  
jail 
  health 
  services 
  in 
  the 
  Unites 
  States, 
  and 
  I 
  will 
  refer 
  to 
  those 
  standards 
  in 
  this 
  
report.1 
  
 
  
In 
  addition 
  to 
  the 
  NCCHC 
  standards, 
  I 
  will 
  make 
  reference 
  in 
  this 
  report 
  to 
  
community 
  medical 
  standards. 
   
  While 
  the 
  acceptable 
  clinical 
  practice 
  of 
  medicine 
  
allows 
  for 
  a 
  wide 
  variety 
  of 
  approaches 
  to 
  practice, 
  community 
  medical 
  standards 
  
are 
  the 
  point 
  in 
  which 
  the 
  greater 
  body 
  of 
  experts 
  and 
  practitioners 
  in 
  the 
  field 
  have 
  
found 
  agreement 
  and 
  are 
  established 
  by 
  the 
  standard 
  of 
  care 
  accepted 
  by 
  the 
  
community 
  at 
  large. 
   
  
 
  
Broadly 
  speaking, 
  a 
  community 
  medical 
  standard 
  has 
  been 
  established 
  which 
  has 
  
already 
  taken 
  into 
  consideration 
  all 
  points 
  of 
  view 
  and 
  evidence, 
  and 
  that 
  is 
  what 
  I 
  
will 
  use 
  as 
  a 
  standard 
  for 
  care. 
   
  There 
  is 
  no 
  separate 
  or 
  unequal 
  standard 
  of 
  care 
  for 
  
inmates 
  of 
  correctional 
  institutions; 
  there 
  are 
  merely 
  logistical 
  challenges 
  and 
  
reasonable 
  accommodations 
  and 
  modifications 
  of 
  standard 
  medical 
  approaches 
  that 
  
are 
  a 
  direct 
  result 
  of 
  the 
  constraints 
  of 
  confinement 
  settings. 
   
  Those 
  exceptions 
  and 
  
accommodations 
  to 
  security 
  needs 
  should 
  be 
  absolutely 
  minimal 
  and 
  rarely 
  
interrupt 
  and 
  never 
  prevent 
  essential 
  healthcare 
  delivery. 
   
  To 
  the 
  extent 
  that 
  
providing 
  medical 
  care 
  in 
  a 
  correctional 
  setting 
  raises 
  some 
  unique 
  challenges, 
  I 
  
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  
1 
  When 
  I 
  cite 
  the 
  2014 
  NCCHC 
  Standards 
  for 
  Health 
  Services 
  in 
  Jails, 
  the 
  standard 
  is 
  
in 
  the 
  following 
  format: 
   
  the 
  letter 
  “J” 
  followed 
  by 
  letter 
  “A” 
  through 
  “I” 
  and 
  a 
  
number. 
   
  For 
  example, 
  the 
  standard 
  for 
  Receiving 
  Screening 
  is 
  J-­‐E-­‐02. 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

3 
  

draw 
  on 
  my 
  knowledge 
  of 
  standards 
  and 
  practices 
  as 
  a 
  physician 
  experienced 
  in 
  
correctional 
  healthcare 
  and 
  familiar 
  with 
  standards 
  of 
  the 
  field. 
  
 
  
In 
  general, 
  when 
  I 
  refer 
  to 
  minimal 
  community 
  standards, 
  I 
  refer 
  to 
  services 
  a 
  
patient 
  with 
  Medicaid 
  coverage 
  would 
  likely 
  be 
  eligible 
  to 
  receive 
  in 
  a 
  community 
  
health 
  center 
  or 
  similar 
  setting, 
  recognizing 
  that 
  inmates 
  are 
  not 
  constitutionally 
  
entitled 
  to 
  the 
  most 
  sophisticated 
  care 
  money 
  can 
  by, 
  but 
  to 
  adequate 
  medical 
  care. 
   
  
 
  
Finally, 
  when 
  I 
  do 
  make 
  reference 
  to 
  constitutional 
  standards 
  to 
  health 
  care 
  (based 
  
on 
  the 
  Eighth 
  Amendment 
  prohibition 
  on 
  cruel 
  and 
  unusual 
  punishment), 
  I 
  do 
  so 
  
not 
  as 
  a 
  lawyer 
  (which 
  I 
  clearly 
  am 
  not) 
  but 
  as 
  a 
  physician 
  with 
  extensive 
  experience 
  
in 
  actually 
  providing 
  that 
  level 
  of 
  care 
  in 
  jails 
  and 
  prisons 
  and 
  in 
  helping 
  the 
  courts 
  
to 
  define 
  that 
  standard 
  in 
  practical 
  terms. 
  
 
  
 
  
Methods 
  
 
  
My 
  investigation 
  of 
  the 
  medical 
  services 
  at 
  the 
  Riverside 
  County 
  Jail 
  involved 
  the 
  
following 
  methods: 
   
  
 
  
1) Site 
  Visits: 
   
  In 
  the 
  course 
  of 
  my 
  review 
  of 
  medical 
  services 
  in 
  the 
  county 
  jails, 
  I 
  
have 
  personally 
  visited 
  all 
  five 
  jail 
  facilities 
  at 
  least 
  once 
  and 
  two 
  facilities 
  
(Robert 
  Presley 
  and 
  Southwest) 
  twice. 
  
 
  
2) Record 
  Reviews: 
   
  I 
  have 
  reviewed 
  selected 
  medical 
  records 
  and 
  medication 
  
administration 
  records 
  at 
  all 
  five 
  sites. 
   
  Records 
  typically 
  were 
  selected 
  
because 
  the 
  inmate 
  had 
  a 
  chronic 
  medical 
  condition 
  or 
  had 
  been 
  recently 
  
seen 
  by 
  medical 
  staff. 
  
 
  
3) Staff 
  Interviews: 
   
  During 
  all 
  site 
  visits 
  I 
  had 
  the 
  opportunity 
  to 
  conduct 
  staff 
  
interviews. 
   
  During 
  the 
  course 
  of 
  my 
  investigation, 
  I 
  had 
  opportunities 
  to 
  
question 
  the 
  RUMC 
  Medical 
  Director 
  Arnold 
  Tabuenca, 
  MD, 
  Correctional 
  
Health 
  Services 
  (CHS) 
  Administrator 
  William 
  Wilson, 
  the 
  CHS 
  Medical 
  
Director 
  Victor 
  Laus, 
  MD, 
  nurses 
  supervisors 
  at 
  all 
  of 
  the 
  facilities 
  as 
  well 
  as 
  
physicians 
  and 
  nurses 
  at 
  various 
  sites. 
   
  In 
  addition, 
  I 
  had 
  the 
  opportunity 
  to 
  
speak 
  with 
  a 
  number 
  of 
  Sheriff’s 
  Deputies 
  about 
  the 
  interface 
  of 
  security 
  with 
  
the 
  health 
  care 
  operations. 
  
 
  
4) Inmate 
  Interviews: 
   
  I 
  interviewed 
  a 
  sampling 
  of 
  inmates 
  at 
  all 
  five 
  facilities. 
   
  In 
  
total, 
  I 
  conducted 
  private 
  one-­‐on-­‐one 
  interviews 
  with 
  over 
  fifty 
  individual 
  
inmates. 
   
  In 
  addition, 
  I 
  conducted 
  some 
  brief 
  interviews 
  with 
  a 
  number 
  of 
  
inmates 
  in 
  segregation 
  at 
  their 
  cell 
  doors 
  in 
  the 
  housing 
  unit. 
  
 
  
5) Document 
  Review: 
   
  I 
  reviewed 
  numerous 
  documents 
  provided 
  by 
  the 
  parties 
  
relating 
  to 
  the 
  health 
  services 
  at 
  the 
  Riverside 
  County 
  Jail. 
   
  In 
  addition 
  to 
  the 
  
comments 
  provided, 
  I 
  also 
  reviewed 
  publicly 
  available 
  documents 
  including 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

the 
  2011 
  Grand 
  Jury 
  Report, 
  the 
  2011 
  IQM 
  report 
  and 
  the 
  Riverside 
  County 
  
budget. 
  

4 
  

 
  
Background 
  of 
  Medical 
  Services 
  at 
  Riverside 
  County 
  Jail 
  
 
  
Impact 
  of 
  budget 
  cuts 
  to 
  jail 
  health 
  care 
  services: 
  
 
  
According 
  to 
  Sheriff 
  Sniff’s 
  July 
  15, 
  2011 
  response 
  to 
  the 
  2010-­‐2011 
  Grand 
  Jury 
  
Report, 
  “…beginning 
  fiscal 
  year 
  2008/2009, 
  the 
  conflict 
  between 
  legal 
  responsibility 
  
and 
  practical 
  authority 
  resulted 
  in 
  deep 
  cuts 
  to 
  medical 
  personnel 
  staffing 
  levels, 
  
without 
  consideration 
  for 
  how 
  those 
  cuts 
  affected 
  the 
  respondent’s 
  (the 
  Sheriff’s 
  
Department) 
  ability 
  to 
  fulfill 
  the 
  legal 
  responsibility.” 
   
  [Emphasis 
  added]. 
   
   
  Sheriff 
  Sniff 
  
then 
  went 
  on 
  to 
  report 
  that: 
  
 
  
 
  
… 
  the 
  budget 
  and 
  medical 
  personnel 
  staffing 
  cuts 
  beginning 
  fiscal 
  year 
  
2008/2009 
  unacceptably 
  impacted 
  the 
  delivery 
  of 
  medical 
  services, 
  and 
  
unacceptably 
  impacted 
  other 
  jail 
  operations 
  as 
  well. 
   
  To 
  confirm 
  and 
  
accurately 
  assess 
  the 
  extent 
  of 
  this 
  impact, 
  the 
  respondent 
  requested 
  
evaluations 
  from 
  the 
  Corrections 
  Standards 
  Authority 
  (CSA) 
  and 
  the 
  Institute 
  
for 
  Medical 
  Quality 
  (IMQ). 
   
  Both 
  CSA 
  and 
  IMQ 
  found 
  that 
  emergency 
  and 
  
basic 
  medical 
  services 
  were 
  not 
  being 
  delivered 
  within 
  the 
  intent 
  of 
  the 
  CCR 
  
Title 
  15 
  Minimum 
  Standards 
  for 
  Local 
  Detention 
  Facilities. 
   
  
 
  
According 
  to 
  the 
  2011 
  IMQ 
  assessment, 
  as 
  of 
  January 
  2011, 
  the 
  detention 
  health 
  
staff 
  experienced 
  a 
  44% 
  reduction 
  in 
  staff 
  due 
  to 
  budget 
  cuts. 
   
  My 
  own 
  interviews 
  
with 
  administrators 
  and 
  physicians 
  confirmed 
  that 
  the 
  2008/2009 
  budget 
  
directives 
  devastated 
  medical 
  staffing. 
   
  In 
  the 
  case 
  of 
  the 
  physicians, 
  staffing 
  went 
  
from 
  five 
  physicians 
  (including 
  Dr. 
  Laus, 
  the 
  medical 
  director 
  and 
  four 
  other 
  
physicians) 
  to 
  three. 
   
  However, 
  in 
  the 
  face 
  of 
  almost 
  doubled 
  workloads, 
  two 
  of 
  the 
  
remaining 
  physicians 
  resigned. 
   
  In 
  spite 
  of 
  efforts 
  to 
  find 
  replacements, 
  the 
  County 
  
was 
  unable 
  to 
  fill 
  those 
  vacancies, 
  and 
  for 
  a 
  period 
  of 
  roughly 
  two 
  years, 
  one 
  
physician, 
  Dr. 
  Laus, 
  remained 
  to 
  provide 
  health 
  care 
  to 
  all 
  five 
  adult 
  facilities 
  from 
  
Blythe 
  to 
  Temecula. 
   
  Nursing 
  staff 
  was 
  similarly 
  devastated, 
  resulting 
  in 
  only 
  one 
  
facility 
  out 
  of 
  the 
  five 
  with 
  continuing 
  24/7 
  health 
  coverage. 
   
  To 
  put 
  this 
  in 
  
perspective, 
  this 
  reduced 
  staffing 
  was 
  asked 
  to 
  provide 
  adequate 
  care 
  across 
  five 
  
geographically 
  spread 
  facilities 
  with 
  an 
  average 
  daily 
  population 
  of 
  over 
  3700, 
  and 
  
annual 
  admissions 
  numbering 
  nearly 
  sixty 
  thousand 
  in 
  2014. 
  
 
  
The 
  2011 
  IMQ 
  consultants 
  also 
  noted 
  a 
  rise 
  in 
  court 
  orders 
  directing 
  the 
  department 
  
to 
  address 
  unmet 
  health 
  needs 
  of 
  inmates 
  appearing 
  before 
  the 
  court 
  as 
  part 
  of 
  their 
  
routine 
  criminal 
  proceedings. 
   
  My 
  finding 
  confirms 
  that 
  some 
  four 
  years 
  later, 
  the 
  
courts 
  continue 
  to 
  issue 
  numerous 
  orders 
  to 
  the 
  department 
  to 
  address 
  unmet 
  
health 
  needs 
  of 
  inmates. 
   
  Court 
  orders 
  relating 
  to 
  health 
  care 
  have 
  been 
  in 
  excess 
  of 
  
150 
  per 
  month 
  as 
  recently 
  as 
  the 
  first 
  quarter 
  of 
  this 
  year. 
   
  This 
  is 
  an 
  extraordinary 
  
finding, 
  and 
  documents 
  a 
  lack 
  of 
  faith 
  by 
  the 
  courts 
  in 
  the 
  County’s 
  ability 
  to 
  meet 
  its 
  
statutory 
  and 
  constitutional 
  obligations 
  for 
  the 
  provision 
  of 
  health 
  care 
  to 
  county 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

5 
  

inmates. 
   
  As 
  noted 
  by 
  IMQ 
  in 
  2011, 
  such 
  court 
  orders 
  “should 
  be 
  rare 
  and 
  only 
  seen 
  
under 
  unusual 
  circumstances.” 
   
  In 
  my 
  experience, 
  I 
  have 
  never 
  seen 
  such 
  a 
  high 
  
number 
  of 
  court 
  orders 
  directed 
  at 
  a 
  correctional 
  healthcare 
  program. 
  
 
  
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  
Inter-­‐departmental 
  Issues 
  
 
  
The 
  provision 
  of 
  health 
  care 
  in 
  Riverside 
  County 
  Jails 
  is 
  complicated 
  by 
  evolving 
  
relationships 
  between 
  County 
  departments 
  – 
  specifically 
  the 
  Sheriff’s 
  Department 
  
and 
  the 
  County 
  Hospital 
  (Riverside 
  University 
  Medical 
  Center 
  – 
  previously 
  known 
  as 
  
Riverside 
  County 
  Regional 
  Medical 
  Center). 
   
  In 
  response 
  to 
  the 
  confused 
  lines 
  of 
  
authority 
  noted 
  in 
  the 
  grand 
  jury 
  reports, 
  a 
  MOU 
  was 
  drafted 
  and 
  signed 
  outlining 
  
the 
  responsibilities 
  and 
  expectations 
  of 
  each 
  department 
  in 
  the 
  provision 
  of 
  care. 
  
 
  
However, 
  in 
  my 
  interviews 
  with 
  key 
  personnel 
  and 
  administrators 
  from 
  both 
  
departments, 
  I 
  found 
  that 
  some 
  confusion 
  remains 
  in 
  relation 
  to 
  budgeting 
  for 
  
services 
  provided. 
   
  By 
  the 
  end 
  of 
  my 
  investigation, 
  it 
  was 
  not 
  clear 
  to 
  me 
  that 
  the 
  
County 
  has 
  resolved 
  what 
  I 
  would 
  call 
  perverse 
  economic 
  incentives 
  for 
  the 
  
individual 
  departments 
  that 
  could 
  lead 
  to 
  inappropriate 
  or 
  costly 
  care 
  by 
  one 
  
department 
  on 
  the 
  one 
  hand 
  or 
  could 
  lead 
  to 
  limited 
  access 
  to 
  care 
  by 
  the 
  other 
  
department 
  on 
  the 
  other 
  hand. 
   
   
  
 
  
For 
  example, 
  it 
  was 
  the 
  belief 
  of 
  the 
  County 
  hospital 
  administration 
  that 
  RUMC 
  is 
  
budgeted 
  for 
  a 
  fixed 
  amount 
  to 
  provide 
  inpatient 
  and 
  consultation 
  medical 
  care. 
   
  
This 
  at 
  least 
  theoretically 
  creates 
  an 
  incentive 
  for 
  the 
  Sheriff 
  to 
  shift 
  care 
  to 
  the 
  
higher 
  cost 
  setting 
  by 
  pressing 
  to 
  send 
  inmates 
  to 
  hospital 
  earlier 
  than 
  clinically 
  
indicated 
  and 
  keep 
  them 
  in 
  hospital 
  longer 
  than 
  clinically 
  indicated 
  as 
  hospital 
  care 
  
does 
  not 
  cost 
  the 
  Sheriff 
  any 
  additional 
  funds. 
   
  At 
  the 
  same 
  time, 
  the 
  hospital 
  may 
  
feel 
  pressure 
  to 
  discharge 
  inmate 
  patients 
  prematurely 
  as 
  each 
  day 
  results 
  in 
  
additional 
  costs 
  that 
  cannot 
  be 
  recouped. 
   
  It 
  is 
  important 
  to 
  be 
  clear 
  that 
  I 
  see 
  no 
  
evidence 
  that 
  either 
  department 
  has 
  actually 
  yielded 
  to 
  these 
  real 
  or 
  perceived 
  
perverse 
  fiscal 
  pressures, 
  but 
  if 
  these 
  perceptions 
  are 
  indeed 
  based 
  on 
  reality, 
  
budgeting 
  should 
  be 
  reviewed 
  in 
  order 
  to 
  mitigate 
  these 
  perverse 
  incentives 
  so 
  that 
  
decisions 
  regarding 
  the 
  appropriate 
  level 
  of 
  care 
  and 
  setting 
  are 
  not 
  unduly 
  
influenced 
  by 
  them 
  and 
  the 
  appropriate 
  agencies 
  are 
  adequately 
  funded 
  for 
  any 
  care 
  
they 
  provide. 
   
  While 
  in 
  the 
  end, 
  this 
  is 
  all 
  County 
  money, 
  I 
  am 
  trying 
  to 
  draw 
  
attention 
  to 
  an 
  arrangement 
  that 
  might 
  actually 
  be 
  driving 
  overall 
  costs 
  to 
  the 
  
County 
  to 
  a 
  higher 
  level 
  than 
  they 
  need 
  to 
  be 
  while 
  at 
  the 
  same 
  time 
  creating 
  
unnecessary 
  liability 
  risks. 
   
   
  
 
  
 
  
Challenges 
  of 
  Realignment 
  
 
  
California 
  is 
  currently 
  undergoing 
  a 
  historic 
  reform 
  of 
  incarceration 
  practices 
  
largely 
  driven 
  by 
  litigation. 
   
  Sweeping 
  changes 
  have 
  resulted, 
  including 
  AB 
  109, 
  also 
  
known 
  as 
  “realignment,” 
  legislation 
  crafted 
  in 
  an 
  effort 
  to 
  deal 
  with 
  state 
  prison 
  
overcrowding 
  among 
  other 
  concerns. 
   
  As 
  a 
  result 
  of 
  realignment, 
  county 
  jails 
  across 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

6 
  

the 
  state 
  now 
  face 
  significant 
  new 
  and 
  previously 
  unanticipated 
  challenges. 
  In 
  
addition 
  to 
  being 
  asked 
  to 
  accommodate 
  higher 
  numbers 
  of 
  inmates 
  who 
  
historically 
  would 
  have 
  been 
  held 
  in 
  the 
  custody 
  of 
  the 
  state 
  in 
  state 
  prisons, 
  jail 
  
facilities 
  are 
  being 
  asked 
  to 
  provide 
  what 
  essentially 
  is 
  prison 
  care 
  in 
  facilities 
  that 
  
were 
  designed 
  as 
  jails. 
   
  Jails 
  historically 
  house 
  inmates 
  for 
  shorter 
  periods 
  of 
  time. 
   
  
The 
  new 
  AB 
  109 
  inmates 
  will 
  typically 
  serve 
  much 
  longer 
  terms 
  in 
  the 
  county 
  jails, 
  
terms 
  ranging 
  from 
  months 
  to 
  years. 
  
 
  
This 
  change 
  has 
  consequences 
  for 
  both 
  the 
  conditions 
  of 
  confinement, 
  
programming, 
  educational 
  and 
  work 
  opportunities. 
   
  But 
  it 
  also 
  has 
  consequences 
  for 
  
health 
  care. 
  Realignment 
  has 
  created 
  a 
  host 
  of 
  new 
  challenges 
  to 
  county 
  jails 
  and 
  
placed 
  increased 
  burdens 
  on 
  the 
  provision 
  of 
  health 
  care 
  in 
  a 
  system 
  that 
  was 
  
designed 
  around 
  short 
  stays, 
  but 
  now 
  has 
  a 
  significant 
  sub-­‐population 
  that 
  can 
  be 
  
expected 
  to 
  be 
  confined 
  to 
  the 
  county 
  facilities 
  for 
  months 
  or 
  even 
  years. 
  
 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

7 
  

 
  
 
  
Overall 
  Findings 
  
 
  
The 
  current 
  level 
  of 
  care 
  in 
  the 
  Riverside 
  County 
  Jails 
  is 
  inadequate, 
  poses 
  a 
  
significant 
  risk 
  of 
  serious 
  harm 
  to 
  inmates 
  confined 
  there 
  and 
  in 
  the 
  opinion 
  of 
  this 
  
expert 
  does 
  not 
  meet 
  minimal 
  constitutional 
  standards. 
   
   
  
 
  
The 
  inadequacy 
  of 
  the 
  current 
  health 
  system 
  can 
  be 
  almost 
  entirely 
  attributed 
  to 
  
two 
  factors: 
  1) 
  inadequate 
  financial 
  support 
  provided 
  to 
  the 
  department 
  by 
  the 
  
County 
  over 
  a 
  period 
  of 
  years 
  and 
  2) 
  correctable 
  programmatic 
  deficiencies 
  and 
  
institutional 
  barriers 
  both 
  within 
  the 
  facilities 
  and 
  within 
  the 
  County 
  Hospital 
  and 
  
clinic 
  system. 
   
   
  
 
  
At 
  the 
  same 
  time, 
  I 
  found 
  the 
  department 
  medical 
  staff 
  including 
  nurses, 
  doctors 
  and 
  
administrators 
  and 
  the 
  Sheriff’s 
  Department 
  liaisons 
  on 
  the 
  whole 
  to 
  be 
  professional 
  
and 
  competent.2 
   
  This 
  finding 
  is 
  critical 
  because 
  it 
  suggests 
  that 
  if 
  the 
  historical 
  
structural 
  and 
  resourced 
  based 
  issues 
  are 
  addressed, 
  care 
  could 
  be 
  brought 
  up 
  to 
  
meet 
  constitutional 
  standards. 
  
 
  
In 
  my 
  opinion, 
  the 
  department 
  has 
  the 
  capacity 
  to 
  correct 
  their 
  many 
  deficiencies 
  if 
  
they 
  are 
  provided 
  with 
  adequate 
  resources 
  on 
  an 
  ongoing 
  basis. 
   
  Indeed, 
  a 
  plan 
  for 
  
reform 
  articulated 
  by 
  Correctional 
  Health 
  Administrator 
  William 
  Wilson 
  is 
  well 
  
thought 
  out 
  and 
  holds 
  promise 
  for 
  eliminating 
  deficiencies. 
  In 
  the 
  course 
  of 
  my 
  
investigation 
  I 
  was 
  able 
  to 
  learn 
  about 
  the 
  plan 
  for 
  reform 
  in 
  some 
  detail, 
  and 
  I 
  can 
  
confirm 
  that 
  important 
  initial 
  steps 
  to 
  bring 
  health 
  care 
  into 
  compliance 
  with 
  
constitutionals 
  standards 
  have 
  recently 
  been 
  undertaken. 
   
  The 
  department 
  has 
  a 
  
reasonable 
  plan. 
   
  I 
  reference 
  this 
  plan 
  where 
  helpful 
  in 
  relevant 
  findings 
  and 
  
recommendations 
  in 
  this 
  report. 
  
 
  
Yet 
  while 
  the 
  department 
  has 
  a 
  reasonable 
  plan, 
  what 
  the 
  department 
  doesn’t 
  have 
  
yet 
  is 
  a 
  track 
  record 
  of 
  success 
  in 
  providing 
  constitutionally 
  appropriate 
  care. 
   
   
  
 
  
A 
  Riverside 
  Grand 
  Jury 
  and 
  an 
  outside 
  consultant 
  noted 
  deficiencies 
  in 
  health 
  care 
  
delivery 
  as 
  far 
  back 
  as 
  2011. 
   
  Four 
  years 
  have 
  passed 
  with 
  only 
  initial 
  and 
  
incomplete 
  reforms 
  and 
  improvements, 
  most 
  of 
  them 
  relatively 
  recent. 
   
  In 
  the 
  past 
  
year, 
  meaningful 
  corrective 
  measures 
  have 
  picked 
  up 
  in 
  pace, 
  but 
  there 
  has 
  not 
  been 
  
enough 
  time 
  for 
  those 
  interventions 
  to 
  have 
  corrected 
  the 
  deficiencies 
  brought 
  on 
  
by 
  years 
  of 
  fiscal 
  neglect. 
  
 
  
 
  
 
  
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  
2 
  This 
  is 
  an 
  overall 
  impression. 
   
  I 
  will 
  make 
  specific 
  comments 
  about 
  the 
  
professional 
  qualifications 
  of 
  the 
  physicians 
  elsewhere 
  in 
  this 
  report 
  as 
  not 
  all 
  are 
  
fully 
  qualified 
  to 
  provide 
  care 
  to 
  adults. 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

8 
  

 
  
Specific 
  Findings 
  
 
  
The 
  section 
  that 
  follows 
  outlines 
  specific 
  deficiencies 
  noted 
  in 
  my 
  review. 
   
  If 
  there 
  is 
  
a 
  relevant 
  NCCHC 
  standard, 
  I 
  note 
  it. 
  3 
   
  No 
  adverse 
  finding 
  is 
  based 
  solely 
  on 
  an 
  
inmate 
  claim 
  made 
  during 
  an 
  interview 
  although 
  some 
  were 
  identified 
  first 
  by 
  an 
  
interview; 
  all 
  problems 
  described 
  were 
  verified 
  either 
  by 
  the 
  medical 
  record 
  or 
  by 
  
staff 
  or 
  in 
  some 
  cases, 
  by 
  both. 
  
 
  
Accreditation 
  status: 
   
  
 
  
Currently, 
  the 
  Riverside 
  County 
  Jail 
  Health 
  Services 
  are 
  not 
  accredited 
  with 
  NCCHC 
  
or 
  the 
  American 
  Correctional 
  Association. 
   
  According 
  to 
  the 
  Medical 
  Administrator, 
  
Mr. 
  Wilson, 
  the 
  department 
  is 
  considering 
  applying 
  for 
  accreditation 
  with 
  the 
  
NCCHC. 
  
 
  
Staffing: 
   
   
  
 
  
Currently 
  staffing 
  remains 
  short 
  of 
  the 
  department’s 
  own 
  stated 
  plan 
  and 
  is 
  not 
  
sufficient 
  to 
  deliver 
  appropriate 
  medical 
  care. 
   
  A 
  reasonable 
  staffing 
  recruitment 
  
plan 
  is 
  in 
  place, 
  and 
  efforts 
  to 
  recruit 
  new 
  physicians 
  and 
  nurses 
  is 
  underway, 
  but 
  
four 
  years 
  after 
  the 
  department 
  was 
  made 
  aware 
  by 
  consultants 
  of 
  staffing 
  
deficiencies, 
  the 
  staffing 
  levels 
  proposed 
  by 
  the 
  department 
  have 
  not 
  yet 
  been 
  met. 
   
  
According 
  to 
  a 
  Correctional 
  Healthcare 
  Services 
  Personnel 
  Tracking 
  report 
  provided 
  
to 
  me 
  through 
  counsel, 
  as 
  of 
  May 
  28, 
  2015, 
  one 
  of 
  the 
  five 
  full 
  time 
  physician 
  
positions 
  and 
  three 
  of 
  the 
  six 
  nurse 
  practitioner 
  positions 
  remain 
  unfilled. 
   
  For 
  the 
  
entire 
  health 
  care 
  service, 
  62 
  of 
  217 
  (roughly 
  28%) 
  of 
  the 
  authorized 
  positions 
  
remain 
  unfilled. 
   
  
 
  
Current 
  physician 
  salaries 
  may 
  not 
  be 
  competitive 
  with 
  other 
  correctional 
  medicine 
  
opportunities 
  in 
  the 
  state 
  and 
  this 
  is 
  likely 
  related 
  to 
  the 
  failure 
  of 
  the 
  department 
  to 
  
attract 
  board 
  certified 
  physicians. 
  Of 
  the 
  seven 
  physicians 
  identifies 
  as 
  working 
  for 
  
the 
  department, 
  I 
  can 
  verify 
  only 
  one 
  (Dr. 
  Chakmakian) 
  currently 
  holds 
  current 
  
board 
  certification 
  in 
  a 
  recognized 
  American 
  Board 
  of 
  Medical 
  Specialties 
  discipline. 
   
  
Dr. 
  Montenegro 
  is 
  one 
  of 
  the 
  physicians 
  who 
  is 
  not 
  board 
  certified, 
  and 
  only 
  appears 
  
to 
  have 
  training 
  in 
  pediatrics 
  – 
  training 
  that 
  is 
  not 
  appropriate 
  for 
  an 
  adult 
  facility. 
   
  
One 
  of 
  the 
  physicians, 
  Dr. 
  Sawires 
  was 
  previously 
  disciplined 
  by 
  the 
  licensure 
  board 
  
in 
  Michigan 
  for 
  an 
  apparent 
  failure 
  to 
  disclose 
  past 
  disciplinary 
  issues 
  on 
  an 
  
application. 
  (J-­‐C-­‐07) 
  
 
  
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  
3 
  My 
  inclusion 
  of 
  the 
  standards 
  is 
  merely 
  for 
  reference 
  and 
  although 
  I 
  do 
  describe 
  
deficiencies, 
  inclusion 
  of 
  the 
  standard 
  in 
  this 
  section 
  does 
  not 
  mean 
  I 
  have 
  
necessarily 
  concluded 
  that 
  the 
  standard 
  is 
  not 
  being 
  met. 
   
  I 
  do 
  summarize 
  standards 
  
that 
  I 
  feel 
  are 
  not 
  being 
  met 
  later 
  in 
  this 
  document. 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

9 
  

Physical 
  space 
  for 
  medical 
  care: 
   
  
 
  
With 
  the 
  exception 
  of 
  the 
  Southwest 
  Detention 
  Center, 
  clinic 
  space 
  in 
  most 
  facilities 
  
small, 
  cramped 
  and 
  poorly 
  designed. 
   
  Some 
  clinic 
  spaces 
  in 
  the 
  Banning 
  facility 
  have 
  
open 
  walls 
  that 
  allow 
  people 
  outside 
  the 
  clinic 
  to 
  listen 
  in 
  on 
  private 
  medical 
  
consultations. 
   
  Much 
  of 
  the 
  clinic 
  space 
  appears 
  not 
  to 
  have 
  been 
  architecturally 
  
designed 
  to 
  be 
  clinic 
  space 
  – 
  especially 
  in 
  the 
  older 
  facilities. 
   
  Overall, 
  outside 
  of 
  the 
  
Southwest 
  Detention 
  Center, 
  clinic 
  space 
  too 
  small 
  and 
  is 
  inadequately 
  designed. 
   
  
The 
  small 
  clinical 
  space 
  can 
  limit 
  the 
  number 
  of 
  patients 
  being 
  seen 
  and 
  the 
  
efficiency 
  of 
  flow 
  or 
  multitasking 
  (such 
  as 
  a 
  doctor 
  and 
  nurse 
  working 
  together 
  at 
  
the 
  same 
  time 
  in 
  the 
  same 
  space) 
  and 
  the 
  lack 
  of 
  privacy 
  violates 
  confidentiality 
  and 
  
inhibits 
  patients 
  from 
  providing 
  candid 
  histories 
  that 
  are 
  required 
  for 
  provision 
  of 
  
care 
  and 
  is 
  a 
  violation 
  of 
  NCCHC 
  standards 
  and 
  the 
  community 
  standard. 
   
  (J-­‐D-­‐03, 
  J-­‐
A-­‐09) 
  
 
  
Infirmary 
  or 
  Intermediate 
  Level 
  of 
  Care 
  
 
  
Across 
  the 
  entire 
  system, 
  the 
  Riverside 
  County 
  Jail 
  has 
  no 
  ability 
  to 
  provide 
  
infirmary 
  level 
  or 
  intermediate 
  level 
  of 
  care. 
   
  As 
  a 
  result, 
  inmate 
  patients 
  requiring 
  
higher 
  level 
  of 
  must 
  be 
  transferred 
  to 
  outside 
  facilities 
  with 
  the 
  attendant 
  higher 
  
medical 
  and 
  security 
  costs. 
  (J-­‐G-­‐03) 
  
 
  
Screening 
  on 
  Intake 
  and 
  Initial 
  Health 
  Assessments: 
  
 
  
Currently, 
  non-­‐medically 
  licensed 
  Deputies 
  (who 
  have 
  been 
  trained 
  in 
  the 
  Academy) 
  
perform 
  much 
  of 
  the 
  initial 
  screening 
  of 
  inmates 
  for 
  health 
  problems. 
   
   
  The 
  facility 
  is 
  
moving 
  towards 
  a 
  screening 
  process 
  performed 
  entirely 
  by 
  licensed 
  staff, 
  but 
  to 
  
date, 
  they 
  have 
  not 
  reached 
  that 
  goal. 
   
  In 
  cases 
  where 
  Deputies 
  perform 
  screening, 
  
nurses 
  only 
  evaluate 
  those 
  inmates 
  who 
  have 
  positive 
  findings 
  based 
  on 
  the 
  short 
  
20 
  question 
  screening 
  questionnaire 
  administered 
  by 
  the 
  deputies. 
   
  There 
  does 
  not 
  
appear 
  to 
  be 
  a 
  subsequent 
  initial 
  health 
  assessment 
  performed 
  on 
  the 
  full 
  
population 
  within 
  14 
  days. 
   
  Currently, 
  initial 
  assessments 
  are 
  being 
  done 
  only 
  if 
  
screening 
  identifies 
  a 
  problem 
  or 
  if 
  the 
  inmate 
  seeks 
  care 
  themselves. 
   
  This 
  
approach 
  does 
  not 
  meet 
  NCCHC 
  standards 
  and 
  by 
  increasing 
  the 
  risk 
  that 
  significant 
  
health 
  issues 
  are 
  not 
  identified 
  early 
  places 
  patients 
  at 
  an 
  unreasonable 
  risk 
  of 
  
harm. 
  The 
  department 
  is 
  moving 
  towards 
  screening 
  by 
  licensed 
  nursing 
  staff 
  for 
  all 
  
inmates, 
  but 
  has 
  not 
  yet 
  reached 
  that 
  goal, 
  and 
  therefore 
  has 
  not 
  yet 
  met 
  the 
  
standard. 
  (J-­‐E-­‐02 
  and 
  J-­‐E-­‐04) 
  
 
  
Currently, 
  screening 
  for 
  TB 
  involves 
  a 
  risk 
  based 
  strategy 
  rather 
  than 
  a 
  universal 
  
screening 
  protocol 
  at 
  intake. 
   
  The 
  department 
  is 
  in 
  the 
  process 
  of 
  changing 
  to 
  
universal 
  intake 
  screening 
  by 
  nurses 
  and 
  a 
  more 
  effective 
  universal 
  TB 
  screening 
  
protocol. 
   
  All 
  facilities 
  visited 
  do 
  have 
  negative 
  pressure 
  isolation 
  rooms 
  for 
  the 
  
housing 
  of 
  inmates 
  suspected 
  of 
  having 
  active 
  TB. 
  (J-­‐B-­‐01) 
  
 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

10 
  

Continuous 
  Quality 
  Improvement: 
  
 
  
Continuous 
  Quality 
  Improvement, 
  recommended 
  in 
  May 
  2011 
  by 
  IMQ, 
  has 
  only 
  just 
  
started. 
   
  There 
  is 
  insufficient 
  track 
  record 
  to 
  assess 
  the 
  quality 
  and 
  effectiveness 
  of 
  
this 
  essential 
  program. 
   
  The 
  facilities 
  currently 
  have 
  very 
  little 
  data 
  to 
  help 
  guide 
  
medical 
  operations. 
  The 
  Correctional 
  Health 
  Administrator 
  and 
  Medical 
  Director 
  in 
  
cooperation 
  with 
  the 
  staff 
  have 
  initiated 
  initial 
  efforts 
  at 
  assembling 
  and 
  analyzing 
  
programmatic 
  information. 
   
  Initial 
  CQI 
  efforts 
  focus 
  on 
  analysis 
  the 
  specialty 
  referral 
  
process 
  in 
  order 
  to 
  reduce 
  backlogs 
  and 
  wait 
  times. 
   
  CQI 
  is 
  an 
  essential 
  process 
  to 
  
assure 
  quality 
  and 
  timeliness 
  of 
  health 
  care 
  delivery 
  and 
  is 
  required 
  to 
  meet 
  
standard 
  of 
  care. 
  (J-­‐A-­‐06) 
  
 
  
Utilization 
  Management: 
  
 
  
There 
  is 
  no 
  formal 
  identifiable 
  process 
  for 
  reviewing 
  utilization 
  of 
  medical 
  services. 
   
  
Specifically, 
  there 
  is 
  no 
  utilization 
  management 
  committee. 
   
  Utilization 
  management 
  
is 
  a 
  process 
  that 
  comes 
  out 
  of 
  the 
  managed 
  care 
  field 
  and 
  it 
  is 
  used 
  for 
  standardizing 
  
criteria 
  and 
  approval 
  procedures 
  for 
  outside 
  high 
  cost 
  care. 
   
  It 
  can 
  be 
  an 
  effective 
  
tool 
  for 
  both 
  cost 
  containment 
  and 
  for 
  establishing 
  standardized 
  approaches 
  to 
  
specialty 
  care 
  and 
  other 
  high 
  cost 
  items 
  such 
  as 
  durable 
  medical 
  equipment. 
  
 
  
Medical 
  Records: 
  
 
  
Medical 
  records 
  are 
  currently 
  paper-­‐based. 
   
  A 
  paper 
  based 
  medical 
  records 
  in 
  a 
  jail 
  
system 
  that 
  is 
  geographically 
  spread 
  out 
  is 
  woefully 
  inefficient. 
   
  Inmates 
  are 
  
frequently 
  transferred 
  between 
  facilities 
  but 
  records 
  do 
  not 
  always 
  arrive 
  with 
  the 
  
inmate. 
   
  A 
  review 
  of 
  records 
  reveals 
  a 
  pattern 
  of 
  unsigned 
  telephone 
  orders 
  by 
  
physicians 
  – 
  some 
  as 
  old 
  as 
  one 
  week 
  – 
  and 
  key 
  lab 
  results 
  that 
  have 
  been 
  filed 
  
without 
  notation 
  or 
  acknowledgment 
  by 
  a 
  physician 
  or 
  nurse 
  practitioner. 
   
  
Documentation 
  of 
  clinical 
  encounters 
  is 
  often 
  brief 
  and 
  incomplete. 
   
  There 
  is 
  almost 
  
no 
  documentation 
  by 
  physicians 
  of 
  patient 
  education 
  about 
  their 
  illnesses, 
  their 
  lab 
  
or 
  test 
  results 
  or 
  the 
  treatment 
  plan. 
   
  Handwriting 
  is 
  frequently 
  poor, 
  and 
  some 
  
providers 
  do 
  not 
  use 
  a 
  signature 
  stamp 
  so 
  it 
  is 
  unclear 
  to 
  a 
  reviewer 
  who 
  wrote 
  the 
  
note 
  and 
  their 
  professional 
  capacity 
  (doctor 
  versus 
  nurse 
  or 
  other 
  staff). 
  Problem 
  
lists 
  are 
  often 
  incomplete. 
   
  Lab 
  and 
  radiology 
  results 
  are 
  frequently 
  filed 
  without 
  
provider 
  sign 
  off 
  and 
  abnormal 
  results 
  were 
  often 
  filed 
  without 
  any 
  documented 
  
intervention 
  to 
  address 
  the 
  abnormality. 
  Also, 
  a 
  significant 
  deficiency 
  currently 
  is 
  
that 
  the 
  facility 
  is 
  not 
  using 
  a 
  unified 
  health 
  record 
  and 
  mental 
  health 
  records 
  are 
  
kept 
  separately 
  from 
  other 
  medical 
  records. 
   
  This 
  is 
  a 
  bad 
  practice 
  that 
  significantly 
  
increases 
  the 
  risk 
  of 
  drug 
  interactions 
  and 
  inappropriate 
  care. 
  (J-­‐H-­‐01 
  and 
  J-­‐H-­‐03) 
  
 
  
The 
  department 
  has 
  contracted 
  to 
  deploy 
  a 
  correctional 
  Electronic 
  Health 
  Record 
  
(EHR) 
  imminently 
  (at 
  the 
  time 
  of 
  the 
  drafting 
  of 
  this 
  report). 
   
  I 
  was 
  able 
  to 
  see 
  a 
  
brief 
  demonstration 
  of 
  the 
  HER 
  prior 
  to 
  its 
  deployment. 
   
  At 
  the 
  time 
  of 
  my 
  
investigation, 
  this 
  new 
  system 
  had 
  not 
  yet 
  deployed. 
   
  While 
  I 
  was 
  impressed 
  with 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

11 
  

the 
  demonstration 
  of 
  the 
  software 
  by 
  the 
  vendor, 
  it 
  is 
  too 
  early 
  to 
  comment 
  on 
  
whether 
  or 
  not 
  this 
  new 
  system 
  will 
  adequately 
  address 
  charting 
  deficiencies. 
  
 
  
Electronic 
  health 
  systems 
  are 
  living 
  software 
  solutions 
  requiring 
  set 
  up, 
  
maintenance 
  and 
  continuous 
  modification 
  and 
  maintenance 
  of 
  a 
  functioning 
  
computer 
  network. 
   
  It 
  also 
  requires 
  ongoing 
  staff 
  training. 
   
   
  
 
  
The 
  County’s 
  demonstrated 
  ability 
  to 
  deploy 
  an 
  EHR 
  is 
  mixed 
  at 
  best. 
   
  At 
  the 
  County 
  
Hospital 
  where 
  I 
  am 
  on 
  staff, 
  I 
  was 
  part 
  of 
  the 
  initial 
  deployment 
  of 
  the 
  Next-­‐Gen 
  
EHR 
  for 
  outpatient 
  clinics 
  (and 
  I 
  have 
  been 
  part 
  of 
  the 
  launch 
  of 
  two 
  other 
  EHR 
  
systems 
  in 
  previous 
  settings). 
   
  After 
  four 
  years 
  of 
  network 
  problems 
  and 
  training 
  
and 
  maintenance 
  and 
  modification 
  problems, 
  the 
  Next-­‐Gen 
  system 
  proved 
  to 
  be 
  
slow, 
  unreliable 
  (frequent 
  crashes), 
  difficult 
  to 
  find 
  archived 
  scanned 
  items 
  and 
  
nearly 
  impossible 
  to 
  scan 
  or 
  review 
  prior 
  encounters 
  efficiently. 
   
  It 
  is 
  now 
  being 
  
abandoned 
  in 
  favor 
  of 
  an 
  entirely 
  new 
  EHR 
  program 
  in 
  part 
  due 
  to 
  compatibility 
  
issues 
  with 
  partner 
  organizations, 
  something 
  that 
  was 
  not 
  fully 
  anticipated 
  at 
  the 
  
time 
  of 
  the 
  programs 
  initial 
  selection. 
   
  Next-­‐Gen 
  looked 
  good 
  when 
  it 
  was 
  
demonstrated 
  too, 
  but 
  the 
  County 
  was 
  unable 
  to 
  successfully 
  deploy 
  it, 
  or 
  at 
  least 
  it 
  
did 
  not 
  solve 
  all 
  of 
  the 
  problems 
  it 
  was 
  hoped 
  to 
  solve 
  and 
  it 
  created 
  new 
  ones. 
   
  This 
  
does 
  not 
  necessarily 
  mean 
  the 
  County 
  was 
  not 
  thoughtful 
  or 
  reasoned 
  when 
  it 
  
selected 
  Next-­‐Gen, 
  but 
  it 
  illustrates 
  how 
  hard 
  it 
  is 
  to 
  actually 
  deploy 
  a 
  system, 
  and 
  is 
  
some 
  indication 
  of 
  the 
  County’s 
  ability 
  to 
  do 
  so. 
   
  So, 
  while 
  there 
  is 
  reason 
  to 
  be 
  
optimistic 
  that 
  the 
  new 
  EHR 
  system 
  will 
  help 
  correct 
  documentation 
  deficiencies, 
  it 
  
is 
  way 
  too 
  early 
  to 
  tell 
  whether 
  it 
  will 
  actually 
  succeed. 
   
  As 
  with 
  other 
  areas 
  cited 
  in 
  
this 
  report, 
  the 
  County 
  has 
  a 
  reasonable 
  plan, 
  but 
  not 
  a 
  track 
  record 
  of 
  success. 
   
   
  
 
  
 
  
Chronic 
  Disease 
  Management 
  
 
  
Chronic 
  disease 
  management 
  is 
  inadequate. 
  (J-­‐G-­‐01) 
  
 
  
My 
  review 
  found 
  management 
  of 
  chronic 
  illnesses 
  such 
  as 
  asthma, 
  diabetes, 
  HIV 
  and 
  
hypertension, 
  among 
  others, 
  to 
  be 
  ad 
  hoc, 
  incomplete, 
  inconsistent, 
  and 
  reactive 
  as 
  
opposed 
  to 
  proactive. 
  Care 
  of 
  chronic 
  diseases 
  appears 
  to 
  be 
  driven 
  more 
  by 
  inmate 
  
self 
  advocacy 
  including 
  court 
  intervention 
  than 
  by 
  widely 
  accepted 
  clinical 
  
guidelines 
  (including 
  but 
  not 
  limited 
  to 
  those 
  referenced 
  by 
  the 
  NCCHC 
  and 
  Federal 
  
Bureau 
  of 
  Prisons). 
   
   
  
 
  
There 
  is 
  no 
  reliable 
  centralized 
  list 
  of 
  patients 
  with 
  chronic 
  care 
  conditions. 
   
  Lists 
  
are 
  maintained 
  locally 
  at 
  individual 
  housing 
  stations 
  and 
  consist 
  of 
  cases 
  identified 
  
by 
  nurses 
  on 
  the 
  housing 
  units 
  which 
  does 
  not 
  allow 
  for 
  tracking 
  of 
  chronic 
  disease 
  
management 
  as 
  patients 
  move 
  both 
  within 
  the 
  facility 
  or 
  between 
  facilities. 
   
  The 
  
facility 
  did 
  provide 
  me 
  with 
  chronic 
  disease 
  protocols 
  but 
  based 
  on 
  my 
  record 
  
review, 
  but 
  I 
  based 
  my 
  conclusions 
  on 
  the 
  actual 
  ongoing 
  care 
  of 
  chronic 
  illness 
  
being 
  provided 
  and 
  documented, 
  such 
  as 
  regularly 
  scheduled 
  follow 
  up 
  visits 
  (those 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

12 
  

appear 
  to 
  be 
  scheduled 
  inconsistently 
  – 
  if 
  at 
  all 
  – 
  by 
  individual 
  physicians 
  and 
  
nurses 
  with 
  no 
  clearly 
  documented 
  logic 
  or 
  clinical 
  reasoning). 
  
 
  
In 
  a 
  number 
  of 
  reviewed 
  cases, 
  care 
  of 
  chronic 
  disease 
  patients 
  appeared 
  to 
  be 
  
negligent 
  and 
  overall 
  care 
  of 
  chronic 
  diseases 
  could 
  be 
  characterized 
  as 
  deliberately 
  
indifferent. 
   
   
  
 
  
Some 
  examples 
  follow: 
  
 
  
 
  
Asthma-­‐ 
  Asthma 
  care 
  in 
  the 
  cases 
  reviewed 
  does 
  not 
  meet 
  nationally 
  
accepted 
  standards. 
   
  The 
  facility 
  makes 
  no 
  use 
  of 
  Peak 
  flow 
  meters. 
   
  Peak 
  flow 
  
meters 
  are 
  inexpensive 
  plastic 
  devices 
  that 
  allow 
  for 
  reliable 
  objective 
  assessment 
  
of 
  the 
  severity 
  of 
  a 
  patient’s 
  ability 
  to 
  breath 
  and 
  are 
  considered 
  a 
  standard 
  part 
  of 
  
asthma 
  management. 
   
  In 
  some 
  cases 
  reviewed, 
  patients 
  with 
  significant 
  asthma 
  
histories 
  were 
  not 
  evaluated 
  by 
  physicians 
  unless 
  they 
  presented 
  with 
  an 
  acute 
  
attack. 
   
  In 
  one 
  case, 
  an 
  inmate 
  with 
  a 
  significant 
  history 
  of 
  asthma 
  noted 
  on 
  intake 
  
has 
  not 
  ever 
  been 
  seen 
  by 
  a 
  physician 
  at 
  the 
  jail 
  over 
  his 
  entire 
  15 
  month 
  period 
  of 
  
incarceration. 
   
  During 
  this 
  period, 
  he 
  did 
  have 
  an 
  order 
  for 
  a 
  rescue 
  inhaler, 
  but 
  was 
  
not 
  assessed 
  by 
  a 
  physician 
  at 
  any 
  time 
  to 
  assure 
  that 
  the 
  treatment 
  plan 
  was 
  
effective. 
   
  During 
  an 
  acute 
  asthma 
  attack, 
  he 
  was 
  sent 
  to 
  an 
  outside 
  Emergency 
  
Room 
  (the 
  only 
  documented 
  physician 
  encounter 
  during 
  the 
  fifteen 
  month 
  period 
  of 
  
incarceration). 
   
  On 
  return 
  from 
  the 
  Emergency 
  Room, 
  he 
  was 
  not 
  reassessed 
  by 
  a 
  
facility 
  physician. 
   
  An 
  order 
  for 
  prednisone 
  documented 
  by 
  the 
  ER 
  physician 
  was 
  
never 
  noted 
  or 
  ordered 
  by 
  the 
  facility 
  and 
  the 
  inmate 
  never 
  received 
  this 
  critical 
  
medication 
  for 
  his 
  serious 
  and 
  acute 
  medical 
  condition. 
   
   
  
 
  
 
  
Diabetes-­‐ 
  Diabetes 
  care 
  at 
  the 
  jail 
  facilities 
  is 
  inconsistent. 
   
  Known 
  diabetics 
  
do 
  typically 
  receive 
  adequate 
  monitoring 
  by 
  nurses 
  with 
  assessment 
  of 
  blood 
  sugar 
  
by 
  finger 
  stick 
  testing 
  as 
  ordered 
  by 
  a 
  physician. 
   
  However, 
  regular 
  evaluation 
  by 
  a 
  
physician 
  is 
  inconsistent. 
   
  Measurement 
  of 
  Hemoglobin 
  A1C 
  (HgbA1C 
  – 
  a 
  standard 
  
measure 
  of 
  diabetic 
  control) 
  on 
  arrival 
  and 
  at 
  recommended 
  intervals 
  (typically 
  
every 
  90 
  days) 
  is 
  inconsistent. 
   
  In 
  one 
  case, 
  a 
  known 
  diabetic 
  had 
  been 
  detained 
  for 
  
nearly 
  3 
  months 
  with 
  no 
  lab 
  work 
  or 
  HgbA1c 
  ordered. 
   
  Accommodation 
  for 
  special 
  
footwear 
  for 
  diabetic 
  with 
  diabetic 
  neuropathy 
  was 
  inconsistent 
  (failure 
  to 
  provide 
  
adequate 
  footwear 
  can 
  result 
  in 
  significant 
  foot 
  injuries 
  leading 
  to 
  significant 
  
complications 
  including 
  infections 
  and 
  amputations. 
   
  The 
  standard 
  footwear 
  in 
  
Riverside 
  jails 
  is 
  inexpensive 
  disposable 
  slippers 
  which 
  are 
  not 
  appropriate 
  and 
  
provide 
  inadequate 
  protection 
  for 
  diabetics 
  and 
  others 
  with 
  neuropathies.) 
   
  In 
  
another 
  case, 
  the 
  inmate 
  discontinued 
  his 
  own 
  diabetic 
  medication, 
  but 
  this 
  was 
  
never 
  reported 
  to 
  a 
  physician 
  by 
  nursing, 
  and 
  the 
  patient 
  was 
  not 
  called 
  in 
  to 
  discuss 
  
his 
  decision 
  to 
  unilaterally 
  discontinue 
  his 
  medications. 
   
  In 
  yet 
  another 
  case, 
  an 
  
inmate 
  did 
  receive 
  blood 
  work 
  with 
  a 
  significantly 
  high 
  HgbA1c 
  documented 
  in 
  
March 
  2015 
  documenting 
  poorly 
  controlled 
  diabetes. 
   
  As 
  of 
  May 
  20, 
  2015, 
  a 
  
physician 
  had 
  not 
  reassessed 
  the 
  patient 
  nor 
  had 
  the 
  results 
  been 
  explained 
  to 
  the 
  
patient. 
   
  In 
  another 
  case 
  at 
  Robert 
  Presley, 
  an 
  elevated 
  HgbA1C 
  was 
  noted 
  by 
  the 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

13 
  

doctor 
  in 
  March, 
  but 
  the 
  treatment 
  plan 
  was 
  not 
  adjusted 
  and 
  the 
  results 
  were 
  never 
  
discussed 
  with 
  the 
  patient. 
   
   
  
 
  
 
  
Hypertension-­‐ 
  Management 
  of 
  hypertension 
  in 
  the 
  Riverside 
  County 
  Jail 
  did 
  
not 
  meet 
  nationally 
  accepted 
  guidelines 
  for 
  the 
  cases 
  I 
  reviewed 
  (Ref: 
  NCCHC 
  
October 
  2014 
  guidelines 
  for 
  hypertension, 
  JNC 
  8). 
   
  Specifically, 
  patients 
  with 
  
hypertension 
  did 
  not 
  typically 
  receive 
  complete 
  initial 
  exams 
  and 
  work-­‐ups, 
  they 
  
did 
  not 
  consistently 
  receive 
  appropriate 
  laboratory 
  or 
  EKG 
  tests. 
   
  In 
  one 
  case, 
  the 
  
inmate 
  went 
  four 
  days 
  without 
  medications. 
  
 
  
HIV-­‐ 
  HIV 
  care 
  in 
  the 
  Riverside 
  County 
  Jail 
  does 
  not 
  meet 
  nationally 
  accepted 
  
guidelines. 
   
  In 
  the 
  cases 
  I 
  reviewed, 
  I 
  documented 
  interruption 
  in 
  critical 
  
antiretroviral 
  medications 
  on 
  arrival 
  (April 
  26, 
  2015 
  the 
  inmate 
  submitted 
  a 
  slip 
  
reporting 
  HIV 
  and 
  need 
  for 
  continuation 
  of 
  medications. 
   
  First 
  meds 
  given 
  on 
  May 
  7, 
  
2015, 
  some 
  ten 
  days 
  later). 
   
  In 
  one 
  case 
  of 
  an 
  inmate 
  with 
  HIV 
  who 
  had 
  been 
  
incarcerated 
  for 
  two 
  years, 
  CD4 
  cell 
  counts 
  (which 
  should 
  be 
  checked 
  every 
  90 
  
days) 
  had 
  not 
  been 
  ordered 
  since 
  late 
  2013 
  (over 
  a 
  year 
  and 
  a 
  half). 
   
  In 
  that 
  same 
  
case, 
  he 
  had 
  not 
  been 
  seen 
  by 
  an 
  HIV 
  specialist 
  in 
  over 
  a 
  year 
  and 
  a 
  half. 
   
  In 
  general, 
  
consultation 
  with 
  HIV 
  specialists 
  for 
  inmates 
  with 
  HIV 
  appears 
  to 
  be 
  rare 
  if 
  it 
  occurs 
  
at 
  all. 
  
 
  
 
  
Other 
  chronic 
  conditions-­‐ 
  In 
  other 
  cases 
  where 
  inmates 
  had 
  known 
  chronic 
  
care 
  needs, 
  care 
  was 
  infrequent 
  and 
  cavalier. 
   
  In 
  Blythe, 
  an 
  inmate 
  with 
  known 
  
chronic 
  lung 
  disease, 
  heart 
  disease 
  (previous 
  heart 
  attack), 
  diabetes 
  and 
  gout 
  had 
  
not 
  been 
  seen 
  by 
  a 
  physician 
  in 
  nearly 
  five 
  months. 
   
  A 
  patient 
  at 
  Southwest 
  was 
  
noted 
  on 
  intake 
  to 
  have 
  a 
  history 
  of 
  Barrett’s 
  esophagus, 
  a 
  serious 
  esophageal 
  
condition 
  that 
  requires 
  chronic 
  acid 
  suppression 
  with 
  medications, 
  but 
  no 
  acid 
  
blocking 
  medication 
  was 
  ordered 
  and 
  the 
  patient 
  was 
  placed 
  on 
  daily 
  aspirin 
  
(presumably 
  for 
  stroke 
  risk), 
  a 
  medication 
  that 
  can 
  exacerbate 
  the 
  condition. 
   
  A 
  
patient 
  who 
  had 
  undergone 
  a 
  kidney 
  transplant 
  in 
  the 
  past 
  went 
  four 
  days 
  without 
  
medications. 
   
  A 
  patient 
  at 
  Southwest 
  with 
  seizure 
  history 
  on 
  medications 
  noted 
  on 
  
intake 
  waited 
  two 
  days 
  without 
  medications. 
   
  Later, 
  when 
  labs 
  were 
  drawn, 
  he 
  was 
  
never 
  informed 
  of 
  results. 
   
   
  
 
  
Timely 
  Access 
  to 
  Care: 
  
 
  
The 
  Riverside 
  County 
  Jail 
  is 
  not 
  consistently 
  providing 
  timely 
  access 
  to 
  care 
  for 
  
serious 
  medical 
  conditions. 
   
  Shortcomings 
  in 
  timely 
  access 
  to 
  care 
  occur 
  in 
  two 
  
distinct 
  areas. 
   
  The 
  first 
  is 
  timely 
  access 
  to 
  a 
  facility 
  physician 
  for 
  serious 
  medical 
  
care. 
   
  The 
  second 
  is 
  timely 
  access 
  to 
  specialty 
  care 
  that 
  cannot 
  be 
  provided 
  on-­‐site. 
  
 
  
 
  
Timely 
  access 
  to 
  facility 
  physicians-­‐ 
  Across 
  the 
  system, 
  I 
  documented 
  
unacceptably 
  long 
  waits 
  to 
  see 
  a 
  physician, 
  with 
  typical 
  waits 
  ranging 
  from 
  
five 
  days 
  to 
  two 
  months 
  or 
  more. 
   
  For 
  the 
  most 
  part, 
  this 
  appeared 
  to 
  be 
  
related 
  to 
  limited 
  staffing 
  of 
  physician 
  providers. 
   
  In 
  other 
  cases 
  where 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

 
  

14 
  

physician 
  availability 
  has 
  been 
  improved, 
  it 
  appeared 
  to 
  be 
  simply 
  an 
  
established 
  informal 
  standard 
  based 
  on 
  past 
  practice. 
  (J-­‐A-­‐01) 
  
Timely 
  access 
  to 
  specialty 
  care 
  -­‐The 
  Riverside 
  County 
  Jail 
  is 
  not 
  providing 
  
timely 
  access 
  to 
  specialty 
  care 
  for 
  patients 
  with 
  serious 
  medical 
  conditions. 
   
  
This 
  appears 
  largely 
  to 
  be 
  the 
  result 
  of 
  barriers 
  to 
  access 
  to 
  specialty 
  care 
  at 
  
the 
  Riverside 
  University 
  Medical 
  Center. 
   
  Due 
  to 
  limits 
  in 
  its 
  own 
  capacity, 
  
RUMC 
  has 
  difficulty 
  accommodating 
  specialty 
  consultations 
  for 
  patients 
  in 
  
the 
  community 
  as 
  well, 
  but 
  when 
  RUMC 
  is 
  unable 
  to 
  accommodate 
  a 
  
detention 
  health 
  consultation 
  need, 
  the 
  County 
  has 
  no 
  alternative 
  
arrangements 
  with 
  other 
  clinical 
  providers 
  to 
  secure 
  the 
  needed 
  care. 
   
   
  In 
  the 
  
past, 
  some 
  of 
  the 
  delay 
  was 
  the 
  result 
  of 
  limitations 
  in 
  availability 
  of 
  deputies 
  
to 
  accompany 
  inmate 
  patients 
  (at 
  Robert 
  Presley, 
  outside 
  trips 
  were 
  limited 
  
to 
  two 
  patients 
  per 
  day 
  owing 
  to 
  security 
  staffing 
  constraints 
  – 
  this 
  
information 
  was 
  volunteered 
  by 
  deputies 
  at 
  my 
  initial 
  briefing), 
  but 
  this 
  
barrier 
  has 
  reportedly 
  been 
  removed. 
  (J-­‐D-­‐05) 
  

 
  
Telemedicine 
  
 
  
Despite 
  being 
  spread 
  across 
  a 
  very 
  large 
  geographical 
  areal 
  and 
  despite 
  high 
  
logistical 
  and 
  financial 
  costs 
  of 
  transporting 
  patients 
  for 
  specialty 
  visits, 
  the 
  
Riverside 
  County 
  Jail 
  currently 
  does 
  not 
  use 
  telemedicine 
  technology 
  for 
  either 
  
general 
  physician 
  or 
  specialty 
  consultation. 
  
 
  
Physical 
  Disability 
  Issues 
  
 
  
The 
  Riverside 
  County 
  Jail 
  makes 
  minimal 
  accommodations 
  for 
  inmates 
  with 
  physical 
  
disabilities 
  and 
  in 
  many 
  cases 
  the 
  accommodations 
  are 
  overly 
  restrictive 
  or 
  
inadequate 
  to 
  accommodate 
  the 
  disability. 
   
  For 
  inmates 
  who 
  require 
  durable 
  
medical 
  equipment 
  such 
  as 
  wheelchairs, 
  walkers 
  or 
  canes, 
  they 
  are 
  restricted 
  to 
  
special 
  housing 
  units 
  (SHU’s) 
  that 
  do 
  not 
  offer 
  a 
  higher 
  level 
  of 
  care 
  and 
  sometimes 
  
don’t 
  even 
  offer 
  fully 
  accessible 
  facilities 
  (such 
  as 
  fully 
  accessible 
  showers). 
   
  Their 
  
restriction 
  to 
  those 
  units 
  is 
  based 
  simply 
  on 
  their 
  use 
  of 
  durable 
  medical 
  equipment 
  
and 
  the 
  policy 
  is 
  presumably 
  designed 
  to 
  contain 
  such 
  equipment 
  to 
  a 
  restricted 
  
area 
  for 
  security 
  purposes. 
   
  The 
  resulting 
  restriction 
  on 
  housing 
  and 
  movement 
  for 
  
disabled 
  inmates 
  based 
  solely 
  on 
  administrative 
  convenience 
  or 
  security 
  concerns 
  
without 
  individualized 
  risk 
  assessment, 
  alternative 
  risk 
  mitigation 
  efforts 
  and 
  
without 
  providing 
  adequate 
  housing 
  accommodations 
  with 
  or 
  without 
  a 
  higher 
  level 
  
of 
  care 
  and 
  support 
  for 
  the 
  disability 
  raises 
  ADA 
  concerns. 
  
 
  
Additionally, 
  the 
  facility 
  has 
  an 
  overly 
  restrictive 
  approach 
  to 
  accommodating 
  
medical 
  conditions. 
   
  Two 
  common 
  examples 
  include 
  mattresses 
  and 
  shoes. 
   
  The 
  
standard 
  shoe 
  provided 
  by 
  the 
  facility 
  is 
  a 
  disposable 
  slipper 
  that 
  offers 
  little 
  
support 
  or 
  foot 
  protection. 
   
  This 
  is 
  not 
  appropriate 
  for 
  patients 
  with 
  diabetes, 
  other 
  
neuropathies 
  or 
  other 
  lower 
  extremity 
  injuries 
  or 
  disease; 
  yet, 
  requests 
  for 
  
accommodation 
  for 
  a 
  more 
  supportive 
  shoe 
  are 
  often 
  dismissed 
  due 
  to 
  overly 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

15 
  

restrictive 
  medical 
  criteria. 
   
  Similarly, 
  the 
  standard 
  mattress 
  provided 
  for 
  inmates 
  is 
  
quite 
  thin 
  – 
  even 
  by 
  correctional 
  standards 
  – 
  and 
  yet 
  reasonable 
  requests 
  for 
  an 
  
additional 
  mattress 
  to 
  accommodate 
  chronic 
  conditions 
  are 
  often 
  dismissed 
  due 
  to 
  
overly 
  restrictive 
  criteria. 
   
  Staff 
  are 
  understandably 
  concerned 
  about 
  “opening 
  the 
  
floodgates” 
  to 
  requests 
  for 
  special 
  accommodations, 
  but 
  many 
  other 
  facilities 
  in 
  the 
  
state 
  and 
  the 
  country 
  manage 
  these 
  same 
  issues 
  more 
  effectively 
  without 
  adverse 
  
consequences 
  to 
  the 
  staff 
  or 
  facility. 
  (J-­‐G-­‐02 
  and 
  J-­‐G-­‐10) 
  
 
  
Pharmacy 
  Services 
  
 
  
The 
  Riverside 
  County 
  Jail 
  operates 
  locked 
  residential 
  facilities 
  seven 
  days 
  a 
  week, 
  
twenty 
  four 
  hours 
  a 
  day, 
  yet 
  pharmacy 
  services 
  are 
  provided 
  by 
  the 
  County 
  Hospital 
  
Pharmacy 
  only 
  five 
  days 
  a 
  week 
  and 
  not 
  on 
  holidays. 
   
  The 
  facilities 
  manage 
  on 
  
weekends 
  and 
  holidays 
  by 
  use 
  of 
  a 
  limited 
  stick 
  of 
  common 
  medications, 
  and 
  in 
  rare 
  
occasions, 
  they 
  can 
  access 
  support 
  from 
  the 
  hospital 
  pharmacy 
  on 
  weekends 
  or 
  
holidays. 
  (J-­‐D-­‐01) 
  
 
  
The 
  facility 
  makes 
  little 
  use 
  of 
  Keep 
  On 
  Person 
  (KOP) 
  medications. 
   
  Keep 
  On 
  Person 
  
programs 
  remove 
  unnecessary 
  barriers 
  to 
  care 
  by 
  allowing 
  appropriate 
  patients 
  to 
  
have 
  immediate 
  access 
  to 
  low 
  risk 
  medicines 
  such 
  as 
  lotions 
  or 
  inhalers. 
   
   
  
 
  
Ordered 
  medications 
  are 
  not 
  provided 
  to 
  inmates 
  who 
  are 
  in 
  transit 
  or 
  at 
  court. 
  
(This 
  deficiency 
  was 
  noted 
  in 
  2011 
  by 
  IQM 
  but 
  facility 
  staff 
  were 
  apparently 
  
unaware 
  of 
  this 
  when 
  I 
  raised 
  the 
  issue 
  during 
  my 
  visit). 
   
  In 
  one 
  case, 
  an 
  inmate 
  who 
  
had 
  been 
  hospitalized 
  for 
  a 
  soft 
  tissue 
  infection 
  (cellulitis) 
  and 
  was 
  discharged 
  from 
  
the 
  hospital 
  with 
  a 
  continuing 
  order 
  for 
  oral 
  antibiotics 
  and 
  then 
  missed 
  four 
  doses 
  
of 
  antibiotics 
  over 
  a 
  day 
  and 
  a 
  half 
  following 
  his 
  hospital 
  discharge 
  because 
  that 
  is 
  
how 
  long 
  he 
  was 
  in 
  transit 
  from 
  the 
  County 
  Hospital 
  back 
  to 
  the 
  Blythe 
  facility 
  by 
  
way 
  of 
  Indio 
  and 
  Riverside 
  facilities. 
   
  The 
  facility 
  currently 
  has 
  no 
  mechanism 
  for 
  
providing 
  necessary 
  medications 
  for 
  inmates 
  in 
  transit 
  or 
  in 
  court 
  despite 
  the 
  
department 
  being 
  made 
  aware 
  of 
  this 
  deficiency 
  for 
  over 
  four 
  years. 
   
  
 
  
 
  
Sick 
  Call 
  
 
  
Provisions 
  for 
  sick 
  call 
  at 
  Riverside 
  County 
  Jails 
  are 
  inadequate. 
   
  Current 
  practice 
  
requires 
  inmate 
  to 
  submit 
  written 
  requests 
  in 
  order 
  to 
  be 
  considered 
  for 
  a 
  sick-­‐call 
  
evaluation. 
   
  Across 
  all 
  facilities 
  with 
  the 
  exception 
  of 
  Blythe, 
  nurses 
  rarely 
  assessed 
  
acute 
  complaints 
  within 
  24 
  hours, 
  and 
  typically 
  inmates 
  had 
  to 
  wait 
  days. 
   
  Waits 
  to 
  
be 
  evaluated 
  by 
  a 
  physician 
  were 
  even 
  longer, 
  typically 
  ranging 
  from 
  five 
  days 
  to 
  
weeks 
  or 
  even 
  months. 
  By 
  the 
  NCCHC 
  standard, 
  when 
  an 
  inmate 
  request 
  involves 
  a 
  
clinical 
  symptom, 
  a 
  face 
  to 
  face 
  encounter 
  should 
  occur 
  within 
  48 
  hours, 
  72 
  hours 
  
on 
  weekends.(J-­‐E-­‐07) 
   
  Also, 
  inmates 
  report 
  that 
  face 
  to 
  face 
  requests 
  for 
  care 
  are 
  
often 
  rebuffed 
  by 
  directing 
  the 
  inmate 
  to 
  file 
  a 
  written 
  request 
  on 
  the 
  “kite,” 
  the 
  
standard 
  medical 
  request 
  form. 
  
 
  
Grievances 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

16 
  

 
  
All 
  facilities 
  experience 
  a 
  high 
  level 
  of 
  grievances 
  by 
  inmates 
  alleging 
  inadequate 
  
care. 
   
  While 
  there 
  are 
  procedures 
  for 
  staff 
  review 
  of 
  grievances, 
  there 
  is 
  no 
  
comprehensive 
  analysis 
  or 
  summary 
  by 
  category 
  of 
  types 
  of 
  grievance 
  that 
  could 
  be 
  
used 
  to 
  alert 
  health 
  administrators 
  to 
  systematic 
  problems. 
  (J-­‐A-­‐11) 
  
 
  
Dental 
  
 
  
Dental 
  care 
  when 
  provided 
  appears 
  to 
  meet 
  minimal 
  standards, 
  but 
  there 
  are 
  
significant 
  delays 
  in 
  access 
  to 
  such 
  care. 
   
  In 
  one 
  case 
  of 
  a 
  dental 
  abscess 
  noted 
  by 
  
medical 
  staff 
  in 
  Banning, 
  the 
  inmate 
  had 
  waited 
  14 
  days 
  for 
  consultation 
  with 
  dental 
  
clinic. 
  (J-­‐E-­‐06) 
  
 
  
Segregation 
  
 
  
Standards 
  dictate 
  that 
  inmates 
  held 
  in 
  segregation 
  are 
  evaluated 
  by 
  both 
  mental 
  
health 
  and 
  medical 
  staff. 
   
  Nursing 
  staff 
  reported 
  that 
  they 
  do 
  check 
  on 
  inmates 
  held 
  
in 
  segregation, 
  often 
  when 
  they 
  are 
  on 
  a 
  housing 
  unit 
  doing 
  a 
  pill 
  pass, 
  but 
  there 
  is 
  
not 
  documentation 
  or 
  log 
  to 
  document 
  that 
  these 
  important 
  checks 
  are 
  being 
  
performed 
  at 
  the 
  required 
  intervals 
  (a 
  daily 
  check 
  is 
  required 
  for 
  complete 
  isolation 
  
in 
  a 
  one 
  man 
  cell). 
   
   
  This 
  does 
  not 
  meet 
  the 
  NCCHC 
  standard 
  for 
  the 
  monitoring 
  of 
  
inmates 
  in 
  segregation. 
  (J-­‐E-­‐09) 
  
 
  
Restraints 
  
 
  
There 
  is 
  inadequate 
  documentation 
  of 
  medical 
  monitoring 
  of 
  inmates 
  held 
  in 
  
restraints. 
   
  In 
  one 
  case 
  in 
  Blythe, 
  there 
  was 
  no 
  available 
  documentation 
  that 
  an 
  
inmate 
  who 
  had 
  been 
  held 
  in 
  a 
  restraint 
  chair 
  (a 
  very 
  high 
  risk 
  restraint 
  mechanism 
  
that 
  is 
  rarely 
  used 
  in 
  most 
  correctional 
  settings) 
  had 
  been 
  monitored 
  for 
  adverse 
  
health 
  effects 
  by 
  medical 
  staff. 
   
  (J-­‐I-­‐01) 
  
 
  
Impact 
  of 
  a 
  high 
  security 
  environment 
  on 
  health 
  care 
  
 
  
It 
  is 
  important 
  to 
  note 
  for 
  context 
  that 
  the 
  Riverside 
  County 
  Jail 
  is 
  one 
  of 
  the 
  
restrictive 
  jail 
  environments 
  I 
  have 
  ever 
  seen. 
   
  I 
  base 
  this 
  conclusion 
  not 
  only 
  on 
  my 
  
direct 
  observations 
  but 
  on 
  numerous 
  discussions 
  with 
  deputies 
  and 
  patients 
  during 
  
my 
  visits. 
   
   
  
 
  
There 
  appears 
  to 
  be 
  no 
  meaningful 
  risk-­‐based 
  classification 
  and 
  all 
  inmates 
  are 
  
treated 
  as 
  if 
  they 
  are 
  high 
  risk. 
   
  While 
  this 
  may 
  seem 
  to 
  allow 
  for 
  some 
  efficiency 
  for 
  
security 
  purposes, 
  such 
  restrictive 
  conditions 
  of 
  confinement 
  create 
  unnecessary 
  
barriers 
  to 
  care 
  and 
  introduce 
  significant 
  inefficiencies 
  and 
  risks 
  in 
  the 
  delivery 
  of 
  
health 
  care. 
   
  This 
  approach 
  seems 
  particularly 
  harsh 
  and 
  problematic 
  for 
  inmates 
  
who 
  may 
  be 
  detained 
  in 
  these 
  facilities 
  for 
  longer 
  periods, 
  such 
  as 
  the 
  AB 
  109 
  
population. 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

17 
  

In 
  all 
  facilities, 
  the 
  vast 
  majority 
  inmates 
  are 
  confined 
  to 
  their 
  cells 
  (or 
  very 
  small 
  
housing 
  units) 
  nearly 
  twenty-­‐four 
  hours 
  a 
  day. 
   
  (They 
  are 
  let 
  out 
  for 
  daily 
  showers 
  
and 
  twice 
  a 
  week 
  for 
  recreation 
  time 
  in 
  a 
  closed 
  gymnasium). 
   
  There 
  is 
  little 
  or 
  no 
  
programming 
  and 
  little 
  out 
  door 
  time. 
   
  They 
  rarely 
  if 
  ever 
  get 
  direct 
  sunlight 
  or 
  fresh 
  
air. 
   
  Their 
  access 
  to 
  health 
  care 
  personnel 
  is 
  limited 
  by 
  their 
  limited 
  movement 
  and 
  
relies 
  on 
  a 
  paper 
  driven 
  “kite” 
  system 
  for 
  reporting 
  a 
  health 
  concern. 
   
  If 
  nursing 
  does 
  
not 
  come 
  to 
  their 
  cell 
  to 
  give 
  them 
  the 
  opportunity 
  to 
  raise 
  concerns, 
  their 
  only 
  
other 
  alternative 
  to 
  get 
  medical 
  attention 
  is 
  to 
  call 
  a 
  “man 
  down” 
  medical 
  
emergency. 
  
 
  
Conditions 
  that 
  are 
  overly 
  restrictive 
  can 
  and 
  do 
  have 
  impact 
  on 
  inmate 
  health 
  and 
  
well-­‐being 
  and 
  increase 
  risks 
  of 
  adverse 
  health 
  events. 
   
  Minimally, 
  they 
  create 
  
barriers 
  to 
  access 
  to 
  required 
  medical 
  care. 
   
  I 
  use 
  the 
  term 
  “barrier 
  to 
  care” 
  broadly, 
  
but 
  in 
  this 
  case, 
  there 
  are 
  literal 
  physical 
  barriers 
  to 
  care 
  in 
  the 
  form 
  of 
  cells 
  and 
  
housing 
  units. 
   
  Obviously 
  all 
  correctional 
  facilities 
  have 
  these 
  barrier, 
  but 
  many 
  have 
  
more 
  freedom 
  of 
  movement 
  and 
  provide 
  for 
  more 
  opportunities 
  for 
  the 
  inmates 
  to 
  
interact 
  with 
  health 
  care 
  staff. 
  
 
  
 
  
Reviews 
  of 
  In-­‐Custody 
  Deaths 
  
 
  
NCCHC 
  Standards 
  call 
  for 
  a 
  multi-­‐disciplinary 
  review 
  of 
  all 
  in-­‐custody 
  deaths 
  within 
  
30 
  days 
  to 
  include 
  an 
  administrative 
  review, 
  a 
  clinical 
  review 
  and 
  if 
  a 
  suicide, 
  a 
  
psychological 
  review. 
   
  According 
  to 
  a 
  corrected 
  list 
  of 
  29 
  in-­‐custody 
  deaths 
  since 
  
2008 
  provided 
  by 
  the 
  County 
  through 
  counsel, 
  the 
  department 
  was 
  unable 
  to 
  locate 
  
files 
  for 
  5 
  deaths. 
   
  Of 
  the 
  seven 
  deaths 
  that 
  occurred 
  more 
  than 
  30 
  days 
  ago 
  but 
  less 
  
than 
  one 
  year, 
  no 
  multi-­‐disciplinary 
  death 
  reviews 
  appear 
  to 
  have 
  occurred 
  based 
  
on 
  the 
  documentation 
  provided 
  to 
  me 
  in 
  response 
  to 
  my 
  request 
  for 
  in-­‐custody 
  
death 
  reviews. 
  This 
  is 
  a 
  missed 
  opportunity 
  to 
  identify 
  preventable 
  causes 
  of 
  death. 
  
(J-­‐A-­‐10) 
  
 
  
Records 
  for 
  the 
  other 
  deaths 
  provided 
  have 
  no 
  consistent 
  format. 
   
  Some 
  are 
  short 
  
summaries 
  of 
  one 
  or 
  two 
  pages. 
   
  Others 
  are 
  hundreds 
  of 
  pages. 
   
  In 
  some 
  cases, 
  the 
  
documentation 
  includes 
  a 
  sign-­‐in 
  sheet 
  or 
  Power 
  Point 
  presentation 
  apparently 
  
from 
  a 
  death 
  review 
  meeting, 
  and 
  in 
  some 
  of 
  those 
  cases, 
  medical 
  personnel 
  are 
  in 
  
attendance. 
  Based 
  on 
  the 
  documentation 
  provided, 
  proper 
  death 
  reviews 
  as 
  
described 
  in 
  the 
  relevant 
  NCCHC 
  standard 
  are 
  not 
  occurring 
  with 
  consistency 
  if 
  at 
  
all 
  and 
  if 
  they 
  have 
  occurred, 
  there 
  is 
  no 
  documentation 
  provided 
  in 
  response 
  to 
  my 
  
request 
  to 
  demonstrate 
  that 
  they 
  have 
  occurred 
  at 
  all 
  in 
  the 
  past 
  year. 
   
   
  
 
  
In 
  addition, 
  after 
  providing 
  an 
  initial 
  lists 
  of 
  in-­‐custody 
  deaths, 
  the 
  department 
  
submitted 
  a 
  revised 
  list 
  that 
  removed 
  a 
  number 
  of 
  names, 
  with 
  the 
  explanation 
  that 
  
the 
  earlier 
  list 
  included 
  inmates 
  who 
  had 
  not 
  died 
  “in-­‐custody.” 
   
  The 
  corrected 
  list, 
  
though, 
  also 
  included 
  deaths 
  noted 
  as 
  “NIC” 
  which 
  I 
  read 
  as 
  “not 
  in-­‐custody” 
  as 
  there 
  
also 
  were 
  no 
  files 
  provided 
  for 
  those 
  cases, 
  but 
  also 
  removed 
  names 
  from 
  the 
  earlier 
  
list 
  who 
  clearly 
  had 
  died 
  in 
  custody 
  (Julio 
  Negrete, 
  for 
  example, 
  an 
  in-­‐custody 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

18 
  

homicide 
  death 
  from 
  2013 
  appears 
  on 
  original 
  list, 
  but 
  is 
  removed 
  without 
  
explanation 
  from 
  the 
  revised 
  list). 
   
  At 
  the 
  same 
  time, 
  a 
  suicide 
  from 
  2012 
  (Sonny 
  
Mazon) 
  correctly 
  appears 
  on 
  the 
  revised 
  list, 
  but 
  was 
  not 
  listed 
  on 
  the 
  earlier 
  more 
  
comprehensive 
  list 
  of 
  deaths. 
   
  (Mazon 
  died 
  from 
  injuries 
  related 
  to 
  a 
  hanging 
  while 
  
in-­‐custody 
  and 
  so 
  should 
  appear 
  on 
  the 
  list 
  of 
  in-­‐custody 
  deaths 
  even 
  though 
  he 
  
died 
  in 
  an 
  outside 
  hospital.) 
   
   
  
 
  
The 
  overall 
  impression 
  I 
  am 
  left 
  with 
  is 
  that 
  the 
  department 
  does 
  not 
  have 
  a 
  good 
  
handle 
  on 
  in-­‐custody 
  deaths. 
   
  Records 
  of 
  five 
  deaths 
  are 
  missing. 
   
  This 
  is 
  nothing 
  
short 
  of 
  stunning 
  and 
  reflects 
  very 
  poorly 
  on 
  the 
  department. 
   
  For 
  cases 
  where 
  
records 
  are 
  provided, 
  reviews 
  are 
  inconsistent 
  and 
  incomplete 
  and 
  tend 
  to 
  be 
  
heavily 
  biased 
  towards 
  events 
  following 
  the 
  death 
  and 
  not 
  events 
  leading 
  up 
  to 
  the 
  
death, 
  and 
  the 
  medical 
  and 
  psychological 
  viewpoint 
  is 
  often 
  missing. 
   
  This 
  is 
  a 
  
critical 
  failing 
  because 
  careful 
  reviews 
  of 
  in-­‐custody 
  deaths 
  are 
  essential 
  in 
  
identifying 
  ongoing 
  risks 
  to 
  health 
  and 
  safety 
  of 
  inmates 
  in 
  an 
  institution. 
   
  In 
  this 
  
area, 
  the 
  department 
  falls 
  well 
  short 
  of 
  correctional 
  standards 
  and 
  raises 
  a 
  real 
  
concern 
  that 
  inmates 
  are 
  at 
  unreasonable 
  risk 
  of 
  harm 
  from 
  preventable 
  cuases 
  of 
  
death. 
  
 
  
 
  
Summary 
  of 
  2014 
  NCCHC 
  Jail 
  Not 
  Being 
  Met 
  or 
  Requiring 
  Further 
  Work 
  
 
  
The 
  following 
  is 
  my 
  summary 
  of 
  priority 
  areas 
  that 
  the 
  department 
  should 
  continue 
  
focus 
  on 
  in 
  order 
  to 
  be 
  ready 
  for 
  NCCHC 
  accreditation: 
  
 
  
J-­‐A-­‐01 
   
  Access 
  to 
  Care 
  
J-­‐A-­‐06 
  Continuous 
  Quality 
  Improvement 
  Plan 
  
J-­‐A-­‐09 
  Privacy 
  of 
  Care 
  
J-­‐A-­‐10 
  Procedure 
  in 
  the 
  Event 
  of 
  an 
  Inmate 
  Death 
  
J-­‐A-­‐11 
  Grievance 
  Mechanism 
  for 
  Health 
  Complaints 
  
J-­‐C-­‐02 
   Clinical 
  Performance 
  Enhancement 
  
J-­‐D-­‐03 
  Clinic 
  Space, 
  Equipment, 
  And 
  Supplies 
  
J-­‐D-­‐05 
   
  Hospital 
  and 
  Specialty 
  Care 
  
J-­‐E-­‐02 
   Receiving 
  Screening 
  
J-­‐E-­‐04 
   Initial 
  Health 
  Assessment 
  
J-­‐E-­‐07 
   
  Non-­‐Emergency 
  Health 
  Care 
  Requests 
  and 
  Services 
  
J-­‐E-­‐09 
   Segregated 
  Inmates 
  
J-­‐E-­‐12 
   
  Continuity 
  and 
  Coordination 
  of 
  Care 
  During 
  Incarceration 
  
J-­‐G-­‐01 
  Chronic 
  Disease 
  Services 
  
J-­‐G-­‐02 
  Patients 
  with 
  Special 
  Health 
  Needs 
  
J-­‐I-­‐01 
   
  Restraint 
  and 
  Seclusion 
  
 
  
 
  
 
  
 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

19 
  

Discussion 
  
 
  
The 
  Medical 
  Program 
  at 
  the 
  Riverside 
  County 
  Jails 
  was 
  challenged 
  by 
  drastic 
  cuts 
  to 
  
budget 
  and 
  personnel 
  that 
  occurred 
  more 
  than 
  five 
  years 
  ago. 
   
  My 
  review 
  concludes 
  
that 
  those 
  cuts 
  had 
  significant 
  impact 
  on 
  the 
  quality 
  of 
  health 
  care 
  in 
  the 
  County 
  jails 
  
resulting 
  in 
  my 
  current 
  finding 
  that 
  care 
  in 
  the 
  Riverside 
  County 
  Jails 
  does 
  not 
  meet 
  
constitutional 
  standards. 
   
  Other 
  reviewers 
  as 
  far 
  back 
  as 
  2011, 
  including 
  a 
  Grand 
  
Jury, 
  reached 
  the 
  same 
  conclusion. 
   
  Yet, 
  four 
  years 
  after 
  those 
  findings, 
  care 
  is 
  still 
  
sub-­‐standard 
  and 
  unacceptable. 
  
 
  
The 
  budget 
  cuts 
  visited 
  upon 
  the 
  medical 
  program 
  by 
  the 
  Riverside 
  County 
  Board 
  of 
  
Supervisors 
  prior 
  to 
  the 
  2011 
  Grand 
  Jury 
  Report 
  are 
  deeply 
  troubling 
  as 
  they 
  
document 
  a 
  failure 
  of 
  the 
  Supervisors 
  to 
  recognize 
  or 
  accept 
  their 
  constitutional 
  
obligations 
  to 
  provide 
  health 
  care 
  to 
  inmates 
  detained 
  in 
  county 
  facilities. 
   
  
 
  
Health 
  care 
  budgets 
  are 
  determined 
  by 
  factors 
  such 
  as 
  the 
  number 
  of 
  admissions 
  
and 
  releases 
  of 
  inmates 
  and 
  the 
  acute 
  and 
  chronic 
  health 
  care 
  needs 
  of 
  those 
  
inmates. 
   
  While 
  the 
  County 
  does 
  indeed 
  have 
  a 
  legitimate 
  interest 
  and 
  responsibility 
  
to 
  assure 
  that 
  care 
  is 
  fiscally 
  responsible, 
  efficient 
  and 
  cost-­‐effective, 
  cutting 
  funding 
  
for 
  necessary 
  medical 
  services 
  based 
  on 
  financial 
  pressures 
  alone 
  without 
  regard 
  to 
  
adverse 
  effects 
  on 
  the 
  ability 
  of 
  the 
  department 
  to 
  provide 
  minimally 
  appropriate 
  
care 
  is 
  not 
  defensible 
  from 
  a 
  constitutional 
  and 
  statutory 
  point 
  of 
  view. 
   
  Simply 
  put, 
  
reasonable 
  access 
  of 
  inmates 
  to 
  medical 
  care 
  cannot 
  be 
  limited 
  simply 
  to 
  contain 
  
cost, 
  no 
  matter 
  how 
  pressing 
  the 
  fiscal 
  pressures 
  on 
  the 
  County. 
   
  In 
  my 
  opinion, 
  
these 
  draconian 
  budget 
  cuts 
  done, 
  in 
  Sheriff 
  Smith’s 
  words 
  “without 
  consideration 
  
for 
  how 
  those 
  cuts 
  affected 
  the 
  respondent’s 
  (the 
  Sheriff’s 
  Department) 
  ability 
  to 
  fulfill 
  
the 
  legal 
  responsibility,” 
  are 
  a 
  clear 
  foundation 
  for 
  any 
  claim 
  of 
  deliberate 
  
indifference 
  by 
  the 
  County 
  to 
  the 
  serious 
  health 
  needs 
  of 
  the 
  inmates 
  in 
  their 
  
custody. 
  
 
  
At 
  the 
  same 
  time, 
  it 
  is 
  clear 
  to 
  me 
  that 
  the 
  County 
  has 
  now 
  embarked 
  on 
  significant 
  
efforts 
  to 
  remedy 
  the 
  self-­‐inflicted 
  wounds 
  to 
  the 
  department 
  brought 
  on 
  by 
  the 
  
drastic 
  budget 
  and 
  personnel 
  cuts. 
   
  Significantly, 
  an 
  experienced 
  correctional 
  health 
  
administrator, 
  Mr. 
  William 
  Wilson, 
  was 
  hired, 
  while 
  structural 
  changes 
  were 
  made 
  
to 
  the 
  health 
  care 
  delivery 
  program 
  with 
  the 
  full 
  support 
  of 
  the 
  Sheriff 
  and 
  the 
  
County 
  Hospital. 
   
  Equally 
  important, 
  requisite 
  financial 
  resources 
  are 
  now 
  
increasing. 
  
 
  
The 
  plan 
  for 
  improvement 
  of 
  care 
  described 
  to 
  me 
  by 
  key 
  leaders 
  including 
  Dr. 
  
Arnold 
  Tabuenca, 
  Mr. 
  William 
  Wilson 
  and 
  Dr. 
  Victor 
  Laus 
  is 
  encouraging 
  and 
  largely 
  
consistent 
  with 
  the 
  recommendations 
  I 
  have 
  made 
  in 
  this 
  report. 
  I 
  have 
  confidence 
  
that, 
  given 
  the 
  correct 
  level 
  of 
  ongoing 
  and 
  sustained 
  support 
  by 
  the 
  County, 
  these 
  
individuals 
  are 
  capable 
  of 
  bringing 
  care 
  within 
  the 
  Jails 
  up 
  to 
  standard. 
   
  While 
  they 
  
have 
  taken 
  initial 
  steps, 
  at 
  the 
  time 
  of 
  my 
  review, 
  it 
  is 
  too 
  early 
  to 
  measure 
  
significant 
  impact. 
   
  But 
  the 
  early 
  signs 
  are 
  encouraging, 
  including 
  the 
  successful 
  
recruitment 
  of 
  physicians 
  and 
  nurses, 
  the 
  securing 
  of 
  a 
  contract 
  for 
  an 
  Electronic 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

20 
  

Health 
  Record, 
  initial 
  CQI 
  and 
  data 
  collection 
  strategies, 
  and 
  revisions 
  to 
  the 
  
functional 
  relationship 
  between 
  the 
  Sheriff’s 
  department 
  and 
  the 
  County 
  Hospital. 
  
 
  
I 
  will 
  take 
  care 
  to 
  point 
  out 
  that, 
  in 
  my 
  opinion, 
  the 
  significant 
  deficits 
  in 
  care 
  that 
  I 
  
have 
  documented 
  in 
  this 
  report 
  do 
  not 
  appear 
  to 
  be 
  the 
  result 
  of 
  unqualified 
  or 
  
uncaring 
  medical 
  professionals. 
   
  On 
  the 
  contrary, 
  Dr. 
  Victor 
  Laus 
  and 
  the 
  nurses 
  who 
  
did 
  not 
  abandon 
  their 
  posts 
  during 
  the 
  long 
  period 
  of 
  short 
  staffing 
  are 
  to 
  be 
  
commended 
  for 
  their 
  commitment 
  to 
  the 
  County 
  and 
  their 
  patients. 
   
  The 
  vast 
  
majority 
  of 
  the 
  fifty 
  or 
  so 
  inmates 
  I 
  interviewed 
  spoke 
  well 
  of 
  the 
  nursing 
  staff, 
  and 
  I 
  
found 
  those 
  nurses 
  with 
  whom 
  I 
  interacted 
  to 
  be 
  both 
  competent 
  and 
  caring. 
   
  While 
  
the 
  inmates 
  opinion 
  of 
  doctors 
  was 
  mixed, 
  their 
  most 
  common 
  complaint 
  was 
  that 
  
the 
  doctors 
  were 
  rushed 
  and 
  did 
  not 
  take 
  the 
  time 
  to 
  explain 
  things 
  to 
  them 
  or 
  
answer 
  their 
  questions 
  – 
  this 
  is 
  consistent 
  with 
  my 
  finding 
  that 
  the 
  physicians 
  
historically 
  have 
  been 
  stretched 
  much 
  too 
  thin. 
   
   
  
 
  
In 
  my 
  professional 
  opinion, 
  the 
  failure 
  to 
  provide 
  adequate 
  care 
  is 
  a 
  direct 
  result 
  of 
  
decision 
  by 
  the 
  County 
  to 
  cut 
  funding 
  for 
  an 
  essential 
  and 
  constitutionally 
  mandated 
  
basic 
  service. 
   
  All 
  that 
  followed 
  was 
  completely 
  predictable 
  and 
  completely 
  
preventable. 
   
  The 
  good 
  news, 
  then, 
  is 
  that 
  it 
  is 
  also 
  fixable. 
   
  To 
  that 
  end, 
  I 
  provide 
  
both 
  general 
  and 
  specific 
  recommendations 
  going 
  forward. 
  
 
  
General 
  Recommendations 
  
 
  
It 
  is 
  imperative 
  that 
  the 
  Riverside 
  County 
  Board 
  of 
  Supervisors 
  recognizes 
  and 
  acts 
  
upon 
  the 
  obligation 
  of 
  the 
  County 
  to 
  provide 
  adequate 
  access 
  to 
  health 
  services 
  for 
  
inmates 
  in 
  the 
  County 
  jails 
  as 
  required 
  by 
  California 
  law 
  and 
  the 
  U.S. 
  Constitution. 
   
  I 
  
am 
  encouraged 
  to 
  see 
  that 
  the 
  Board 
  has 
  supported 
  the 
  recent 
  efforts 
  to 
  improve 
  
access 
  to 
  care 
  as 
  I 
  have 
  described 
  in 
  this 
  report, 
  but 
  is 
  critical 
  that 
  this 
  support 
  be 
  
durable 
  and 
  ongoing. 
  
 
  
While 
  recent 
  efforts 
  to 
  improve 
  care 
  are 
  laudable, 
  the 
  overall 
  record 
  of 
  the 
  County 
  in 
  
the 
  past 
  five 
  years 
  is 
  cause 
  for 
  concern. 
   
  Going 
  forward, 
  the 
  parties 
  would 
  be 
  advised 
  
to 
  develop 
  mechanisms 
  to 
  guarantee 
  ongoing 
  support 
  of 
  health 
  services 
  
commensurate 
  with 
  the 
  ever 
  changing 
  needs 
  of 
  the 
  Jail 
  population. 
  
 
  
According 
  to 
  medical 
  leadership 
  in 
  the 
  department, 
  the 
  County 
  has 
  been 
  supportive 
  
to 
  individual 
  and 
  specific 
  requests 
  for 
  funding 
  to 
  secure 
  needed 
  resources, 
  but 
  that 
  
funding 
  is 
  being 
  doled 
  out 
  in 
  a 
  piecemeal 
  fashion. 
   
  It 
  is 
  essential 
  that 
  the 
  department 
  
be 
  provided 
  with 
  an 
  appropriate 
  and 
  predictable 
  overall 
  budget 
  to 
  allow 
  for 
  proper 
  
long-­‐term 
  planning. 
  
 
  
At 
  the 
  same 
  time, 
  effects 
  of 
  realignment 
  must 
  be 
  considered. 
   
  The 
  County, 
  along 
  with 
  
all 
  other 
  counties 
  in 
  the 
  state, 
  must 
  recognize 
  and 
  deal 
  with 
  the 
  fact 
  that 
  the 
  jails 
  
now 
  house 
  two 
  different 
  populations: 
   
  the 
  traditional 
  jail 
  population 
  and 
  the 
  
translocated 
  prison 
  population 
  created 
  by 
  AB 
  109. 
   
  The 
  facilities 
  were 
  designed 
  for 
  
short-­‐term 
  detention, 
  but 
  a 
  growing 
  population 
  of 
  inmates 
  may 
  spend 
  years 
  housed 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

21 
  

in 
  the 
  county 
  jails. 
   
  This 
  will 
  require 
  a 
  rethinking 
  of 
  all 
  detention 
  programming, 
  
including 
  medical. 
  
 
  
Specific 
  Recommendations 
  
 
  
 
  
1. 
  Accreditation 
  status: 
   
  
 
  
The 
  department 
  should 
  move 
  forward 
  with 
  the 
  process 
  of 
  preparing 
  for, 
  applying 
  for 
  
and 
  securing 
  accreditation 
  with 
  the 
  National 
  Commission 
  on 
  Correctional 
  Care. 
   
   
  
 
  
If 
  the 
  department 
  follows 
  through 
  with 
  its 
  current 
  plan, 
  I 
  think 
  the 
  jail 
  would 
  be 
  able 
  
to 
  secure 
  accreditation 
  within 
  a 
  year 
  or 
  so. 
   
  In 
  addition 
  to 
  providing 
  a 
  standardized 
  
approach 
  to 
  improving 
  the 
  health 
  delivery 
  system, 
  securing 
  accreditation 
  would 
  do 
  
much 
  to 
  re-­‐establish 
  trust 
  in 
  a 
  department 
  whose 
  reputation 
  has 
  suffered, 
  and 
  
would 
  make 
  a 
  positive 
  impression 
  on 
  the 
  courts 
  as 
  it 
  relates 
  to 
  the 
  epidemic 
  of 
  court 
  
orders. 
  
 
  
 
  
2. 
   
  Staffing: 
   
   
  
 
  
The 
  department 
  should 
  follow 
  through 
  in 
  restoring 
  appropriate 
  medical 
  professional 
  
staffing 
  levels, 
  and 
  then 
  work 
  to 
  maintain 
  them 
  and 
  adjust 
  them 
  to 
  address 
  changing 
  
needs. 
   
   
  
 
  
The 
  department 
  has 
  made 
  important 
  strides 
  in 
  correcting 
  staffing 
  deficits 
  that 
  
resulted 
  from 
  the 
  draconian 
  budget 
  cuts 
  of 
  recent 
  years, 
  but 
  by 
  its 
  own 
  tracking, 
  still 
  
needs 
  to 
  fill 
  (at 
  the 
  time 
  of 
  the 
  tracking 
  report 
  provided 
  to 
  me) 
  62 
  full 
  time 
  
positions, 
  mostly 
  in 
  nursing. 
  If 
  necessary, 
  salary 
  levels 
  should 
  be 
  adjusted 
  to 
  make 
  
sure 
  they 
  are 
  competitive 
  with 
  other 
  jobs 
  in 
  the 
  California 
  correctional 
  medicine 
  
market. 
   
  Competitive 
  salaries 
  for 
  board 
  certified 
  internal 
  medicine 
  or 
  family 
  
medicine 
  physicians 
  working 
  in 
  correctional 
  settings 
  should 
  be 
  above 
  $200,000 
  
annually 
  and 
  include 
  continuing 
  medical 
  education 
  support 
  and 
  health 
  and 
  
retirement 
  benefits. 
  As 
  board 
  certification 
  has 
  become 
  the 
  community 
  standard, 
  I 
  
strongly 
  recommend 
  that 
  the 
  department 
  actively 
  recruit 
  primary 
  care 
  physicians 
  
who 
  are 
  board 
  certified 
  in 
  either 
  Internal 
  Medicine 
  or 
  Family 
  Medicine. 
   
   
  
 
  
When 
  target 
  staffing 
  levels 
  are 
  achieved, 
  ongoing 
  reassessment 
  of 
  changing 
  needs 
  
and 
  appropriate 
  adjustments 
  to 
  staffing 
  levels 
  is 
  essential. 
   
  Key 
  measures 
  such 
  as 
  
wait 
  times 
  to 
  see 
  provider 
  and 
  compliance 
  with 
  chronic 
  care 
  guidelines 
  can 
  be 
  used 
  
to 
  assess 
  adequacy 
  of 
  staffing 
  levels. 
  
 
  
 
  
 
  
 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

22 
  

3. 
   
  Physical 
  space 
  for 
  medical 
  care: 
   
  
 
  
The 
  department 
  should 
  examine 
  and 
  consider 
  options 
  to 
  develop 
  newer 
  and 
  more 
  
suitable 
  clinic 
  space 
  to 
  support 
  health 
  operation; 
  space 
  should 
  be 
  large 
  enough 
  to 
  
accommodate 
  clinical 
  operations 
  while 
  also 
  securing 
  appropriate 
  privacy 
  for 
  patients. 
  
 
  
With 
  the 
  increasing 
  population 
  and 
  changing 
  character 
  of 
  detention 
  (longer 
  
sentences 
  with 
  the 
  AB 
  109 
  population) 
  combined 
  with 
  national 
  trends 
  in 
  aging 
  
populations 
  in 
  jails, 
  the 
  department 
  should 
  consider 
  options 
  to 
  develop 
  newer 
  and 
  
more 
  suitable 
  clinic 
  space 
  to 
  support 
  health 
  operation. 
   
  The 
  clearest 
  opportunity 
  is 
  
in 
  the 
  new 
  East 
  County 
  Detention 
  Center. 
   
  It 
  would 
  be 
  advisable 
  to 
  consult 
  closely 
  
with 
  county 
  correctional 
  health 
  staff 
  on 
  the 
  plans 
  for 
  clinic 
  space 
  before 
  breaking 
  
ground 
  on 
  this 
  project. 
  
 
  
 
  
4. 
   
  Infirmary 
  or 
  Intermediate 
  Level 
  of 
  Care 
  
 
  
The 
  department 
  should 
  explore 
  options 
  for 
  developing 
  at 
  least 
  one 
  facility 
  that 
  could 
  
provide 
  a 
  higher 
  level 
  of 
  medical 
  care 
  such 
  as 
  infirmary 
  or 
  sub-­‐acute 
  levels 
  of 
  care. 
  
 
  
Currently, 
  the 
  department 
  does 
  not 
  have 
  any 
  unit 
  in 
  any 
  facility 
  that 
  is 
  capable 
  of 
  
providing 
  for 
  a 
  higher 
  level 
  of 
  care 
  than 
  that 
  expected 
  for 
  an 
  essentially 
  healthy 
  
“ambulatory” 
  or 
  “community” 
  population. 
   
  This 
  forces 
  the 
  department 
  into 
  situation 
  
where 
  the 
  only 
  mechanism 
  for 
  providing 
  any 
  care 
  that 
  requires 
  a 
  higher 
  level 
  is 
  
through 
  Emergency 
  Rooms 
  or 
  the 
  County 
  Hospital. 
   
  The 
  department 
  should 
  
consider 
  the 
  development 
  of 
  at 
  least 
  a 
  small 
  infirmary 
  that 
  could 
  provide 
  care 
  such 
  
as 
  simple 
  intravenous 
  medications 
  or 
  basic 
  post-­‐operative 
  wound 
  care 
  so 
  that 
  
inmates 
  are 
  not 
  kept 
  in 
  higher 
  cost 
  settings 
  any 
  longer 
  than 
  they 
  need 
  to 
  be. 
   
  It 
  
should 
  be 
  noted 
  that 
  the 
  space 
  would 
  have 
  to 
  be 
  appropriately 
  designed 
  to 
  support 
  
this 
  function 
  and 
  would 
  likely 
  involve 
  new 
  construction. 
  
 
  
 
  
5. 
   
  Screening 
  on 
  Intake: 
  
 
  
The 
  department 
  should 
  follow 
  through 
  with 
  its 
  plans 
  to 
  ensure 
  that 
  all 
  newly 
  arrived 
  
inmates 
  are 
  screened 
  on 
  arrival 
  by 
  licensed 
  nursing 
  staff. 
   
  Similarly, 
  all 
  new 
  arrivals 
  
should 
  be 
  screened 
  for 
  tuberculosis. 
  
 
  
In 
  order 
  to 
  comply 
  with 
  NCCHC 
  standards 
  on 
  screening 
  and 
  initial 
  health 
  
assessment, 
  the 
  department 
  has 
  two 
  options. 
   
  In 
  option 
  one, 
  a 
  licensed 
  nurse 
  would 
  
screen 
  all 
  newly 
  arrived 
  inmates 
  and 
  those 
  with 
  problems 
  identified 
  by 
  the 
  nurse 
  
would 
  be 
  referred 
  to 
  licensed 
  providers 
  (nurse 
  practitioners 
  or 
  physicians) 
  as 
  
indicated. 
   
  In 
  option 
  two, 
  screening 
  would 
  continue 
  to 
  be 
  done 
  by 
  trained 
  non-­‐
licensed 
  deputies, 
  but 
  all 
  inmates 
  would 
  be 
  seen 
  for 
  a 
  complete 
  intake 
  health 
  
assessment 
  performed 
  by 
  an 
  appropriately 
  trained 
  registered 
  nurse 
  within 
  14 
  days. 
   
   
  
 
  

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23 
  

While 
  both 
  approaches 
  would 
  meet 
  standard, 
  I 
  support 
  the 
  departments 
  stated 
  plan 
  
to 
  move 
  forward 
  with 
  universal 
  screening 
  by 
  licensed 
  nurses 
  of 
  all 
  newly 
  arrived 
  
inmates 
  in 
  accordance 
  with 
  the 
  NCCHC 
  “Full 
  Population 
  Assessment” 
  option 
  (J-­‐E-­‐
04). 
  
 
  
While 
  past 
  procedures 
  for 
  tuberculosis 
  likely 
  meet 
  minimum 
  standards, 
  I 
  am 
  
supportive 
  of 
  the 
  department’s 
  newly 
  implemented 
  procedures 
  for 
  more 
  
comprehensive 
  screening 
  of 
  this 
  high 
  risk 
  population. 
   
  Effective 
  screening 
  is 
  
important 
  not 
  only 
  for 
  the 
  facility, 
  but 
  for 
  the 
  public 
  health 
  at 
  large. 
  
 
  
 
  
6. 
   
  Continuous 
  Quality 
  Improvement: 
  
 
  
The 
  department 
  should 
  continue 
  to 
  develop 
  a 
  Continuous 
  Quality 
  Improvement 
  
program. 
  
 
  
Continuous 
  Quality 
  Improvement, 
  recommended 
  in 
  May 
  2011 
  by 
  IMQ, 
  has 
  only 
  just 
  
started, 
  but 
  the 
  fact 
  that 
  it 
  has 
  started 
  is 
  critically 
  important. 
   
  As 
  the 
  department 
  
steps 
  up 
  its 
  CQI 
  program, 
  it 
  may 
  wish 
  to 
  confer 
  with 
  Riverside 
  University 
  Medical 
  
Center 
  as 
  that 
  facility 
  has 
  technical 
  expertise 
  and 
  experience 
  in 
  developing 
  and 
  
deploying 
  CQI 
  programs. 
  
 
  
Information 
  gleaned 
  form 
  well 
  functioning 
  CQI 
  processes 
  helps 
  administrators 
  
improve 
  both 
  quality 
  of 
  care 
  as 
  well 
  as 
  efficiency 
  of 
  care 
  and 
  can 
  help 
  identify 
  
opportunities 
  for 
  cost 
  containment. 
  
 
  
 
  
7. 
   
  Utilization 
  Management: 
  
 
  
The 
  department 
  should 
  develop 
  a 
  utilization 
  management 
  process. 
  
 
  
Most 
  inmates 
  housed 
  in 
  correctional 
  facilities 
  are 
  the 
  sole 
  responsibility 
  of 
  the 
  
detaining 
  authority, 
  an 
  arrangement 
  that 
  makes 
  most 
  jail 
  and 
  prison 
  health 
  systems 
  
both 
  the 
  health 
  provider 
  and 
  the 
  insurer. 
   
  Managed 
  care 
  approaches 
  to 
  allocating 
  
resources 
  for 
  high 
  cost 
  care 
  have 
  become 
  an 
  established 
  mechanism 
  for 
  
standardizing 
  and 
  controlling 
  utilization 
  of 
  health 
  resources. 
   
  The 
  department 
  could 
  
consult 
  with 
  other 
  detaining 
  institutions 
  both 
  in 
  the 
  state 
  and 
  elsewhere 
  to 
  learn 
  
more 
  about 
  the 
  utilization 
  management 
  process 
  for 
  incarcerated 
  populations. 
   
   
  
 
  
8. 
  Medical 
  Records: 
  
 
  
The 
  department 
  should 
  follow 
  through 
  with 
  its 
  plan 
  to 
  deploy 
  a 
  correctional 
  Electronic 
  
Health 
  Record 
  and 
  provide 
  ongoing 
  IT 
  support 
  to 
  both 
  the 
  network 
  infrastructure 
  and 
  
IT 
  support 
  for 
  end 
  users 
  of 
  the 
  software. 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

24 
  

Based 
  on 
  a 
  very 
  brief 
  demonstration 
  of 
  the 
  EHR 
  system 
  that 
  will 
  soon 
  be 
  deployed, 
  I 
  
am 
  optimistic 
  that 
  it 
  has 
  the 
  promise 
  to 
  dramatically 
  improve 
  documentation, 
  
communication, 
  and 
  continuity 
  of 
  care 
  across 
  a 
  dispersed 
  system, 
  as 
  well 
  as 
  
allowing 
  health 
  administrators 
  to 
  better 
  track 
  and 
  address 
  shifting 
  healthcare 
  needs 
  
across 
  multiple 
  facilities. 
   
  At 
  the 
  same 
  time, 
  it 
  will 
  only 
  work 
  if 
  this 
  system 
  receives 
  
ongoing 
  competent 
  and 
  timely 
  IT 
  support 
  for 
  the 
  system. 
   
  The 
  contract 
  signed 
  by 
  the 
  
County 
  with 
  the 
  vendor 
  does 
  indeed 
  address 
  this 
  aspect, 
  but 
  it 
  will 
  take 
  time 
  to 
  
ensure 
  that 
  the 
  system 
  does 
  deploy 
  properly, 
  is 
  modified 
  according 
  to 
  facility 
  needs 
  
and 
  is 
  maintained 
  and 
  improved 
  in 
  an 
  ongoing 
  basis. 
   
  This 
  will 
  require 
  ongoing 
  
evaluation 
  and 
  monitoring 
  to 
  verify 
  successful 
  deployment 
  and 
  ongoing 
  support 
  of 
  a 
  
functioning 
  EHR 
  given 
  the 
  inherent 
  complexity 
  of 
  these 
  systems 
  and 
  the 
  County’s 
  
mixed 
  track 
  record 
  with 
  EHR's. 
  
 
  
9. 
   
  Chronic 
  Disease 
  Management 
  
 
  
The 
  Department 
  should 
  develop 
  a 
  chronic 
  disease 
  management 
  process 
  that 
  
references 
  established 
  guidelines 
  (both 
  correctional 
  and 
  community) 
  for 
  the 
  
management 
  of 
  common 
  chronic 
  conditions 
  such 
  as, 
  but 
  not 
  limited 
  to, 
  diabetes 
  
mellitus, 
  asthma, 
  hypertension, 
  HIV 
  and 
  hepatitis 
  C. 
  
 
  
A 
  functioning 
  chronic 
  disease 
  program 
  identifies 
  inmates 
  with 
  chronic 
  diseases 
  and 
  
follows 
  them 
  proactively 
  with 
  documented 
  treatment 
  plans 
  based 
  on 
  widely 
  
accepted 
  clinical 
  guidelines 
  (including 
  but 
  not 
  limited 
  to 
  those 
  referenced 
  by 
  the 
  
NCCHC 
  and 
  Federal 
  Bureau 
  of 
  Prisons). 
   
  With 
  the 
  deployment 
  of 
  an 
  Electronic 
  
Health 
  Record, 
  one 
  of 
  the 
  major 
  barriers 
  to 
  tracking 
  inmates 
  with 
  chronic 
  disease 
  is 
  
removed. 
   
  This 
  provides 
  an 
  excellent 
  opportunity 
  for 
  the 
  department 
  to 
  develop 
  and 
  
deploy 
  a 
  chronic 
  disease 
  program. 
  
 
  
 
  
10. 
  Timely 
  Access 
  to 
  Care 
  
 
  
a. 
  Timely 
  access 
  to 
  facility 
  physicians-­‐ 
  The 
  Department 
  should 
  adjust 
  staffing 
  in 
  
order 
  to 
  accommodate 
  timely 
  access 
  to 
  care 
  consistent 
  with 
  the 
  timely 
  access 
  
benchmarks 
  established 
  by 
  the 
  NCCHC. 
  
 
  
The 
  current 
  staffing 
  plan, 
  if 
  fully 
  realized, 
  is 
  likely 
  to 
  solve 
  this 
  problem 
  of 
  
timely 
  access 
  to 
  care 
  within 
  the 
  facilities. 
   
  CQI 
  approaches 
  should 
  be 
  used 
  to 
  
monitor 
  wait 
  times 
  so 
  that 
  staffing 
  patterns 
  can 
  be 
  adjusted 
  based 
  on 
  need. 
  
 
  
 
  
b. 
  Timely 
  access 
  to 
  specialty 
  care 
  –The 
  Department 
  should 
  continue 
  to 
  work 
  
with 
  the 
  Riverside 
  University 
  Medical 
  Center 
  to 
  provide 
  more 
  timely 
  access 
  to 
  
specialty 
  care 
  for 
  serious 
  medical 
  problems. 
   
  If 
  the 
  RUMC 
  is 
  unable 
  to 
  provide 
  
timely 
  access 
  to 
  care, 
  the 
  Department 
  must 
  secure 
  those 
  specialty 
  services 
  from 
  
other 
  community 
  providers 
  as 
  the 
  community 
  standard 
  for 
  timeliness 
  is 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

25 
  

established 
  by 
  the 
  entire 
  community, 
  not 
  by 
  the 
  standard 
  set 
  by 
  department’s 
  
chosen 
  community 
  partner. 
  
 
  
Providing 
  timely 
  access 
  to 
  specialty 
  consultation 
  should 
  probably 
  be 
  
approached 
  on 
  two 
  different 
  tracks 
  simultaneously. 
   
  The 
  department 
  should 
  
continue 
  to 
  work 
  with 
  the 
  County 
  hospital 
  in 
  order 
  to 
  prioritize 
  and 
  
accommodate 
  inmate 
  specialty 
  care 
  needs 
  in 
  a 
  timely 
  manner. 
   
  Whenever 
  the 
  
hospital 
  is 
  able 
  to 
  provide 
  care 
  in 
  a 
  timely 
  manner, 
  it 
  is 
  likely 
  to 
  be 
  the 
  most 
  
cost-­‐effective 
  option. 
   
  However, 
  the 
  department 
  should 
  also 
  explore 
  
establishing 
  alternative 
  providers 
  to 
  be 
  used 
  when 
  the 
  County 
  hospital 
  is 
  
unable 
  to 
  provide 
  the 
  care 
  in 
  a 
  timely 
  manner. 
   
   
  
 
  
Also, 
  a 
  department 
  review 
  of 
  off-­‐site 
  specialty 
  consultations 
  (from 
  the 
  last 
  
annual 
  report) 
  reveals 
  that 
  eye 
  clinics 
  account 
  for 
  a 
  large 
  proportion 
  of 
  
consultations 
  (roughly 
  a 
  quarter 
  of 
  the 
  1622 
  annual 
  off-­‐site 
  consultations). 
   
  
As 
  one 
  of 
  the 
  greatest 
  costs 
  associated 
  with 
  specialty 
  care 
  is 
  actually 
  the 
  
security 
  costs 
  of 
  transporting 
  and 
  guarding 
  the 
  inmate 
  patients, 
  it 
  may 
  be 
  
more 
  cost 
  effective 
  to 
  contract 
  with 
  outside 
  providers 
  to 
  provide 
  care 
  on-­‐site 
  
in 
  the 
  facility. 
   
  Eye 
  clinics 
  do 
  require 
  some 
  special 
  equipment, 
  so 
  it 
  is 
  hard 
  to 
  
say 
  if 
  on-­‐site 
  care 
  can 
  be 
  provided 
  in 
  a 
  cost-­‐effective 
  manner, 
  but 
  the 
  costs 
  of 
  
transport 
  and 
  security 
  high 
  enough 
  that 
  on-­‐site 
  care 
  even 
  with 
  specialized 
  
equipment 
  may 
  less 
  expensive. 
  
 
  
11. 
  Telemedicine 
  
 
  
Given 
  the 
  obstacles 
  in 
  moving 
  inmates 
  across 
  a 
  geographically 
  dispersed 
  system, 
  the 
  
Department 
  should 
  explore 
  Telemedicine 
  as 
  an 
  option 
  for 
  access 
  to 
  sub-­‐specialty 
  
consultation. 
  
 
  
With 
  improvements 
  in 
  technology 
  and 
  the 
  lowering 
  of 
  costs, 
  telemedicine 
  is 
  
becoming 
  more 
  common 
  both 
  in 
  and 
  out 
  of 
  correctional 
  environments. 
   
  
Telemedicine 
  is 
  a 
  particularly 
  useful 
  tool 
  in 
  correctional 
  settings 
  with 
  facilities 
  that 
  
are 
  geographically 
  remote 
  from 
  community 
  health 
  settings 
  as 
  is 
  the 
  case 
  in 
  the 
  
Riverside 
  County 
  system. 
   
   
  
 
  
12. 
  Physical 
  Disability 
  Issues 
  
 
  
The 
  Department 
  should 
  review 
  the 
  handling 
  of 
  inmates 
  with 
  disabilities 
  who 
  are 
  
currently 
  confined 
  to 
  restrictive 
  units 
  not 
  for 
  the 
  purposes 
  of 
  accommodating 
  their 
  
special 
  needs 
  per 
  se 
  or 
  for 
  the 
  purposes 
  of 
  providing 
  a 
  higher 
  level 
  of 
  care, 
  but 
  for 
  
administrative 
  convenience 
  in 
  meeting 
  legitimate 
  security 
  concerns. 
   
   
  
 
  
The 
  department 
  should 
  consult 
  with 
  other 
  facilities 
  in 
  the 
  state 
  or 
  country 
  to 
  learn 
  
about 
  less 
  restrictive 
  approaches 
  to 
  dealing 
  with 
  inmates 
  with 
  disabilities. 
  
 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

26 
  

13. 
  Pharmacy 
  Services 
  
 
  
The 
  Department 
  should 
  consider 
  increasing 
  on-­‐site 
  pharmacy 
  services 
  at 
  the 
  jails 
  from 
  
the 
  current 
  five 
  days 
  a 
  week 
  to 
  seven 
  days 
  a 
  week. 
   
  The 
  department 
  should 
  liberalize 
  
the 
  use 
  of 
  Keep 
  on 
  Person 
  medications 
  – 
  especially 
  for 
  inhalers 
  and 
  medications 
  that 
  
are 
  available 
  over-­‐the-­‐counter 
  in 
  the 
  community. 
  
 
  
The 
  Riverside 
  County 
  Jails 
  operate 
  and 
  admit 
  new 
  inmates 
  twenty-­‐four 
  hours 
  a 
  day 
  
seven 
  days 
  a 
  week. 
   
  Although 
  there 
  are 
  back-­‐up 
  procedures 
  for 
  weekends 
  and 
  
holidays 
  including 
  use 
  of 
  stock 
  medicines 
  at 
  each 
  facility 
  (a 
  practice 
  I 
  support), 
  
regular 
  pharmacy 
  support 
  seven 
  days 
  a 
  week, 
  or 
  minimally 
  six 
  days 
  a 
  week, 
  would 
  
decrease 
  the 
  risk 
  of 
  interruptions 
  in 
  continuity 
  of 
  medical 
  treatments 
  
 
  
Keep 
  on 
  Person 
  (KOP) 
  medications 
  can 
  improve 
  asthma 
  care 
  as 
  well 
  as 
  decrease 
  
utilization 
  of 
  nursing 
  resources 
  for 
  routine 
  care 
  involving 
  common 
  medications 
  that 
  
are 
  over-­‐the-­‐counter 
  in 
  the 
  community. 
  
 
  
The 
  department 
  must 
  develop 
  a 
  process 
  to 
  provide 
  scheduled 
  medications 
  for 
  
serious 
  and/or 
  chronic 
  health 
  conditions 
  for 
  inmates 
  who 
  are 
  in 
  transit 
  or 
  transport 
  
between 
  facilities, 
  to 
  and 
  from 
  hospitals 
  and 
  clinics 
  and 
  courts. 
   
  This 
  can 
  be 
  
accomplished 
  in 
  many 
  cases 
  by 
  providing 
  unit 
  dosing 
  or 
  blister 
  packs 
  of 
  non-­‐
controlled 
  medications 
  to 
  cover 
  the 
  transport 
  period 
  directly 
  to 
  the 
  inmate 
  for 
  self-­‐
administration. 
  
 
  
 
  
14. 
  Sick 
  Call 
  
 
  
The 
  department 
  should 
  review 
  Sick-­‐Call 
  procedures 
  to 
  remove 
  unnecessary 
  barriers 
  to 
  
timely 
  access 
  to 
  care. 
   
  
 
  
A 
  nurse 
  should 
  evaluate 
  patients 
  with 
  symptomatic 
  complaints 
  in 
  a 
  timely 
  manner 
  
as 
  defined 
  by 
  the 
  guidelines 
  established 
  by 
  the 
  NCCHC 
  Jail 
  Standards. 
  Those 
  needing 
  
consultation 
  with 
  a 
  nurse 
  practitioner 
  or 
  physician 
  should 
  not 
  be 
  subjected 
  to 
  
unreasonably 
  long 
  waits. 
   
  Attempts 
  should 
  be 
  made 
  to 
  see 
  patients 
  as 
  soon 
  as 
  
possible, 
  and 
  the 
  practice 
  of 
  making 
  inmates 
  arbitrarily 
  wait 
  a 
  specified 
  period 
  to 
  be 
  
evaluated 
  is 
  not 
  defensible 
  and 
  should 
  be 
  abandoned. 
   
  Also, 
  while 
  a 
  written 
  request 
  
for 
  health 
  services 
  (a 
  “kite”) 
  is 
  a 
  reasonable 
  option, 
  it 
  should 
  not 
  be 
  a 
  requirement 
  to 
  
request 
  care. 
   
  For 
  tracking 
  purposes, 
  face-­‐to-­‐face 
  requests 
  can 
  be 
  logged 
  by 
  nursing 
  
staff. 
  
 
  
15. 
  Grievances 
  
 
  
Grievances 
  should 
  be 
  categorized 
  and 
  analyzed 
  as 
  part 
  of 
  a 
  Continuous 
  Quality 
  
Improvement 
  process. 
  
 
  
The 
  facilities 
  continue 
  to 
  experience 
  high 
  numbers 
  of 
  medical 
  grievances. 
   
  Although 
  
these 
  can 
  be 
  a 
  lagging 
  indicator 
  in 
  an 
  environment 
  that 
  is 
  experiencing 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

27 
  

improvements, 
  a 
  systematic 
  review 
  of 
  these 
  complaints 
  can 
  provide 
  critical 
  
information 
  to 
  guide 
  the 
  administration 
  in 
  areas 
  that 
  might 
  require 
  more 
  attention. 
   
  
Systematic 
  analysis 
  of 
  grievances 
  should 
  be 
  part 
  of 
  a 
  functioning 
  Continuous 
  Quality 
  
Improvement 
  program. 
  
 
  
16. 
  Dental 
  
 
  
Dental 
  Clinics 
  should 
  be 
  scheduled 
  and 
  staffed 
  to 
  allow 
  for 
  timely 
  access 
  to 
  
appropriate 
  dental 
  care. 
  
 
  
The 
  department 
  should 
  look 
  at 
  dental 
  staffing 
  and 
  clinic 
  scheduling 
  to 
  ensure 
  timely 
  
access 
  to 
  care. 
   
  For 
  remote 
  or 
  smaller 
  jails, 
  arrangements 
  for 
  community 
  
consultation 
  should 
  be 
  considered 
  for 
  inmates 
  with 
  acute 
  dental 
  issues 
  (such 
  as 
  
dental 
  abscesses) 
  when 
  an 
  in-­‐facility 
  dental 
  consultation 
  cannot 
  be 
  provided 
  in 
  a 
  
timely 
  manner. 
  
 
  
17. 
  Segregation 
  
 
  
The 
  department 
  should 
  establish 
  procedures 
  to 
  ensure 
  that 
  inmates 
  held 
  in 
  isolation 
  
and 
  segregation 
  have 
  daily 
  assessments 
  by 
  medical 
  personnel 
  and 
  institute 
  a 
  logging 
  
procedure 
  for 
  those 
  encounters. 
  
 
  
Inmates 
  held 
  in 
  isolation 
  face 
  increased 
  adverse 
  physical 
  and 
  mental 
  health 
  risks 
  
while 
  simultaneously 
  experiencing 
  increased 
  barriers 
  in 
  access 
  to 
  care. 
   
  NCCHC 
  
standards 
  require 
  that 
  health 
  staff 
  must 
  check 
  inmates 
  in 
  segregation 
  or 
  isolation 
  
daily. 
   
  Facility 
  staff 
  assured 
  me 
  that 
  nursing 
  staff 
  was 
  checking 
  inmates 
  in 
  
segregation 
  on 
  a 
  daily 
  basis, 
  but 
  they 
  were 
  unable 
  to 
  produce 
  any 
  log 
  or 
  
documentation 
  of 
  this 
  process. 
   
  Clearer 
  policies 
  with 
  a 
  logging 
  procedure 
  would 
  
better 
  document 
  that 
  the 
  facilities 
  are 
  meeting 
  this 
  standard 
  of 
  care. 
  
 
  
18. 
  Restraints 
  
 
  
Policies 
  and 
  procedures 
  for 
  health 
  care 
  monitoring 
  of 
  inmates 
  held 
  in 
  restraints 
  should 
  
be 
  developed 
  in 
  compliance 
  with 
  NCCHC 
  standards. 
  
 
  
Use 
  of 
  restraints 
  carry 
  significant 
  risks 
  to 
  the 
  health 
  and 
  well 
  being 
  of 
  inmates. 
   
  
Standards 
  dictate 
  that 
  health 
  care 
  staff 
  must 
  continuously 
  monitor 
  inmates 
  held 
  in 
  
restraints. 
   
  This 
  is 
  critically 
  important 
  for 
  facilities 
  that 
  use 
  restraint 
  chairs, 
  as 
  these 
  
chairs 
  have 
  been 
  associated 
  with 
  risk 
  of 
  blood 
  clot 
  formation 
  and 
  high 
  risk 
  of 
  
pulmonary 
  emboli 
  and 
  even 
  death. 
  
 
  
19. 
  Impact 
  of 
  a 
  high 
  security 
  environment 
  on 
  health 
  care 
  
 
  
The 
  department 
  should 
  consult 
  with 
  other 
  jail 
  facilities 
  in 
  the 
  state 
  and 
  in 
  the 
  nation 
  to 
  
learn 
  about 
  less 
  restrictive 
  detention 
  practices 
  that 
  do 
  not 
  compromise 
  facility 
  safety 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

28 
  

and 
  security, 
  particularly 
  for 
  those 
  inmates 
  expected 
  to 
  remain 
  incarcerated 
  for 
  longer 
  
periods 
  of 
  time. 
  
 
  
Environment 
  of 
  care 
  can 
  affect 
  the 
  health 
  and 
  well 
  being 
  of 
  both 
  staff 
  and 
  inmates. 
   
  
Corrections 
  as 
  a 
  field 
  continues 
  to 
  evolve, 
  and 
  this 
  time 
  of 
  review 
  provides 
  an 
  
opportunity 
  for 
  the 
  department 
  to 
  learn 
  about 
  alternative 
  approaches 
  to 
  detention 
  
that 
  involve 
  risk-­‐stratification 
  of 
  the 
  population. 
   
  While 
  this 
  particular 
  
recommendation 
  involves 
  the 
  security 
  domain, 
  it 
  is 
  relevant 
  to 
  the 
  health 
  care 
  
insofar 
  as 
  it 
  affects 
  removal 
  of 
  barriers 
  in 
  access 
  to 
  care 
  and 
  opportunities 
  to 
  
promote 
  healthier 
  lifestyles 
  with 
  more 
  activity 
  and 
  freedom 
  of 
  movement 
  for 
  
appropriately 
  screened 
  inmates. 
   
  Many 
  other 
  institutions 
  have 
  demonstrated 
  that 
  
less 
  restrictive 
  opportunities 
  for 
  lower 
  risk 
  inmates 
  can 
  be 
  deployed 
  without 
  
compromise 
  to 
  the 
  safety 
  or 
  security 
  of 
  the 
  institution. 
  
 
  
20. 
  Review 
  of 
  In 
  Custody 
  Deaths 
  
 
  
Documentation 
  provided 
  regarding 
  in 
  custody 
  deaths 
  does 
  not 
  meet 
  compliance 
  
with 
  the 
  NCCHC 
  standard 
  regarding 
  timely 
  review. 
   
  The 
  department 
  should 
  
prioritize 
  implementing 
  standardized 
  death 
  reviews 
  as 
  described 
  by 
  the 
  NCCHC 
  Jail 
  
Standards 
  within 
  30 
  days 
  of 
  the 
  death 
  and 
  keep 
  careful 
  records 
  of 
  those 
  reviews 
  in 
  
order 
  to 
  identify 
  and 
  remedy 
  preventable 
  causes 
  of 
  death. 
  
 
  
 
  
 
  
 
  
 
  
The 
  Issue 
  of 
  Correctional 
  Health 
  Care 
  Cost 
  
 
  
As 
  the 
  history 
  of 
  trouble 
  with 
  detention 
  health 
  services 
  in 
  Riverside 
  County 
  is 
  
largely 
  as 
  story 
  about 
  poorly 
  conceived 
  directives 
  to 
  control 
  the 
  cost 
  and 
  the 
  
disproportionate 
  budget 
  impact 
  of 
  detention 
  health, 
  it 
  is 
  important 
  to 
  consider 
  the 
  
broader 
  issue 
  of 
  rising 
  health 
  care 
  cost 
  and 
  the 
  impact 
  of 
  those 
  rising 
  costs 
  on 
  
correctional 
  health 
  settings. 
   
   
  
 
  
For 
  much 
  of 
  the 
  past 
  decade, 
  all 
  health 
  care 
  costs 
  in 
  the 
  U.S. 
  (in 
  the 
  community 
  and 
  
in 
  corrections) 
  have 
  been 
  rising 
  for 
  a 
  variety 
  of 
  reasons. 
   
  Costs 
  for 
  physician 
  
services, 
  hospitalization 
  and 
  drugs 
  have 
  all 
  gone 
  up. 
   
  Corrections 
  has 
  felt 
  these 
  
increases 
  more 
  acutely 
  in 
  part 
  because 
  the 
  correctional 
  populations 
  concentrate 
  
individuals 
  requiring 
  high 
  cost 
  care, 
  including 
  those 
  with 
  mental 
  illness, 
  HIV 
  and 
  
hepatitis 
  C 
  (all 
  of 
  which 
  have 
  extremely 
  high 
  drug 
  costs) 
  as 
  well 
  as 
  many 
  other 
  
chronic 
  health 
  conditions 
  including 
  aging 
  populations. 
  
 
  
According 
  to 
  publically 
  available 
  FY2014/2015 
  budget 
  figures, 
  the 
  most 
  recent 
  
annual 
  expenditures 
  for 
  detention 
  health 
  services 
  by 
  Riverside 
  County 
  were 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

29 
  

$19,488,022.4 
   
  For 
  an 
  average 
  daily 
  population 
  of 
  roughly 
  3800 
  adults, 
  this 
  
translates 
  roughly 
  to 
  an 
  annualized 
  per 
  inmate 
  health 
  cost 
  of 
  $5000. 
   
  To 
  put 
  that 
  in 
  
some 
  perspective, 
  the 
  average 
  annual 
  per 
  inmate 
  cost 
  of 
  heath 
  care 
  for 
  inmates 
  in 
  
2011 
  nationwide 
  was 
  $6047 
  per 
  inmate 
  per 
  year.5 
   
   
  
 
  
In 
  the 
  California 
  state 
  correctional 
  system, 
  the 
  cost 
  per 
  inmate 
  has 
  now 
  risen 
  to 
  
roughly 
  $18,000 
  per 
  inmate 
  per 
  year. 
   
  It 
  was 
  $7747 
  in 
  2005, 
  prior 
  to 
  the 
  Federal 
  
Receivership.6 
   
  (Per 
  inmate 
  health 
  spending 
  is 
  prisons 
  is 
  generally 
  somewhat 
  higher 
  
than 
  for 
  jails, 
  but 
  accurate 
  jail 
  data 
  is 
  hard 
  to 
  come 
  by 
  so 
  this 
  is 
  still 
  the 
  best 
  
reference 
  point.) 
   
   
  
 
  
The 
  rising 
  costs 
  of 
  incarceration 
  in 
  general, 
  and 
  the 
  cost 
  of 
  providing 
  health 
  care 
  to 
  
those 
  incarcerated, 
  is 
  a 
  growing 
  cause 
  for 
  concern 
  across 
  the 
  nation. 
   
  Efforts 
  to 
  
contain 
  health 
  costs 
  through 
  improved 
  efficiency 
  of 
  detention 
  health 
  operations 
  are 
  
essential, 
  but 
  even 
  with 
  those 
  efforts, 
  the 
  costs 
  of 
  incarceration 
  will 
  remain 
  high. 
  
 
  
Under 
  the 
  Affordable 
  Care 
  Act, 
  some 
  believe 
  there 
  may 
  be 
  new 
  opportunities 
  in 
  
correctional 
  settings 
  recouping 
  some 
  health 
  costs 
  in 
  new 
  ways, 
  but 
  those 
  
mechanisms 
  remain 
  unclear 
  and 
  unproven 
  and 
  in 
  the 
  near 
  term, 
  they 
  cannot 
  be 
  
relied 
  upon. 
  
 
  
It 
  is 
  important 
  to 
  understand 
  that 
  the 
  two 
  factors 
  driving 
  detention 
  health 
  costs 
  
most 
  are 
  1) 
  the 
  rising 
  number 
  of 
  individuals 
  who 
  are 
  incarcerated 
  and 
  2) 
  the 
  rising 
  
cost 
  of 
  health 
  care 
  everywhere. 
   
  The 
  Riverside 
  County 
  Correctional 
  Health 
  Services 
  
has 
  no 
  control 
  over 
  either 
  of 
  these 
  factors. 
  
 
  
There 
  is 
  a 
  growing 
  consensus 
  nationally 
  that 
  the 
  only 
  way 
  to 
  bring 
  down 
  costs 
  of 
  
incarceration 
  is 
  to 
  reduce 
  our 
  dependence 
  on 
  incarceration. 
   
  While 
  the 
  practicality 
  
of 
  that 
  option 
  is 
  beyond 
  the 
  scope 
  of 
  this 
  report, 
  it 
  is 
  important 
  to 
  note 
  that 
  there 
  
are 
  medically 
  based 
  alternatives 
  to 
  incarceration 
  including 
  community 
  based 
  
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  
4 
  County 
  of 
  Riverside 
  2014/2015 
  Recommended 
  Budget. 
   
  Available 
  at: 
  
http://countyofriverside.us/Portals/0/Government/Budget%20Information/2014-­‐
2015%20Recommended%20Budget/BudgetDetail.pdf 
  
 
  
5 
  Pew 
  Charitable 
  Trusts/ 
  MacArthur 
  Foundation. 
   
  State 
  Prison 
  Health 
  Care 
  Spending. 
  
July 
  2014. 
   
  Available 
  at: 
  
http://www.pewtrusts.org/~/media/Assets/2014/07/StatePrisonHealthCareSpen
dingReport.pdf 
  
 
  
6 
  Prison 
  Legal 
  News. 
   
  California 
  Prison 
  Healthcare 
  Costs 
  Soar 
  Under 
  Federal 
  
Receiver. 
   
  October 
  10, 
  2014. 
   
  Available 
  at: 
  
https://www.prisonlegalnews.org/news/2014/oct/10/california-­‐prison-­‐
healthcare-­‐costs-­‐soar-­‐under-­‐federal-­‐receiver/ 
  
 
  

 Review of Medical Care – Riverside County Jails, July 15, 2015 – S. Allen, MD

30 
  

treatment 
  for 
  mental 
  illness 
  and 
  addiction 
  that 
  have 
  been 
  used 
  successfully 
  to 
  divert 
  
appropriate 
  individuals 
  and 
  to 
  reduce 
  recidivism. 
  
 
  
What 
  is 
  within 
  the 
  scope 
  of 
  this 
  report 
  to 
  this 
  report 
  is 
  the 
  fact 
  that 
  while 
  rising 
  jail 
  
health 
  care 
  costs 
  are 
  a 
  compelling 
  and 
  important 
  fiscal 
  issue 
  with 
  profound 
  
implications 
  for 
  other 
  public 
  programs, 
  cost 
  alone 
  can 
  never 
  be 
  used 
  to 
  justify 
  
cutting 
  health 
  care 
  services 
  to 
  inmates 
  below 
  the 
  minimally 
  accepted 
  constitutional 
  
or 
  statutory 
  levels. 
  
 
  
Conclusion 
  
 
  
As 
  a 
  direct 
  result 
  of 
  drastic 
  budget 
  cuts 
  to 
  the 
  medical 
  program 
  in 
  the 
  Riverside 
  
County 
  Jails 
  over 
  five 
  years 
  ago, 
  medical 
  services 
  were 
  severely 
  adversely 
  impacted. 
   
  
In 
  spite 
  of 
  very 
  recent 
  and 
  significant 
  efforts, 
  at 
  this 
  time, 
  medical 
  care 
  at 
  the 
  
Riverside 
  County 
  Jails 
  does 
  not, 
  in 
  the 
  opinion 
  of 
  this 
  expert, 
  meet 
  minimal 
  
constitutional 
  standards 
  and 
  poses 
  a 
  significant 
  risk 
  of 
  serious 
  harm 
  to 
  inmates 
  
confined 
  to 
  jail. 
  
 
  
In 
  my 
  opinion, 
  the 
  plan 
  for 
  reconstituting 
  a 
  functional 
  and 
  minimally 
  acceptable 
  
health 
  care 
  program 
  outlined 
  to 
  me 
  by 
  the 
  County 
  Correctional 
  Health 
  Services 
  
leadership 
  is 
  well 
  thought 
  out 
  and 
  promising. 
   
  That 
  plan 
  deserves 
  the 
  full 
  support 
  of 
  
the 
  County 
  with 
  appropriate 
  dedicated 
  funding 
  as 
  required. 
   
   
  
 
  
Given 
  the 
  history 
  and 
  record 
  of 
  the 
  County 
  in 
  voluntarily 
  meeting 
  its 
  constitutional 
  
obligations 
  to 
  jail 
  inmates 
  in 
  the 
  area 
  of 
  healthcare, 
  I 
  recommend 
  that 
  any 
  consent 
  
agreement 
  include 
  ongoing 
  monitoring 
  and 
  mechanisms 
  for 
  enforcement 
  of 
  such 
  an 
  
agreement 
  in 
  order 
  to 
  ensure 
  the 
  County 
  does 
  not 
  waiver 
  in 
  or 
  abandon 
  its 
  current 
  
commitment 
  to 
  establishing 
  and 
  maintaining 
  constitutionally 
  defensible 
  medical 
  
care 
  for 
  the 
  individuals 
  it 
  detains. 
  
 
  
This 
  revision 
  or 
  the 
  initial 
  draft 
  report, 
  now 
  final 
  with 
  the 
  exception 
  noted 
  below, 
  
respectfully 
  submitted 
  to 
  Counsel 
  for 
  the 
  County 
  of 
  Riverside 
  and 
  the 
  Counsel 
  for 
  
the 
  Plaintiffs 
  in 
  the 
  matter 
  of 
  Gray 
  v. 
  County 
  of 
  Riverside 
  on 
  July 
  15, 
  2015. 
  
 
  
 
  
 
  
 
  
Scott 
  A. 
  Allen, 
  MD 
  
 
  
 
  
Note: 
   
  This 
  draft 
  submitted 
  is 
  missing 
  analysis 
  of 
  medication 
  administration 
  
practices 
  and 
  issues 
  relating 
  to 
  identifying 
  medication 
  interactions 
  between 
  medical 
  
and 
  psychiatry 
  as 
  that 
  analysis, 
  which 
  requires 
  coordination 
  between 
  myself 
  and 
  Dr. 
  
Gage, 
  has 
  not 
  been 
  completed 
  at 
  the 
  time 
  of 
  the 
  submission 
  of 
  this 
  report.