Joe's Jail health care audit: Arpaio still fails.

Many thanks to the AZ Republic for this report... Maybe if that $100 million of inmate programs' funds that Arpaio "misspent" had gone into improving services all along, some of the folks who have died there would have made it.

tent city, phoenix (April 5, 2011)

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County's jails still falling short on health care, audit finds
Millions already spent improving inmate services

by JJ Hensley and Yvonne Wingett Sanchez - Aug. 20, 2011 12:00 AM
The Arizona Republic

Despite spending millions of dollars trying to rectify long-recognized problems, Maricopa County still falls short of its constitutionally mandated obligation to provide adequate health care to jail inmates, a court-appointed expert says.

Her report, filed earlier this month as part of a long-standing lawsuit over jail conditions, is a setback for the county Board of Supervisors and the Sheriff's Office. For years, they have pledged to improve a taxpayer-funded health-care system used in county jails, where about 7,500 inmates are housed.

For years, the county has paid millions of dollars in legal fees, settlements and jury verdicts to inmates and their families for death and injury claims.

With a budget of $55 million, the county's Correctional Health Services oversees the delivery of care to inmates housed in the county's five jails and Tent City.

Jail-reform advocates first sued the county in 1977 to force changes, claiming inmates received substandard care. The court in 1981 issued guidelines for the county to follow, and the court has revisited the matter several times.

The 33-page audit by Kathryn Burns concluded that although the CHS has made substantial advances in a number of areas, serious issues persist, particularly within the Mental Health Unit through which thousands of inmates move annually.

An estimated one-third of inmates are on psychotropic medications, which treat mental disorders, said Dawn Noggle, CHS director of mental health.

The county received positive marks for its investments and improvements in staff training, inmate-health assessments and follow-up appointments.

It has increased the number of mental-health employees at Fourth Avenue Jail. Portions of health screenings during bookings are now electronic to better manage patient information. More group treatment is offered.

However, the audit also found continuing problems with inadequate or incomplete admission assessments on medical charts; premature inmate releases from treatment; discharges of detainees without discussion among staff; lack of continuity of care with outpatient providers; and inconsistent and poor quality of treatment within the Mental Health Unit.

In another related audit, a separate court-appointed expert recently reviewed the CHS' medical services.

Lambert King's 34-page audit cited similar improvements and deficiencies, indicated the agency is understaffed and said that technical problems pose a "significant setback" in implementing a long-awaited electronic-records system to better track patient care.

The system is now "indefinitely delayed" because the county needs time to solve the technical problems involving integration of two separate technologies.

Some of those same problems were cited as reasons for the CHS' loss of accreditation in 2008, and a few even were noted as far back as 1977, when the lawsuit was first filed.

Experts say the loss of accreditation makes Maricopa County vulnerable in its defense of legal claims by current and former inmates and their families.

The accreditation comes from the National Commission on Correctional Health Care, an independent agency that assesses medical and mental-health care in jails and prisons.
Shield against suits

That accreditation gives jails and prisons a national seal of approval that can help defend them against lawsuits over inadequate care.

Noggle acknowledged that problems persist but said correctional-health staffers are "making good progress" in screening detainees for health problems.

But the strengthened screening, she said, has led to a rise in the number of inmates deemed mentally ill, and that has increased demand on staff and resources. Noggle said the Mental Health Unit now admits 200 to 300 inmates a month.

"When you think about what we're doing on a daily basis, it's extraordinary," Noggle said. "We still have a ways to go, there's no doubt about it. It is an enormous challenge."

Burns' audit noted certain cases to highlight problems within the system. For example, it cited:

- Inadequate screening. An inmate previously had been booked into county jail nine times, and his records contained notes about his suicidal tendencies. The report alleges that staff did not notice those notes when the man was booked again last October. He committed suicide in jail in early December.

- Questionable treatment of inmates withdrawing from drugs and alcohol.

One Friday night last April, a pregnant woman who later tested positive for methamphetamine was booked into jail. Two days later, she demanded to go to the hospital. A nurse ordered Tylenol and sent the woman back to her housing unit. She gave birth to a baby boy in a bathroom of the Estrella Jail.

An inmate in the woman's housing unit said the woman "was in labor for several hours, but detention staff attributed her behavior to withdrawal and/or minimized her pain and discomfort and did not call or send her to medical (care) promptly."

Another inmate wrote that the woman was "in extreme pain and howling in the bathroom but not checked by detention staff."

- Unsanitary conditions. Despite periodic cleaning, cells in the Mental Health Unit had "floors, walls and windows appear grimy and stained with what appears to be dirt, feces and/or blood in some instances."

One mentally ill inmate refused to leave his cell for weeks. "When taken out for emergency treatment, his hair and feet were described as being matted with feces."

Members of the Board of Supervisors, ultimately charged with overseeing health care for inmates, said they were unaware of Burns' findings until contacted by a reporter. Staffers said they likely will be briefed on it next week.

Jim Bloom, chief of staff for Supervisor Andy Kunasek, concluded after reading the audit: "I think it's not so bad. In the past, I think we probably had a D. This report, I think, gets us closer to a C+ or a B-. We certainly have a ways to go, but we're committed to going there."

An Arizona Republic series in 2008 found the Board of Supervisors had failed to adequately respond to problems in the jail system despite having been told time and again through court documents, consultant reports and interviews that the CHS was providing inadequate care.

The CHS lost its accreditation as a result of the problems, and the county has paid millions of dollars in legal fees, settlements and jury verdicts to inmates and their families for death and injury claims against the county.

Burns' report was filed as part of the county's ongoing effort to get the Sheriff's Office and CHS out from under court-ordered oversight that began in 2008 after Judge Neil Wake ruled that conditions in the jails violated constitutional protections.

Since then, county lawyers and attorneys for the plaintiffs, who are affiliated with the American Civil Liberties Union's National Prison Project, have tried to develop a plan that would allow the jails to comply with Wake's ruling without the ongoing oversight.

Burns' audit tour was the first since that plan was put in place, and it was intended to gauge how far along the jails were on the path to compliance, said Eric Balaban, an attorney with the National Prison Project.

The plaintiffs' attorneys weren't expecting wholesale changes to be reflected in the jail system immediately, but they were hoping for fewer references to the same problems that have plagued the jails for decades, Balaban said.

"It's not unusual to take years to turn around a system that was essentially non-existent (at the time of Wake's ruling)," he said.

"We're concerned overall with the provision of health care. We're not going to get into ascribing bad motives to anyone involved here. We will continue to push the defendants as quickly as we possibly can to reach compliance with those markers."

The challenges are significant, Noggle said.

Budget-cutting at all levels of government has affected the CHS' funding.

Still, Noggle said, the CHS within the past year has added nine mental-health professionals, a mental-health supervisor, several psychiatric providers, two psychiatric nurses and six administrative workers dedicated to mental health.

And even as the county's jail population has declined in recent years, the number of inmates who are mentally ill or experiencing substance-abuse problems has increased, she said.

Many of those inmates have never, or only intermittently, sought medical help, making it more difficult to diagnose and treat them.

Dr. Jeffrey Metzner, a Colorado psychiatrist who evaluates mental-health systems across the nation, said local jails have become de facto mental-treatment centers.

"The number of mentally ill in jails has skyrocketed . . . and the courts have made it very clear that if you're going to incarcerate people, you've got to provide the treatment," he said.

RULE 11: Maricopa County, AZ Legislature, and Competency.

An informative - and troubling - reprint from the Winter 2007 journal issue of "CorrectCare," by the National Commission on Correctional Health Care. People should not be so brutalized for having a mental illness and being too poor to bond out to see a private shrink. We're far too casual about stealing chunks of people's lives like that - it's as if we assume that because they're mentally ill and/or poor their time is of no value to them, their community, or their families anyway - as if their lives have no value, essentially.

THAT's criminal.

This article came out three years ago, by the way - before the county jails lost their health care accreditation. And we know that mental health services in this state just took a huge hit. What a bunch of short-sighted, self-interested idiots we have in the legislature, "saving" our money by selling both our public property and our people's welfare to the highest bidder.

Expect the jails and prisons to swell even more folks - we're going to pay a hell of a lot more to store people there than we would have to treat them in the community or hospital and assure that they have housing (one big reason people are arrested for trespassing is lack of their own home and bathroom).

So much for our government's commitment to keeping us "safe" - it's the Arizona state government we're most endangered by now. Perhaps some of them should be detained for competency hearings...I have an idea of who to start with.

Those of you who have more recent experience with Rule 11, please contact us so we can make sure others are informed on current conditions.

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Restoring Competency: One County’s Solution
By Lindy Funkhouser, JD

In the spring of 2003, Ruben D.* appeared in a Maricopa County Superior Court room. Ruben was chronically mentally ill. His illness got particularly bad one day, leading to an arrest for disorderly conduct and trespassing. Ruben couldn’t make the $300 bail so he had to remain in jail until the court disposed of his charges.

On this day, after Ruben had spent about 60 days in jail, he and 15 other inmates were pulled from their cells to attend 2 ½ hours of a court calendar for defendants with “legal competency” issues. Some months ago, Ruben’s attorney had asked the court to evaluate his ability to understand his charges and to assist in his defense. In Arizona this is called a Rule 11 evaluation, for the Arizona Criminal Rule of Court that governs competency determinations.

In the Maricopa County justice system, Rule 11 was so well-known that it became a colloquial expression, as in “My attorney said I should go Rule 11 to see if it can get me off [criminal charges].” Unfortunately, Rule 11 was not a promising environment for Ruben or anyone else unlucky or gullible enough to be there. Think of George Orwell’s “1984” or Lewis Carroll’s “Alice in Wonderland.”

You see, Ruben’s attorney triggered a cumbersome and lengthy evaluation process. Ruben had to wait in jail for a court-appointed expert to prescreen him and determine whether he was appropriate for an evaluation. In other words, Ruben had to wait for an evaluation of competency to determine whether he needed an evaluation for competency. Chalk up at least 7 to 10 days for the prescreen evaluation.

As in about 75 percent of all referrals, the prescreen evaluation showed that Ruben needed to be evaluated for competency. This meant that Ruben had to wait for the court to schedule a status conference and appoint a psychiatrist and psychologist to perform a full Rule 11 evaluation. At that time in Maricopa County, the evaluators were contract providers who would arrange to meet with Ruben, review his records and write a recommendation to the court. Add another 60 to 90 days for the recommendation to land on the court’s desk.

Three Possible Findings
A competency evaluation typically leads to one of the following three recommendations:

1. Competent. This finding would mean Ruben was capable of understanding his charges. The court would assign his cases back to a trial judge without any further evaluation.

2. Incompetent/restorable. This finding would mean that although Ruben was not capable of understanding his charges, his condition was treatable. In the spring of 2003, this would mean committing him for treatment at the Arizona State Hospital.

3. Incompetent/not restorable. This finding would mean that Ruben was not capable of understanding his charges and that he could not be treated or “restored” to competency.

The evaluators in Ruben’s case picked not one but two of the recommendations; one said he was incompetent/not restorable and the other said he was incompetent/restorable. This meant that Ruben had to wait for a third evaluation, a tiebreaker. This drastically delayed Ruben’s case, adding about 45 to 60 days to his stay in the jail.

By this time, Ruben had waited in line for the court to consider the prescreen report, appoint the initial evaluators and then appoint a third evaluator. In all, Ruben had to wait six months before the court could determine whether he needed competency restoration treatment. Already, Ruben’s incarceration was longer than his likely sentence for disorderly conduct and trespassing.

The tiebreaker evaluation found Ruben was incompetent but restorable. The court promptly committed Ruben to be treated at the Arizona State Hospital.

But Ruben would not be treated soon. His name was placed on a list of 50 inmates who were waiting for an open bed to commence treatment at the hospital. This meant Ruben would likely wait another 60 to 90 days.

State Hospital was no picnic for mentally ill patients like Ruben. The hospital did not classify or restrict mobility of inmates based on their dangerousness or the nature of their charges. Ruben would be placed in the same dormitory setting as dangerous inmates who had skillfully faked a mental illness to avoid trial and sentencing. These patients occasionally attacked and injured other inmates and hospital staff.

Treatment at State Hospital was expensive. The average cost to restore a Maricopa County inmate was about $30,000. Multiply that cost by 250 inmates for the fiscal year and the full cost for Maricopa County restorations was $7,500,000.

The county had been relatively indifferent to this cost because the state paid half of the bill. But the 2003 legislature decided to eliminate the subsidy to make up for shortfalls in the state budget. In the 2004 fiscal year, Maricopa County projected that 300 inmates would need restoration services. This demand, coupled with elimination of the state’s subsidy, threatened to increase Maricopa County’s costs by $5,750,000.

Exploring the Concepts
Many excellent articles and legal opinions have explored and debated the concepts involved in legal competency. The authorities generally agree that legal competency concerns certain fundamental rights in the United States judicial system. For example, a defendant accused of crime is entitled to competent counsel under the Sixth Amendment to the Constitution. This right to effective assistance of counsel means very little if the defendant is mentally incapable of using that counsel in the criminal case. Also, the Sixth Amendment provides that a defendant is entitled to know the nature of her charges. This right is meaningless if the defendant is mentally incapable of understanding her charges.

The Sixth Amendment also guarantees the accused the right to a speedy and public trial. This typically means that the court must meet legal deadlines to resolve the criminal trial as expeditiously as possible.

But speedy trial rules do not apply to a competency determination. So unless the courts and policy makers address competency in a timely manner, incompetent jail inmates will be effectively disenfranchised. Justice will be denied for the inmate who, like Ruben, is charged with a minor offense, needs mental health treatment and is unable to advocate for better treatment. All of this would happen for the cause of protecting Ruben’s constitutional rights. In such cases, justice resembles “Alice in Wonderland” and courts do not like it.

Award-Winning Solution
The Maricopa County Board of Supervisors addressed the problem on June 15, 2003, and provided funds to restore inmates in the county jails. County staff established a forensic team within the Department of Correctional Health Services (CHS) composed of a psychiatrist, psychologist and three masters-level social workers.

The county developed working relationships with the county sheriff, superior court and public defenders. The presiding judge of the Superior Court authorized CHS to restore inmates on the State Hospital waiting list and worked with CHS to change court forms.

CHS implemented the Restoration to Competency (RTC) program on August 15, 2003, less than 60 days after funding by the Board of Supervisors. Social workers contacted each inmate, performed a psychosocial workup and administered a preliminary competency examination. A psychologist met each inmate and evaluated the inmate’s condition. The program employed standardized tests to identify the inmates’ cognitive deficits and strengths. The team used this information to develop a restoration plan tailored to each inmate’s needs.

In the early months of the program, the forensic team used jail staff psychiatrists to prescribe medications. The forensic team met weekly to review and discuss all the cases, assess each inmate’s progress and make adjustments to the restoration plan. By October, staff began attending all court competency proceedings to keep court communication at maximum levels. This process kept the staff up-to-date on all time-sensitive matters.

By late November, the program hired a psychiatrist and added a psychologist and three masters-level social workers to increase the program’s capacity.

By December, the program had diverted 63 cases from the hospital, saving the county more than $2,000,000. The waiting list shrank from 67 inmates in November 2003 to 38 in January 2004. Waiting time for treatment decreased from 90 days to less than 60 days.

By July 2004, Maricopa County assumed virtually all restoration cases and brought all restoration costs under budget, including costs of State Hospital admissions. The Maricopa County RTC program received a National Association of Counties 2004 Achievement Award “in recognition of an innovative program which contributes to and enhances county government in the United States.”

The Maricopa County RTC experience suggests that an organization can adopt innovative solutions to manage and control its costs. Providing services in the jail allowed the county to implement management strategies that improved timeliness and effectiveness of the services. It proved that customized services for the mentally ill could be cost-effective.

In the meantime, the rights of inmates, like Ruben, are better aligned with the spirit of the law.

* This person is fictional.

— About the author: Lindy Funkhouser, JD, is the director of Maricopa County Correctional Health Services, Phoenix, AZ.

[This article first appeared in the Winter 2007 issue of CorrectCare.]

ARPAIO's Jail Health Care Crisis Continues.

In Arpaio's Jails, the Most Basic Healthcare is No Better Despite Years of Lawsuits and Investigations

by Lauren Gilger  

Phoenix New Times

Thursday, Apr 15 2010

When Bertha Oropeza was arrested last summer for marijuana possession, she didn't expect it to nearly cost her life.

But after 10 hours in Maricopa County's Fourth Avenue jail, Oropeza was unconscious, in cardiogenic shock with acute kidney failure at Good Samaritan Hospital. Meanwhile, no one at the jail could tell her family where she was. "She's been released" was their refrain.

Oropeza, 45, had been straightforward with jail personnel about needing medication, which is reflected in jail and hospital records, as well as in Oropeza's recollection.

When she was arrested, she tells New Times, she clearly remembers telling the officer who took her purse that she would need to take her pills again in an hour.

He told her to wait until she got to the jail.

As Maricopa County Sheriff Joe Arpaio's guards took her through the intake process "they asked me when I last took it, and I told them," Oropeza says. "I'm thinking, 'Okay, they're gonna give me my medication.'"

They didn't, so she tried again, telling the guard checking her into the jail that she needed her pills.
"Well, you don't need them right now," he told her. "It's your own fault. What do you think this is, a hospital?"

Oropeza's medical history is summarized in Good Samaritan Hospital records, released by Oropeza to New Times: She was in a car accident in west Phoenix in 2005 that left her disabled and with chronic back and leg pain.

Oropeza says she spent a month in a coma and five months in the hospital after she was thrown from the passenger's side of a car. Her hip "came completely out of socket," she says, and she suffered extensive head trauma after hitting the pavement.

She regularly takes the painkillers morphine and oxycodone as well as the muscle relaxant carisoprodal, according to hospital records.

Jail employees definitely knew about her condition, county records show. At 9:49 a.m. — about the time Oropeza was booked into the jail — a note was entered in her file recording that she was on medication for chronic pain in her legs and back due to a car accident.

Still, she didn't get help.

Oropeza knew what would happen next: The pain in her legs would come back, her stomach would reject anything in it, her muscles would seize up, and her lungs would tighten.

"If I don't take my medication, then I get a withdrawal right away," she says.

She had no power to stop it from coming. It did.

In the first holding cell, waiting to be fingerprinted, Oropeza asked for a bag to throw up in. A guard handed her one.

She sat on the concrete floor in the corner of the cell, vomiting into the bag until it was full, unable to move as the pain in her legs crept back and the painkillers wore off.

When she asked for a second bag, a guard told her to use the trash can on the other side of the cell. But she couldn't get up to walk over to it.

"Just don't throw up on the floor," he told her.

She was struggling to breathe and still throwing up when another woman in the cell began to kick the door to get the guard's attention. Oropeza, afraid of angering the guard, begged her not to.
"No," the woman said. "You need help. You need help now."

When the guard finally came, he walked Oropeza down a long hall and told another guard on duty there to "take her down to medical," Oropeza remembers.

Standing at the end of the hall with the new guard, Oropeza felt increasingly dizzy. She grabbed a nearby chair because she felt like she was going to faint.

"Don't touch that chair," the guard yelled.

"You don't need nothing to hold on to. You just stand there," Oropeza remembers him saying.
She asked him whether she could hold onto the wall. He told her no.

"All you're doing is putting on a show to get out of here. We get it all the time," he said.

When he took her out of the hallway, it was to yet another cell — this one right outside the medical unit, where she could see the nurses through a window.

Oropeza begged the nurses for help, miming that she couldn't breathe. She says Arpaio's guard just laughed at her. The nurses didn't come.

By about 1:30 p.m., after at least three hours of vomiting and dry heaving in a cement jail cell, Arpaio's guards finally turned her over to Correctional Health Services, the medical unit of the jail, according to records.

She was handcuffed to a gurney. When she complained of being cold, "they threw paper over me," she says.

At a few minutes before 7 p.m. on June 2, CHS staff called an ambulance to come for Bertha Oropeza. It arrived at 7:30 p.m., according to records, a full six hours after she had entered the medical unit...

--------------------------finish article at PNT: worth it -----------------------