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Joe Goldenson, M.D.
1406 Cypress Street
Berkeley, CA 94703

(510) 524-3102
F~(510)52a.s134

jgoldenson@Sfgh.org

January 26, 2008

The Honorable J. Kelly Arnold
United States Magistrate Judge
U.s. Court House
1717 Pacific Avenue
Tacoma, WA 98402
Dear Judge Arnold:
Jo Robinson, a mental health expert, and I visited the Pierce County Detention
Center on November 15-16,2007, in order to evaluate the medical and mental
health services. Following completion of a draft of our report, we sent it to the
medical and mental health administration at the Detention Center for their review
and comments. After receiving their response, we have had several subsequent
conversations with them. Attached please find the final version of my report that
has incorporated their concerns and suggestions.
Please distribute copies of the report to the parties.
Please contact me if you have any further questions.
Sincerely,
/"

.--~~~[!<---?
('-

111111111111111111111111111111111111111111111
11111111111111111111111111111111111

\Joe Goldenson, MD

95-CV-05025-RPT

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PIERCE COUNTY
DETENTION & CORRECTIONS CENTER
HEALTH SERVICES

Sandra Herrera, et al v. Pierce County, et al
United States District Court
Western District of Washington
Case No. C9S-S02SFDB

REPORT OF FINDINGS
Submitted by: Joe Goldenson, MD
January 26, 2008

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This is the first progress report of Court Monitor Joe Goldenson, MD, on the status of
health care services at the Pierce County Detention & Corrections Center (PCDC) in
Tacoma, Washington. Jo Robinson, MFT, assisted in the evaluation of the mental health
services. In preparation for this report, we reviewed reports from Steve Shelton, MD, the
prior Court Monitor, the staffing report from Kathryn Knox, RN, the September 1997
report from Bonnie Norman, RN, the Health Services Policy and Procedure Manual, and the
Nursing Guidelines and Protocols. Ms. Robinson and I visited PCDCC on November 15 and
16, 2007. We toured the facility, reviewed medical records, and interviewed health care
and custody staff.
The audit conducted during our first visit was not comprehensive. We primarily focused
on those administrative and programmatic issues that Dr. Shelton had noted as needing
improvement. We did not have the opportunity to fully evaluate the quality of the clinical
care. We will look at this area during future visits through a more extensive review of
medical records.
As noted in Dr. Shelton's 2005 report, many of the concerns raised by the Court in the
stipulations have been adequately addressed. These include housing, administrative and
medical leadership, mental health housing, availability of over the counter medications,
and identification of a referral hospital. In addition, PCDC has finalized the development
of an appropriate set of policies and procedures that are based on the standards of the
National Commission on Correctional Health Care. Some of these policies and procedures
will need to be revised (as discussed below) to either reflect current PCDC practice or to
address deficiencies.
!
Dr. Shelton also rioted that PCDC "has expressed a desire to use the National Commission
on Correctional Health Care (NCCHC) Standards as their guidelines and final goalpost for
their health care system." We agree that while the standards are not in and of themselves
proof of an adequate health care system, they do represent a "well thought out and
systematic approach to the difficulties of providing a quality system of health care in
corrections, and have consistently shown a high level of concern for inmate welfare." For
these reasons, this and future reports will follow the outline of the NCCHC standards, and
will comment on progress towards meeting the standards. Compliance with the standards
does not guarantee, however, that the clinical care being provided at a facility is adequate.
As indicated above, future reports will also evaluate the quality of care based upon a
clinical review of selected medical records.
Prior to submitting this report to the Court, we sent a draft copy to the health care staff at
PCDC for their review and comments. We have incorporated many of their suggestions
into this final report.
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We would like to express our gratitude to all the staff (health care and corrections) that
graciously assisted us throughout our stay and answered our never-ending questions.
They were completely cooperative with our requests, including a large list of documents
we had asked for, and we would like to express our appreciation for their support of our
monitoring effort. Without their help and cooperation, our task would have been
unachievable.
REPORT
The population of the jail was 1,458 on November 15, 2007. There were 655 inmates in the
main facility and 803 in the new facility. There are approximately 75 to 80 new bookings
per day.
Central Health Services Area
The clinic on the third floor of the main jail is clean, well equipped and lighted, and
provides an appropriate environment in which to evaluate patients. The original design
did not allocate sufficient space for administrative offices. Staff has addressed this
deficiency by converting some of the cells into office space. This appears to have been a
successful solution to the problem.
Clinics in the New Tail
The clinics in the housing areas of the new jail are small and do not have medical
equipment. When nurses evaluate or treat patients they must bring their equipment and
supplies with them. Patients who require a more comprehensive examination or who need
to be seen by a practitioner must be transported to the clinic in the main jail.
Medical and Mental Health Infirmary/Sheltered Living Level Housing
The cells in the health services area of the main jail that are designated to be medical and
mental health beds are not being utilized due to a lack of necessary custody and nursing
positions. The exceptions to this are: (1) patients who are being evaluated for suspected
tuberculosis disease are occasionally housed in the negative pressure airborne isolation
rooms; and (2) patients who require a higher level of medical care than is available in
general population are sometimes housed in the medical beds. In those cases, custody and
medical staff is increased in the clinic area. In addition, such patients can be admitted to
the hospital for care or sent to another facility that has an infirmary.
PCDC has stated that it will develop a policy and procedure for the use of the medical
rooms. In addition, it will begin tracking the number and reason that patients are put into
the airborne isolation, infirmary, and sheltered living rooms. We also recommend that
PCDC conduct a survey of incoming and long-term inmates to determine the number who
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would benefit from sheltered living or infirmary housing, such as high risk diabetic,
cardiac, or asthmatic patients, high risk pregnant women, post-operative patients, and
patients requiring observation. During future visits, we will examine this issue more fully.
Access to Care
An inmate can access routine health care services by submitting a kite to the medical staff.
The same forms as are used for these kites as are used for all other types of kites. The
inmate then places the kite in a locked box that is only for health care services. Nursing
staff picks up the kites at night and sorts and reviews them. Patients with medically
related complaints (approximately 70 to 80 per jail per day) are then referred to the triage
nurse the next morning. There are two triage nurses positions assigned to each of the
facilities.
However, one of the positions in the main jail has been vacant since last March. In
addition, there is no coverage when one of the triage nurses is sick or on vacation or
education leave. Mary Scott, RN, the Nursing Supervisor, stated that during times of high
absenteeism, this level of staffing was almost "disabling." On November 15, there was
only one triage nurse on duty for both facilities and on November 16, there was only one
on duty in each facility. (One of the triage nurses informed us that he could usually
evaluate 20 to 25 patients per day). Furthermore, the triage nurses only work five days
per week. On weekends, the medical kites from the main jail are reviewed by a nurse in
the clinic and those from the new jail are reviewed by the nurse at intake. Patients with
"urgent" complaints are to be seen over the weekend. Those with "non-urgent" complaints
are deferred until Monday. Many inmates, however, are medically unsophisticated and
have poor writing skills, and therefore, the kites may not accurately reflect the urgency of
their medical problems. In many cases, such as patients complaining of headaches or
abdominal pain, more information than is written on the request is required before the
immediacy of need can be determined. A nurse needs to interview such inmates in order
to determine the urgency of their problem. Given the responsibilities of the booking and
clinic nurse, it is not clear that they have enough time to adequately screen the medical
kites on the weekends. PCDC should conduct a quality improvement study to evaluate
the process by which inmates access care. This is also an area that we will review during
future visits.
After evaluating the patient, the triage nurses can address minor medical complaints
through the use of protocols, consult with Dr. Balderrama, the Medical Director, or one of
the Physician Assistants, or refer the patient to the medical clinic in the main jail for
further evaluation and care. In his final report, Dr. Shelton recommended that PCDC
implement a well prepared training program for the nurses on triaging, "including
history, exam, findings and what is urgent, what is routine, what can be handled by self
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care methods." While the triage nurses currently undergo training and are closely
monitored by Dr. Balderrama, we recommend the implementation of a more formalized
and documented training program such as the one recommended by Dr. Shelton. We did
not formally evaluate how long it took for patients to be seen by a practitioner following
referral, but it appeared that those in general population units were being seen within an
acceptable time frame. We will review this in more detail during future visits.
Access to medical care in special housing units (such as the administrative segregation
units) also occurs through submission of a written kite that the inmate can place directly in
a locked medical box. The kites are picked up and addressed seven days per week in the
same manner as those from the other housing areas in the jail. In addition, per the
Segregated Inmates policy, nursing staff is to conduct rounds in these units three times per
week and perform "visual checks, e.g., "How are you doing?"" According to audits
condw:ted by PCDC medical staff, this was only occurring approximately 60% of the time.
In addition, staff reported that patients from these units who were referred to a
practitioner by the triage nurse were often not seen in a timely manner. For example,
Patient 1 was seen by the triage nurse on October 17 for a complaint of abdominal pain
due to trauma that he sustained during his arrest. The nurse referred the patient to the
practitioner as a "First-up" appointment. He was not seen by the practitioner until
October 22. The practitioner sCheduled follow-up in 2 weeks, but the patient was not seen
until 4 weeks later. (By that time his discomfort had resolved. This does not Change,
however, the fact that he was not seen in a timely manner.)
Receiving Screening
Initial health screening is performed by a health trained correctional officer. New
arrestees with any medical concerns are to be referred to the booking nurse who is on duty
24 hours per day for further evaluation. (The booking nurse is also often called on by the
custody staff to evaluate the medical complaints of inmates housed in the new jail). 'Staff
reported that it is not uncommon, especially during busy times, for inmates with
identified health concerns to be housed prior to being seen by the booking nurse. PCDC
stated that it would begin tracking the number of daily bookings, the time of day that they
are occurring, and the number of new arrestees that the booking nurses are screening. We
recommend that it also conduct a study to determine if all new arrestees with medical or
mental health problems are being evaluated by the booking nurse.
The booking nurse is also responsible for contacting outside medical providers and
pharmacies in order to verify current prescriptions for newly arrived inmates who state
they are taking medications. Once verified, the nurse contacts a PCDC practitioner to
obtain orders for the medication. If the nurse is unable to verify a current prescription, the
patient is referred to see a practitioner at sick call. It was reported that at times, if the
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patient appears knowledgeable about his/her medications, the booking nurse will contact
the practitioner for orders even if they can not verify the medication.
The purpose of receiving screening includes the determination of whether newly arriving
arrestees have any urgent or emergent health care needs, have medical conditions that
require referral for follow-up, are receiving medications that must be continued, or may be
suffering from a potentially communicable disease. This screening should include both a
face-to-face interview and, whenever possible, a review of the prisoner's medical record.
In addition, potential for suicide or for withdrawal from alcohol or other drugs must be
addressed. The NCCHC standard on Receiving Screening a-E-02) states, "In all facilities
where health professionals are available, it is expected that they conduct the initial
screening." The standard does allow for health-trained correctional staff members to
perform the screening in facilities where medical staff is not on site at all times. However,
given the staffing and the number of daily bookings conducted at PCDC, we would expect
that a health professional perform the initial screening. This would ensure that all newly
arrived arrestees are appropriately evaluated. This would also allow the nurse to review
the electronic medical records of all incoming inmates.
Furthermore, the current system for continuing outside medications needs to be reviewed.
We are concerned that some patients may not receive essential medications until days
after they have been arrested. For example, a 54-year-old man who had been taking
Coumadin since he had had a pulmonary embolus in 2003 (Patient 11) was booked into
the jail on October, 26, 2003. The booking nurse was unable to verify his medication and
referred him to a provider on an urgent basis. There was an entry in the medical record
later that morning that the patient had "refused to the CO." (There was no refusal form in
the medical record). The patient was not seen until October 29. At that time the provider
noted that the patient received his medication from a pharmacy in Canada. He further
noted that the patient was very knowledgeable and that he would start the Coumadin that
day. There had been, however, a three day delay before the patient received an essential
medication. In those cases where medications for serious medical problems, such as
diabetes, hypertension, and HIV disease, cannot be verified, the nurse should consult with
a practitioner about those patients who give a reliable history or have physical findings
consistent with their illness, so that the medications can be ordered pending verification.
We recommend that PCDC conduct. a quality improvement study to evaluate the
timeliness with which patients receive essential medications when they first enter the jail.
Finally, there is no examination table or electrocardiogram (EKG) machine in the medical
clinic in the booking area. The booking nurse is called on to evaluate both newly arriving
arrestees who may have acute medical problems, as well as inmates housed in the new jail
with acute problems. In order to adequately assess patients, such as those with abdominal
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or chest pain, an examination table and EKG machine need to be available.
Staffing
The current medical program at PCDC is budgeted for 28 nursing positions (14 LPN and
14 RN), a full time physician, 3 full time physician's assistants (FA), a health services
administrator, and support staff (clerical, medical records, contract x-ray). As of
November 2007, there was 1 RN vacancy. As noted above, no coverage is provided when
one of the triage nurses is absent from work. In addition, the staffing plan does not
include a relief factor to provide coverage for nurses in other positions (such as booking or
clinic) who are on sick, vacation, or education leave. PCDC uses overtime, per diem, and
agency nurses to cover these shifts. Staff informed us that it is not always possible,
however, to find coverage, and they have to work short handed. PCDC stated that it
would begin tracking the number of open shifts per month.
As noted above, there is a need for additional nursing positions in order to implement a
system where receiving screening is performed by a registered nurse. Additional staff
may also be needed if it is determined that they are required to ensure that health care
requests are appropriately addressed seven days per week or if studies reveal that there
are enough patients who require a higher level of care to warrant opening medical beds in
the clinic area. In addition, staffing needs will have to be re-assessed as PCDC implements
a chronic disease management program and begins performing health assessments.
At the time of our visit, mental health staffing consisted of 5 Mental Health Program
Specialists (MHP) who provide seven-day per week coverage, from approximately 7 am to
9 pm. The MHPs also provide emergency night coverage on a rotating basis. There were
two MHP applicants who were going through the comprehensive clearance process. In
addition, a clerical position was open. With this position unfilled, the MHPs have to do
the work usually done by this assistant. (Since our visit one of the two MHPs and the
clerical assistant have been hired.) In addition, there was psychiatric coverage on
Tuesdays, Wednesdays, and Thursdays. (Since our visit psychiatric coverage has been
expanded to 4 day per week, though the total number of hours per week of psychiatric
coverage has not changed).
PCDC has a very large number of patients with mental health needs. Dave Stewart,
Acting Director of Human Services, advised us of a study conducted in the 1990's to
determine the percentage of serious mentally ill prisoners housed at the facility. The study
concluded that between 25% and 28% of the inmate population had a serious and
persistent mental illness. This percentage is significantly higher than the 16% suggested
by the 2002, Council of State Governments' Criminal Justice/Mental Health Consensus Project.
Mr. Stewart states that PCDes percentage is high because of the multitude of mental
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health institutions within the county. These include a state hospital, two prisons housing
mental health facilities, and a seven-state VA hospital, all of whom release to this county
increasing the concentration of mentally ill people in the county. Staff also reported that
there has been an alarming trend over the last 5 years of increasing numbers of
individuals, who have had prior contact with the community mental health system,
coming into PCDe. Despite this, the number of inmates seen for mental health services
has decreased by over 1,000 inmates over this same period.
In light of PCDe's significant need for mental health screenings, suicide evaluations, and
scheduled rounds in the higher security level mental health housing units, we are
concerned that there may not be enough MHPs to provide adequate mental health care to
the mentally ill inmates housed in lower level psychiatric housing and general population
areas. Even if all of the positions were filled, staffing may still not be adequate to provide
an appropriate level of mental health care. We will further review the adequacy of the
mental health staffing during future visits.
In addition to concerns regarding the adequacy of MHP staffing, we are also concerned
that the psychiatric coverage may be insufficient. The mental health program has had a
fulltime, psychiatric nurse practitioner position open for approximately two years. As
noted above, currently there is psychiatric coverage four days per week, leaving no
scheduled psychiatric coverage for three days. Mental Health has a priority list of inmates
(high, medium, and low) to see the psychiatrists for an evaluation for psychiatric
medication. Because of constant additions to the list, it is very rare that inmates with a low
priority are seen by a psychiatrist to receive a medication evaluation. This is of concern
because inmates are told that they will be receiving this evaluation. It is advised that
mental health conduct a review of the low priority list with one of their psychiatrists and
an MHP to determine if the referrals on this list are clinically indicated. If so, the patients
should be seen by a psychiatrist. If not, a different system of care for addressing the needs
of the patients on the low priority list should be developed. We will also review the level
of psychiatric coverage during subsequent visits.
Medical staff informed us that the hiring process is an impediment to hiring health
services staff. This is largely attributed to the amount of time applicants must wait before
they can be hired. Health care personnel in the community can be hired within two to
four weeks. Currently, the hiring process at PCDC takes three to six months. As a result,
filling any vacancies is a long process. Much of this delay is due to the background checks
performed by the Sheriff's Department. This has been a longstanding problem at the
PCDe. In her November 1997 report, Bonnie Norman noted,
It will be very difficult to hire qualified professional staff unless PCDC is
able to streamline the process of hiring. Sheriff French .needs to review
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options to the current prolonged hiring process, especially for highly skilled
professional personnel whose state or professional licenses are already
carefully and strictly regulated, and do everything he can as soon as he can
to streamline the health services hiring process.
PCDC stated that it would prepare a report of the last year documenting:
•
•
•
•
•
•
•

The length of time from when a healthcare position became vacant to when it was
filled.
The number of healthcare professionals who submitted applications.
The number who were hired.
The length of time from submission of the application to hiring.
The number of applicants who withdrew their applications before completing the
background process.
The number of applicants who withdrew their applications before they were
contacted.
The number of applicants who took other jobs before completing the background
process.

If the background procedures are contributing to the difficulty in hiring healthcare staff, a
process will need to be developed that fulfills the security needs of the facility while
allowing hiring to take place in a more timely fashion.

Intoxication and Withdrawal
The protocols for identifying and managing inmate-patients who are at risk for alcohol
withdrawal are not adequate. Alcohol withdrawal is a clinical syndrome that occurs when
individuals who are physically dependent on alcohol stop drinking or reduce their alcohol
consumption. If not managed appropriately, alcohol withdrawal can result in severe
complications such as withdrawal seizures, delirium tremens, and possibly death.
Individuals may not initially display signs/symptoms of intoxication and still may be at
high risk for withdrawal. Symptoms of withdrawal can begin within 6 hours of the last
drink and initially may not be severe (Le., mild tremors, nausea and anxiety). Medical
staff must identify and closely monitor individuals who are at risk for withdrawal, so that
early recognition and treatment can occur. Frequent re-evaluation of patients is
paramount in the management of alcohol withdrawaL At a minimum, medical staff needs
to monitor and document a patient's vital signs, mental status and behavior.
Benzodiazepines, such as Librium, are used to prevent progression from minor
withdrawal to more severe manifestations of withdrawaL It is common practice to
monitor patients for the symptoms of alcohol withdrawal and to dose the benzodiazepines
based on the level of symptomatology. Alternatively, minor withdrawal symptoms may
be treated with fixed regimens (Le., giving medication at specified intervals). When this is
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done, patients must be closely monitored and given additional medication if progression
to higher stages is observed. With appropriate and timely care, the serious consequences
of alcohol withdrawal can be avoided.
The PCDC policy and procedure on Intoxication and Withdrawal (J-G-06) correctly notes
that, "Inmates at risk need to be identified and appropriate treatment initiated." The
procedure states that the booking officer is to refer any inmates with a history of substance
abuse to the booking nurse. It further states that the booking nurse needs to promptly
contact a provider if any of the following are present: severe tremors, seizure or history of
same, abnormal vital sings, irregular heart rate, abnormal postural vital signs, vomiting or
pregnancy. The PCDC Guide for Booking Nurse states that individuals who are at high risk
for alcohol withdrawal (not defined) should have vital signs checked two times per day
for three days and be placed on the urgent list to see the practitioner, and that the provider
should be called if there are signs of current alcohol withdrawal. There are no guidelines
for identifying patients who are initially asymptomatic but who are at risk of developing
signs and symptoms of alcohol abuse, or for appropriately monitoring and treating these
patients.
PCDC needs to revise its current alcohol withdrawal protocol to provide for a better
method of identifying, monitoring and treating those patients at risk for alcohol
withdrawal.
Nursing Protocols
PCDC has developed a set of nursing protocols that address the nursing response to and
management of many common medical problems. These protocols provide clinical criteria
on when to send patients to the emergency room, when to refer them to the practitioner,
and when only nursing intervention is required. The protocols do not, however, provide
guidance as to when a provider should be contacted immediately and when it is
acceptable to refer the patient to the clinic. For instance, the protocol for abdominal pain
states that a patient with severe pain, rebound tenderness, and localized right lower
quadrant pain should be referred to a practitioner. The protocol for dandruff also advises
the nurse to refer the patient to the clinic if the problem has failed to respond to prior
nursing intervention. Clearly, in the first scenario, an immediate call to the provider is
required, whereas in the latter example, it is appropriate for the patient to wait until he is
seen in clinic. An example of this problem is Patient 2, is an 80 year-old-man who has a
defibrillator and pacemaker and has had several heart attacks and bypass surgery. On
September 9, 2007, custody staff brought him to the booking nurse because he was
complaining of shortness of breath and chest pain. The nurse noted that the pain radiated
to the patient's neck and across his upper back, and that he reported that his fingertips felt
numb. She also noted his prior cardiac history. The patient's history and symptoms were
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of great concern for a possible heart attack. However, instead of sending the patient
immediately to the emergency room or calling the provider on-call for further guidance,
the nurse sent the patient to the main jail clinic for an electrocardiogram. It was not until
almost one hour after the patient had initially presented that the on-call provider was
contacted and the patient was sent to the emergency room via ambulance. Fortunately, he
had not sustained a heart attack.
The nursing protocols need to be revised to differentiate between those situations which
require immediate consultation and those where it is acceptable to wait for the patient to
be seen in clinic. In addition, the policy and procedure on Nursing Assessment Protocols
E-ll) needs to be updated to address the use of the nursing protocols.

a-

Mental Health Services
The mental health staff is knowledgeable about the mentally ill inmate population and
expressed commitment to the work they do. Referrals for mental health come from
multiple sources: correctional officers, medical staff, self-referrals, attorneys, and families.
Due to staffing shortages, the mental health court-screening program referenced in the last
monitoring report was abated and only recently re-established in mid-November. The
staff provides a significant number of assessments and coverage with limited resources. In
addition, the MHPs work closely with community mental health treatment providers to
assist with continuity of care and discharge planning and have an innovative electronic
system that encourages community involvement when clients are incarcerated.
Even with a dedicated mental health staff, however, we have serious concerns regarding
the mental health program at PCDe. (See the discussion of mental health staffing above.)
PCDe's mental health staff currently conducts monitoring rounds with mental health
inmates housed in the danger-to-self (DTS) observation cells and the danger-to others
(DTO), level-one security cells. The DTS cells are monitored daily by mental health staff
. and the level ones are monitored three times a week. Those housed in lower level mental
health housing or in general population do not receive monitoring rounds by a Mental
Health Professional (MHP). We were not able to fully evaluate the adequacy of the types
of treatment and level of care available to mental health clients. This is an area that we
will concentrate on during our next visit to PCDe.
Some of the mental health staff expressed particular concern regarding the housing for
mentally ill women. According to these staff, while some of the mentally ill women who
are housed in the level one security housing area are not appropriate for general
population, they do not need to be housed in such a restrictive environment. Such
housing severely limits the time out of their cells and can be harmful to their mental
health. If an inmate is not classified as a danger-to-self or danger-to-others, they need to
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be housed, with the input of mental health staff, in a less restrictive environment. We did
not have a chance to look into this concern during this visit. We will examine it during
future visits.
The PA's continue psychiatric medications that have been verified from the community
and provide the follow-up care for many inmates on psychiatric medications during their
incarceration. It does not appear that a psychiatrist sees or reviews the medication while
the inmates are in jail. No policy was located describing this practice. Mental health and
medical staff need to create a policy that addresses this practice. The policy needs to
include both guidelines and limitations.
Medical Records
PCDC has implemented the use of an electronic medical record (EMR). Clinical
documentation is directly entered into the EMR by the clinical staff. Other information
such as laboratory results, x-ray reports and records from outside providers is scanned
into the system. Medical information that predates the EMR was not scanned and is
available in the form of a paper chart. One concern is that medication administration
records are not scanned into the EMR and may not be available when the patient is being
evaluated. In addition, it is possible to view a list of the medications that have been
ordered for a patient. Insulin, however, does not appear on this list, so one would not
know that a patient is receiving insulin unless they looked elsewhere in the medical
record. The medication list should include all medications that a patient is receiving.
Another concern is the fact that there is no consistent way of entering information.
Progress notes from the practitioners and the nurses can be in one of multiple sections Synopsis, Appointments, or Correspondence (the scanned copy of the booking sheet). This
makes it very difficult to review a medical record and increases the likelihood that
important clinical information may be missed. In addition, chronic illnesses are not
always noted on the Problem List. Our concerns were shared by some of the clinical staff
that we interviewed. PCDC needs to develop a policy and procedure for the EMR that
delineates where information should be entered. In addition, many of the notes from
booking and triage are poorly written and do not contain sufficient information about the
patient's condition.
Billing/Co-Pay
As noted by Dr. Shelton, the co-pay policy for inmates at PCDC appears to be appropriate
and adequate to meet the constitutional requirements for access to health care. Inmates
are assessed a $5.00 charge, subject to leaving a balance of $4.50 in his/her book account for
certain medical encounters, such as an initial visit for a minor complaint that is not
referred to a provider. A fee is not imposed for most health care services, including intake
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screening, communicable disease screening, mental health services, emergency care, and
any visit that results in a referral to a practitioner. In addition, no inmate is denied
services based on a lack of funds. However, any co-pay system can have an adverse
impact on access to care. Dr. Shelton had recommended certain monitoring studies to
track whether or not there was any impediment to access based upon the co-pay. Staff
had not performed these studies, but was fairly certain that the co-pay had not deterred
patients from accessing the health care system. We recommend that this be documented
using the measures suggested by Dr. Shelton. In addition, during future visits, we will be
interviewing inmates to assess the impact of the co-pay system.

Medical Diets
PCDC offers the standard range of medical diets. Staff reported, however, that the diets
supplied by the food services company were often unsatisfactory in terms of both quality
and quantity. They stated that this was also true for the regular diets supplied by the
company. Since this is an issue that has been raised in prior reports, PCDC should
contract with a dietician to perform a study of the food services at the facility.
Dental Care
Dental care is available only one day per week. This is totally insufficient to meet the
dental needs of the jail population. On November 16, 2007, there were 21 patients on the
dental priority list. According to the policy on Oral Care (J-E-06), dental priorities are to be
seen at the next dental clinic. Many of these patients had been on the list for over 3 weeks.
One patient with a broken tooth (Patient 3) had been on the priority list for 44 days, and
another with a cracked molar and exposed root (Patient 4) had been on the priority list for
10 days. (PCDC informed up that Patient 4 refused care when he saw the dentist. This
does not, however, alter the fact that he was not seen in a timely manner.) In addition, 155
patients were on the waiting list for routine dental care. Many of these patients had been
waiting over 4 to 5 months to see the dentist. Statistical reports indicated that the dentist
was only seeing about 30 to 40 patients per month.
Chronic Disease Management
The sick call process is primarily designed to address acute, self-limited medical problems.
Since a significant proportion of prisoners suffer from diseases, such as hypertension,
diabetes, asthma, seizures and HIV/AIDS, facilities must have a mechanism for monitoring
individuals with chronic health conditions. The development of a chronic care program
helps to ensure routine follow-up and appropriate treatment of patients with serious
medical problems. Such programs serve to identify and monitor patients with chronic
illnesses in order to initiate appropriate therapeutic regimens that will promote good
health and prevent complications, and provide patient education and counseling in order
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to encourage patients to practice healthy behaviors. In contrast to visits for episodic care
of self-limited problems, the chronic care visit should address all issues related to the
patient's illness since the last visit. In addition, there should be a registry that lists by
disease all the patients in custody with chronic illnesses and a method of tracking those
patients to ensure that they are being seen on a routine basis (a minimum of every three
months) and that appropriate monitoring is occurring.
PCDC has not developed or implemented an adequate chronic care program. A disease
registry needs to be developed and training of the practitioners in the chronic disease
model needs to occur. In addition, disease specific chronic care guidelines should be
developed and in-serviced with the staff.
MedicationslPharmaQ'
Pharmacy is being handled by contract from an outside pharmacy. Staff report that
medications are delivered the same day or the next day more than 90% of the time. There·
is also a stock of on-site medications for immediate delivery and usage. PCDC continues
to use a Keep-on-Person (KOP) medication program in the new jail and for the inmate
workers housed in the main jail. We agree with Dr. Shelton's recommendation that this
program be extended to the main jailas it can result in reduced nursing and custody labor
and improved patient care.
Quality Improvement
Continuous Quality Improvement (CQI) is the development and implementation of a
procedure for reviewing the quality of care provided at an institution and, as such, is an
essential component of the health care delivery system. CQI is accomplished through a
combination of studies, audits, record reviews, peer review, mortality reviews and other
quality improvement activities. Both outcome (i.e., the number of diabetic patients whose
disease is well controlled) and process .(Le., whether patients who submit health care
requests are being seen within the required time frame) oriented studies should be
performed. It is through these activities that important problems and concerns with the
health care system can be documented, factors leading to suboptimal performance can be .
identified, and strategies for improving care can be developed. Once changes have been
implemented, follow-up studies need to be done to determine the effectiveness of the
corrective actions. According to the NCCHC aspects of care that must be reviewed
annually include: access to care, reception screening, health assessment, continuity of care,
emergency care and hospitalizations, mental health services, chronic disease management,
discharge planning, infirmary care, and adverse patient outcomes, including deaths.
[Standards for Health Services in Jails, NCCHC, 2003, page 153]
PCDC has begun to implement a CQI program. Medical staff is currently monitoring
certain aspects of the health care program such as segregation rounds, tuberculosis skin
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testing, and booking refusals. Staff is also conducting death reviews. Other aspects of a
comprehensive CQI program have not been fully implemented. The policy and procedure
on Continuing Quality Improvement Program (J-A-06) states that the physician will perform
monthly chart reviews "of at least 5% of the inmate current health encounters during the
month..." While chart reviews are being done, they are not being done to the extent
specified in the policy and procedure. Furthermore, the types of CQI studies described
above are not being performed by either the medical or mental health programs.
A more comprehensive CQI program needs to be developed at PCDe.
Policies and Procedures
As noted above, the policies and procedures on Nursing Assessment Protocols (J-E-11)
and Health Records (J-H-Ol) need to be revised and updated.
Mental health policy and procedures have not been revised for approximately ten years.
Many of their practices have changed and the new facility has opened. The policies and
procedures need to be updated. In addition, the medical program has policies regarding
mental health practices that mental health staff has never seen. A system needs to be in
place for review and approval of shared policies.

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NCCHC STANDARDS
We are using the NCCHC Standards as the framework for our opinions. Only the NCCHC Board
ofAccreditation can officially determine if NCCHC standards have or have not been met.
Governance and Administration
J-A-Ol Access to Care
This standard is not being met. See the discussions of access to care, staffing, and mental
health services above.
J-A-02 Responsible Health Authority
This standard is met. PCDC has a qualified full time Health Authority and a full-time
Medical Director.
J-A-03 Medical Autonomy
This standard is met. Decisions and actions regarding health care services provided to
inmates are the sole responsibility of qualified health care personnel and are not
compromised for security reasons.
J-A-04 Administrative Meetings and Reports
This standard is met. Administrative meetings are being held. Monthly statistical reports
are being produced that include data on areas such as the number of bookings; medical,
nursing, mental health, and dental encounters; emergency room and specialty referrals;
prescriptions; the number and types of medical grievances; the results of skin testing for
tuberculosis; and deaths.
J-A-OS Policies and Procedures
This standard is not met. See the discussion of policies and procedures above.
J-A-06 Continuous Quality Improvement Program
This standard is not being met. See the discussion of CQI above.
J-A-07 Emergency Response Plan
This standard was not evaluated.
J-A-OS Communication on Special Needs Patients
This standard was not evaluated during this visit.
J-A-09 Privacy of care
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This standard is met.
J-A-lO Procedure in the Event of an Inmate Death

This standard is met. Physician review of each death is occurring. In addition, a review
of each death is being done by a committee that includes the appropriate individuals.
Issues that represent possible systems errors are being identified and addressed. In
addition there is a system for notifying an inmate's family in case of emergency such as
serious illness or injury.
J-A-ll Grievance Mechanism for Health Complaints

This standard is met. There is a mechanism in place for allowing inmate grievances and
then for reviewing and responding to these grievances both on an individual and an
aggregate basis to look for patterns of complaints.

Managing a Safe and Healthy Environment
J-B-Ol Infection Control Program

This standard is not being met. PCDC has an adequate program for screening incoming
inmates for tuberculosis. Appropriate monitoring and guidelines for the treatment of
skin and soft tissue infections have also been established.
There is a problem, however, with the airborne isolation cells that are used to house
patients who are being evaluated for suspected tuberculosis disease. These cells are not
being properly monitored. Guidelines from the Centers for Disease Control recommend
that room pressures be confirmed daily while the rooms were occupied by patients with
known or suspected tuberculosis and at least monthly at other times. Monitoring of these
. rooms was not occurring and on the day of our visit we checked the room and it did not
appear that negative pressure was being maintained. This was discussed with the medical
and engineering staff. PCDC needs to develop a policy for the use of the airborne isolation
rooms that includes procedures and logs for monitoring the pressure. The cells should not
be used for patients who may have infectious tuberculosis until an adequate monitoring
system is established.
J-B-02 Environmental Health and Safety

This standard was not evaluated during this visit.
J-B-03 Kitchen Sanitation and Food Handlers

This standard was not evaluated during this visit.

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J-B-04 Ectoparasite control
This standard is met. PCDC has written a policy and procedure to establish active
parasite (lice, scabies) control that is appropriate in that it is applied only_to infected
patients, and not to all inmates upon entering jail. Qualified Health staff is used to
identify infection and authorize treatment. Pregnant women are referred to a providerfor
further evaluation and treatment.

Personnel and Training

,J-C-Ol Credentialing
This standard was not evaluated during this visit.
J-C-02 Clinical Perfonnance Enhancement
This standard was not evaluated during this visit.
J-C-03 Continuing Education for Qualified Health Services Professionals
This standard was not evaluated during this visit.
J-C-04 Training for Correctional Officers
This standard is not being met. Mental health staff no longer offers refresher courses to
PCDe's Correctional Officers on the identification of mental health problems and suicide
prevention. Such a refresher course has not taken place in three years. To meet this
standard, these topics must be reviewed, at a minimum, every two years.
J-C-OS Medication Administration Training
This standard is not being met. Due to the staffing problems described above, agency
nurses, who do not receive sufficient training and orientation, are often used to pass out
medications.
J-C-06 Inmate workers
This standard is met.
J-C-07 Staffing Plan
This standard is not being met. See the staffing discussion above.
J-C-OS Health Care Liaison
This standard does not apply.

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J-C-09 Orientation Health Staff
This standard is met.

Health Care Services and Support
J-D-O! Pharmaceutical Operations
This standard is met. The current contracted off-site pharmacy is doing well to fill the
needs of the patients of peDe. There is a stock of "emergency" medications for off-hours
and there is 24 hour availability from local pharmacies or the hospital if medications are
needed that are not kept on site.
J-D-02 Medication Services
This standard is met.
J-D-03 Clinic Space, Equipment and Supplies
This standard is not being met. This standard requires that there is sufficient and suitable
space, equipment, and medical supplies for the adequate delivery of health care. At this
time, the clinic area in the booking area is not adequately equipped.
J-D-04 Diagnostic Services
This standard is met.
J-D-OS Hospital and Specialty Care
This standard is met. The jail has arrangements for providing hospital and specialized
ambulatory care for medical and mental illnesses.

Inmate Care and Treatment
J-E-O! Information on Health Services
This standard is being met.
J-E-02 Receiving Screening
This standard is not being met. See the discussion of receiving screening above.
J-E-03 Transfer Screening
This standard is not applicable.

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J-E-04 Health assessment
This standard is not being met. Required medical and mental health assessments are not
being done.
J-E-05 Mental Health Screening and Evaluation
.This standard is not being met. Mental health continues to have an impressive electronic
system that automatically identifies those newarrestees who have received mental health
services in the community. As noted above, increasing numbers of individuals who have
had prior contact with the community mental health system are coming into PCDe;
however, the number of inmates seen for mental health services has decreased. It is
unlikely that the number of mentally ill inmates has diminished. It is more probable that
these patients are not being identified or that the capacity to evaluate them has
diminished.
A screening tool, in addition to the correctional officer's intake screen and the community
reference list, needs to be utilized to assure inmates with mental health needs are referred
to mental health. To satisfy this requirement, a series of approved mental health
questions could be asked by nursing staff.
J-E-06 Oral Care
This standard is not being met. See the discussion of dental care above.
J-E-07 Non-Emergency Health Care Requests and Services
This standard is not being met. See the discussions of access to care, mental health
services, and dental care above. In addition, we recommend that different forms or colors
be used to distinguish medical from other kites.
J-E-OS Emergency Services
This standard is being met.
J-E-09 Segregated Inmates
This standard is not being met. Required rounds in the segregation units are not
occurring 3 times per week. In addition, staff reported that access to care is delayed for
inmates in segregation.
J-E-IO Patient Escort
This standard was not evaluated.
J-E-ll Nursing Assessment Protocols
This standard is not being met. See the discussion of nursing protocols above.
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J-E-12: Continuity of Care during Incarceration
This standard is not being met. Continuity of essential medications for newly arrived
inmates needs to be improved. See the discussion of receiving screening above.
This standard is being met for mental health. Continuity care is a priority for the PCDC
mental health staff. An electronic list is generated daily advising both jail mental health
of new arrestees' community mental health history as well as providing a list to
community mental health centers advising the center of their client arrest. Jail mental
health continues verified community psychiatric medication upon admission to the jail.
J-E-13 Discharge Planning
This standard is being met. Mental health begins planning for.re-entry from the
beginning of incarceration and reviews the client's community resources with each
inmate contact. Discharge medication is provided until a follow-up appointment is made
in the community. The mental health staff works with the mentally ill client to inform
them of housing options if homelessness is an issue. Discharge planning for patients with
medical problems is also occurring, although in a less organized manner.

Health Promotion and Disease Prevention
J-F-Ol Health Education and Promotion
This standard was not evaluated during this visit.
J-F-02 Nutrition and Medical Diets
This standard was not evaluated during this visit. As noted above, staff voiced concerns
about the regular and medical diets. We recommend that PCDC contract with a
nutritionist to evaluate the diets.
J-F-03 Exercise
This standard is being met. Discussions with staff revealed that all inmates were allowed
at least the minimum number of hours for recreation.
J-F-04 Personal Hygiene
This standard is not being met. Inmates in segregation are forced to take showers with
their hands are cuffed in front of them. It is not possible to adequately clean oneself
under these circumstances.
J-F-05 Use of Tobacco
This standard is being met. PCDC is a non-smoking facility.

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Special Needs and Services
J-G-O! Special Needs Treatment Plans
This standard is not being met. Inmates identified with special needs requiring close
medical supervision or multi-disciplinary care including the chronically ill, those with
communicable diseases, physically handicapped, frail, elderly inmates, the terminally ill,
inmates with special mental health needs, and the developmentally disabled, should have
special treatment plans listed in their medical charts. The treatment plan should include
instructions about diet, exercise, medication, type and frequency of diagnostic testing,
and frequency of follow up for medical evaluation. These patients are being identified on
a case-by-case basis by the practitioners, and appropriate medical care ordered. There is
no automatic system for insuring on-going and timely follow up on a regular and routine
basis for patients with identified special needs.
While all of the mental health charts reviewed had a "P" for plan and addressed the reentry or discharge plan into the community, few had developed a treatment plan for the
course of therapy during incarceration. Mental health treatment plans need to include
both short and long term goals.
J-G-02 Management of Chronic Disease
This standard is not being met. See the discussion of chronic disease management above.
J-G-03 Infirmary Care
This standard is currently not applicable. However, as noted above, PCDC needs to
conduct a survey to determine how many infirmary/sheltered living beds are needed to
address the needs of the patients housed in the jail.
J-G-04 Mental Health Services
This standard was not fully evaluated. See the discussions of mental health services and
staffing above.
J-G-OS Suicide Prevention Program
This standard is not being met. PCDC has a system for identification, referral, evaluation,
housing, monitoring, and reviewing of suicides or serious attempts. The PCDe's initial
Jail Health Receiving Screen Form asks, "Suicide Attempt in Last 2 Months." Past suicide
attempts are the best predictor of suicide attempts both in and out of jail. Two months is
a low standard for a referral for a mental health assessment. Any inmate that has a
history of in-custody suicide attempts should be referred to mental health for evaluation.
Mental health's computer system will pick up inmates that have made attempts in PCDe;
however, it will not advise of suicide attempts made in other detention centers or mental
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health system outside of Pierce County mental health. An initial training is provided to
all staff; however, a biennial refresher course is not being taught.
J-G-06 Intoxication and Withdrawal
This standard is not being met. See the discussion of intoxication and withdrawal above.
J-G-07 Care of the Pregnant Inmate
This standard is being met.
J-G-OB Inmates with Alcohol and Other Drug Problems
This standard was not evaluated during the recent visit.
J-G-09 Procedure in the Event of Sexual Assault
This standard was not evaluated during the recent visit.
J-G-IO Pregnancy Counseling
This standard was not evaluated during the recent visit.
J-G-ll Orthotics, Prostheses, and Other Aids to Impairment
The standard is being met.
J-G-l2 Care for the Terminally III
This standard does not apply. Terminally ill patients are transferred to the local hospital.

HealthRecords
J-H-Ol Health Record Format and Contents
This standard is not being met. See discussion of health records above.
J-H-02 Confidentiality of Health Records and Information
This standard is being met.
J-H-03 Access to Custody Information
This standard is being met.
J-H-Q4 Availability and Use of Health Records
The standard is being met.

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J-H-OS Transfer of Health Records
This does not apply to PCDC as they have only one facility and a shared electronic health
record.
J-H-06 Retention of Health Records
This standard is being met.

Medical-Legal Issues
J-I-01 Use of Restraint and Seclusion in Correctional Facilities
This standard is being met. Staff advised us that restraint, as part of a treatment program,
is not used for medical or mental health patients. PCDC sends patients with this type of
medical need to the hospital. The custody staff solely orders restraints at PCDe. The
PCDC policy on Use of Restraint and Seclusion in Corrections Facility (J-I-Ol) has a confusing
statement that needs correcting. In the statement, "Medical staff will do a health
assessment no more than two hours after initial placement, ""no more" needs to be
replaced with "within". In future visits, we will monitor the use of the restraint chair and
the "bolts" in the DTO and DTS cells that are used by custody staff to restrain inmates.
J-I-02 Emergency Psychotropic Medication
This standard is not being met. The policy for involuntary medications is unclear and
ambiguous. The requirement of the second practitioner's endorsement is written in .a
confused manner and needs clarification. This policy must also clearly spell out at what
point the first dose of forced, longer-term, on-emergency medications are administered. It
is likely that the practice meets the standard, but the policy needs to be clarified.
J-I-03 Forensic information
This standard is being met.
J-I-04 End-of-life Decision Making
Not applicable to PCDe.

J-I-OS Informed Consent
This standard is being met.
J-I-06 Right to Refuse Treatment
This standard is not being met. The policy on Medical Refusal (J-I-06) states that patients
with emergent or urgent problems who refuse care will be brought to the clinic and the
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practitioner will explain the consequences of refusing. If the patient continues to refuse,
"s/he must sign a refusal form..." Staff stated that this often does not occur and "refused
per CO" is written in the chart. The case of Patient 11, whose care is discussed above in
the section on Receiving Screening, is an example of this. He was referred from booking
to the practitioner in the medical clinic on an urgent basis. He was, however, not seen
that day. The only note states, "refused to the CO." As a result, he did not receive his
essential medication until he was seen by the practitioner 3 days later.
J-I-07 Medical and Other Research
This standard is being met. PCDC does not use inmates for medical research. (Inmates
may stay on an appropriately established research protocol if they were placed on it
while in the community prior to incarceration.)

Summary
The following NCCHCaccreditation standards are not being met:
J-A-Ol Access to Care
J-A-OS Policies and Procedures
J-A-06 Continuous Quality Improvement Program
J-B-Ol Infection control of communicable diseases
J-C-04 Training for Correctional Officers
J-C-OS Medication Administration Training
J-C-Q7 Staffing Plan
J-D-03 Clinic space, Equipment and Supplies
J-E-02 Receiving Screening:
J-E-04 Health assessment
J-E-OS Mental Health Screening and Evaluation
J-E-06 Oral Care
J-E-07 Non-Emergency medical requests
J-E-09 Segregation Inmates
J-E-ll Nursing Assessment Protocols
J-E-12: Continuity of Care
J-F-04 Personal hygiene
J-G-Ol Special treatment plans
J-G-02 Management of Chronic Disease
J-G-OS Suicide prevention program
J-G-06 Intoxication and withdrawal
J-H-Ol Health Record Format and Contents
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J-I-02 Emergency Psychotropic Medication
J-I-06 Right to Refuse Treatment

The following NCCHC accreditation standards were not fully evaluated:
J-A-07 Emergency Plan
J-A-08 Communication on Special Needs Patients
J-B-02 Environmental health and safety
J-B-03 Kitchen Sanitation and Food Handlers
J-C-Ol Credentialing
J-C-02 Clinical Performance Enhancement
J-C-03 ContinUing Education for Qualified Health Services Professionals
J-E-lO Patient Escort
J-F-Ol Health Education and Promotion
J-F-02 Nutrition and Medical Diets
J-G-04 Mental Health Services
J-G-08 Inmates with Alcohol and Other Drug Problems
J-G-09 Procedure in the Event of Sexual Assault
J-G-10 Pregnancy Counseling
Other Issues
1. Staff expressed concerns about the nutritional adequacy of both the regular and the
medical diets. We recommend that PCDC contract with a nutritionist to evaluate the
diets.

2. The following areas require further study through quality improvement activities or
other studies:
a. The need for infirmary/sheltered living housing
b. Access to care
c. The priority list for psychiatric care
d. The hiring process
e. The intake screening process

25