Maricopa County Correctional Health Services Ncchc Assessment Documents 2008
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Maricopa County
Correctional Health Services
•
Dorinne L. Gray
Manager, Quality/Utilization
3250 W. Lowcr Buckeye Rd.
Suite 2100
phoeniX, Arizona 85009
Phone: (602) 876-7109
Fax: (602) 506·2577
Management & Clinical Diagnostics
..
June 21, 2007
Judith Stanley
National Commission on Correctional Health Care
1145 West Diversey Parkway
Chicago, Illinois 60611
This document responds to the NCCHC's accreditation report review of findings dated Mar~h
16, 2007, in which NCCHC requested subsequent documentation of compliance with
Essential Standard J-E-04, on or before July 02, 2007.
.
. Maricopa CoUnty Co~ectional ;H~alth" Services inaintains a robust' comprehensive pro~am for
continual quality improvement. Enclosed in report fonnat and graphical representation, is
Maricopa County Sheriffs Office and Correctional Health Services corrective .action and
evidence of compliance with the NCCHC standard.
:.
Maricopa County Correctional Health Services anticipates the remaining standard, J-E-04,
will be found in full compliance at the next NCCHC review meeting. Thank you for the
opportunity to respond to the March 16,2006 findings.
Best regards,
kwiktag '"
032 907 765
1/1 III/It /I tl/III /I IlitItl/"
MC Confidential (June 08) 001097
MARICOPA COUNTY
CORRECTIONAL-HEALTH SERVICES
3250 W. Lower Buckeye Rd., Suite 2100
Phoenix, AZ ·85009
(602) 876-7109
FAJ«(602)442-86~9
Confidential pursuant to A.R.S. §§ 36-2401 to 36-2404
,
.
In their March 16, 2007 meeting, the Accreditation Committee of the National Commission on
Correctional Health Care (NCCHC) voted to continue Maricopa County Sheriff's OfficeDetention Bureau on Continuing Accreditation upon Verification to allow Maricopa County time
to complete corrective action for one remaining essential standard, J-E-04 Health Assessment.
Notification of this decision was dated May 2, 2007, and received by Maricopa County shortly
thereafter. The notification from NCCHC instructed Maricopa County to forward a report of
corrective action to NeCHC on or before July 2,2007.
As·reported in the NCCHe Accreditatiol). Report Revised03/1612007~ the following standards
required corrective action:
Essential Standards in Partial Compliance
J-E-04 Health Assessment
Maricopa County CHS Report of Accreditation
Co~pliance .
J-E-04 Health Assessment
June 2007:
CHS' robust initiatives for health assessment completion continue as described previously.
Training of healthcare support staffto verify existence of prior incarcerations through patient
identification numbers was completed.
The overall health assessment completion rate has remained greater than 90% for 6_ consecutive months,
rising to a high of 96.2% in June 2007. Maricopa County Correctional Health Ser:vices has also
demonstrated 9 months of continual improvement in health assessment completion within 14 days of
booking, and has reached a high of 82.8% compliance as ofJune 25, 2007. This improvement has
continued even with a recent rise in inmate population, reaching over 10,000 on 6-11-07.
Maricopa County Correctional Health Services maintains that the intent of J-E-04 Health Assessment is
met, and that CHS complies with this standard.
Confidential Pursuant to A.R.S. §§ 36·2401 to 36-2404
Me
Page 1 of4
Confidential
(June 08)
001098
Maricopa County Correctional Health Servlc!!s
Health Assessment Overall Completion Rate- All Facilities
JMS dala. All inmates with LOS>!=
10 15 days, n=avg.
.
. . approx. 9900 each monh
Confidential Pursuant to A.R.S.
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Aug-De Sep-06 Oct-06 Nov-OS Dec-OS Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-D7
Maricopa County Correctional Health Scrviccs
Hcalth Asscssment ~ompletion witJtin 14 days~ All Facilities FY2007
JMS data, Inmates with LOS greater than or equal to 15 days, n ~ 9,900
Confidential Pursuant to A.R.S. 36-2401, et. seq..
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Confidential Pursuant to AR.S. §§ 36-2401 to 36-2404
Page 2 of4
MC Confidential (June 08) 001099
Previou~ly reported'February 2007:
CHS' new initiatives for health assessments have continued from September 2006 to present.
Health Assessments have been brought current and are being maintained current at all Maricopa
County Jail facilities. An extensive effort to validate and make current the documentation of
physical exam, serology, and tuberculin skin testing completion dates in JMS Gail management
system) was completed: Thorough training on the use of JMS was developed and implemented. '
The ongoing process for maintaining ,compliance with 14 day Health Assessments, is to schedule
trained nurses to perfonn health assessments at LBJ 5 days per week, at Intake 24 ho~rs 'per ,
day/7 days per week, at Durango 3 days per week and at 41h Avenue 2 days per week, utilizing a '
"power squad" methodology. Maricopa County Sheriff's Office has contributed to the success of
this project by providing sufficient detention officer staff to accompany medical personnel for
power squads. Medical providers are completing health assessments dl,1ring sick call at all
facilities. To ensure the health assessments are completed within 14 days, ininates needing
physical exams are placed on the sick call roster for completion of their physical exam at day 8-9
of incarceration. Additional training for healthcrn:e support staffto verify existence of prior
incarcerations (especially within the last twelve months) through patient identification numbers
is currently being rolled out.
.
The health assessment completion rate rose to 91.6% in January 2007, and 92.6% in midFebruary 2007. Maricopa County Correctional Health Services contends the intent of J-E-04
Health Assessment is met, and that CRS is in compliance with this stan~ard.
Previously reported September 2006:
CHS hired 8 Traveler nurses to perform physical exams; working 12 hour shifts at both LBJ and
4th Avenue locations. Nurses are scheduled to provide 24/7 coverage at 4th Ayenue Intake in an '
effort to complete health assessments upon inmate's entrance to the jail system. CHS
continue to hire up to a total of 15 Traveler nurses, as needed for improvement efforts, along
with ongoing recruitment of regular staff. CHS staffing plan, based on Maricopa County
Managing for Results program, was approved by the Maricopa County Office ofManagement
and Budget, and the Maricopa County Board of Supervisors. The approved,staffing plan
provides the following increases in positi()ns: Medical Records Technicians - 6 new FTEs,
Mental Health Professionals - 10 new FTEs, MDs (Medical) - 7 new FTEs, MDs (Psycl1iatrist) 3 new FTEs, Correctional Health Techs - 13 new FTEs, Licens'ed'Practical Nurses - 7 new
FTEs, Registered Nurses - 26 new FTEs, Health' Unit Coordinators - 31 new FTEs, Nursing ,
Supervisors - 4 new FTEs, Quality Coordinator - 1 new FTE
'
will ,
CHS has continued system-wide efforts to complete past due health assessments, in an effort to
improve inter-facility transfer of inmates to Department Of Corrections, and to decrease the
number of inmates needing a health assessment. Future improvement emphasis will be on the
completion of the health assessments in the earlier days ofincarceratiori (within 14 days of
booking)
CHS documentation forms have been reviewed and revised to improve the collection of health
infonnation~ Methods of data collection and reporting have been reviewed.
Previously reported May 2006:
,
CHS focused effort at Durango jail to complete the health history, vital signs, and lab/diagnostic'
testing portion of the 14 day health assessment.
'
Medical Providers changed practice for every inmate requesting sick call to include 9ssessment
and treatment of the condition requiring sick call and to also include the physical exam, when
applicable. eRS continues to actively recruit and retain medical providers and nursing
Confidential Pursuant to A.R.S. §§ 36-2401 to 36·2404
Page 3 of4
MC Confidential (June 08) 001100
RI7.~"~
Maricopa County
Correctional Health Services
.A .
'!r:
•
.
Dorinne L. Gray
Manager, Quality/Utilization
Management & Clinical Diagnostics
3250 W. Lower Buckeye Rd.
Suite 2100
l'hoenix. Arizona 85009
Phone: (602) 876-7109
Fax: (602) 506-2577
June 21, 2007
Judith Stanley
National Commission on Correctional Health Care
1145 West Diversey Parkway
Chicago, Illinois 60614
This document responds to the NCCHC's accreditation report review of findings dated March
16, 2007, in which NCCHC requested subsequent documentation of compliance with
Essential Standard J-E-04, on or before July 02, 2007.
Maricopa County Correctional Health Services ni\iintains a robust comprehensive program for
continual quality improvement. Enclosed in report format and graphical representation, is
Maricopa County Sheriff s Office and Correctional Health Services corrective action and
evidence of compliance with the NCCHC standard.
Maricopa County Correctional Health Services anticipates the remaining standard, J-E-04,
will be found in full compliance at the next NCCHC review meeting. Thank you for the
opportunity to respond to the March 16, 2006 findings.
Best regards,
I!tl~tfr
'Orime 1. cit
Manager of Q ality / Utllization Management & Clinical Diagnostics
Maricopa County Correctional Health Services
MC Confidential (June 08) 001101
MARICOPA COUNTY
CORRECTIONAL HEALTH SERVICES
3250 W. L.ower Buckeye Rd., Suite 2100
Phoenix, AZ 85009
.
(602) 876-7109
FAX (602) 442-8659
Confidential Pursuant to A.R-S. §§ 36-2401 to 36-2404
In their March 16,2007 meeting, the Accreditation Committee of the National Commission on
Correctional Health Care (NCCHC) voted to continue Maricopa County Sheriffs OfficeDetention Bureau on Continuing Accreditation upon Verification to allow Maricopa County time
to complete corrective action for one remaining essential standard, J-E-04 Health Assessment.
Notification of this decision was dated May 2,2007, and received by Maricopa County shortly
thereafter. The notification from NCCHC instructed Maricopa County to forward a report of
corrective action to NCCHC on or before July 2,2007.
As reported inthe NCCHC Accreditation Report Revi'sed 03/16/2007, the following standards
required corrective actio:!).:
Essential Standards in Partial Compliance
J-E-04 Health As.sessment
Maricopa County CHS Report of Accreditation Compliance
J-E-04 Health Assessment
June 2007:
CHS' robust initiatives for health assessment completion continue as described previously.
Training of healthcare support staff to verify existence of prior incarcerations through patient
identification numbers was completed.
The overall health assessment completion rate has remained greater than 90% for 6 consecutive months,
rising to a high of 96.2% in June 2007. Maricopa County Correctional Health Services has also
demonstrated 9 months of continual improvement in health assessment completion within 14 days of
booking, and has reached a high of 82.8% compliance as ofJune 25, 2007. This improvement has
continued even with a recent rise in inmate population, reaching over 10,000 on 6-11-07.
Maricopa County Correctional Health Services maintains that the intent of J-E-04 Health Assessment is
met, and that CHS complies with this standard.
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
Page 1 of4
MC Confidential (June 08) 001102
Maricopa County Correctional Health Services
Health Assessment Overall Completion Rate- All Faciliti s
JM Sdala, All inmafes wi!h LOS >/= 10 15 days, n=avg. approx. 9900 each monlh
Confidential Pursuant to A.R.S. 36-2401 et, seq.
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80
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60
50
Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07
Maricopa County Correction.al Health Services
Health Assessme'nt Completion'within 14 days,A11 Facilities.FY2007
JMS data, Inmates with LOS greater than or equal to 15 days, n - 9,900
Confidential Pursuant to A.R.S. 36-2401, et. seq.
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Confidential Pursuant to A,R.S. §§ 36-2401 to 36-2404
Page 2 of4
MC Confidential (June 08) 001103
Previously reported February 2007:
CHS' new initiatives for health assessments have continued from September 2006 to present.
Health Assessments have been brought current and are being maintained. current at all Maricopa
County Jail facilities. An extensive effort to validate and make current the documentation of
physical exam, serology, and tuberculin skin testing completion dates in JMS Gail management
system) was completed. Thorough training on the use of JMS was developed and implemented.
The ongoing process for maintaining compliance with 14 day Health Assessments, is to schedule
trained nurses to perform health assessments at LBJ 5 days per week, at Intake 24 hours per
dayl7 days per week, at Durango 3 days per week and at 4th Avenue 2 days per week, utilizing a
"power squad" methodology. Maricopa County Sheriffs Office has contributed to the success of
this project by providing sufficient detention officer staff to accompany medical personnel for
power squads. Medical providers are completing health assessments during sick call at all
facilities. To ensure the health assessments are completed within 14 days, inmates needing
physical exams are placed on the sick call roster for completion oftheir physical exam at day 8-9
of incarceration. Additional training for healthcare support staff to verify existence of prior
incarcerations (especially within the last twelve months) through patient identification numbers
is currently being rolled out.
The health assessment completion rate rose to 91.6% in January 2007, and 92.6% in midFebruary 2007. Maricopa County Correctional Health Services contends the intent of J-E-04
Health Assessment is met, and that CHS is in compliance with this standard.
. Previously reported $eptember 2006:.
CHS hired 8 Traveler nurses to perform physical exams, working 12 hour shifts at both LBJ and
4th Avenue locations. Nurses are scheduled to provide 2417 coverage at 4th Avenue Intake in an
effort to complete health assessments upon inmate's entrance to the jail system. CHS will
continue to hire up to a total of 15 Traveler nurses, as needed for improvement efforts, along
with ongoing recruitment of regular staff. CHS staffing plan, based on Maricopa County
Managing for Results program, was approved by the Maricopa County Office of Management
and Budget, and the Maricopa County Board of Supervisors. The approved staffing plan
provides the following increases in positions: Medical Records Technicians - 6 new FTEs,
Mental Health Professionals - 10 new FTEs, MDs (Medical) -7 new FTEs, MDs (Psychiatrist)3 new FTEs, Correctional Health Techs - ]3 new FTEs, Licensed Practical Nurses - 7 new
FTEs, Registered Nurses - 26 new FTEs, Health Unit Coordinators - 31 new FTEs, Nursing
Supervisors - 4 new FTEs, Quality Coordinator - 1 new FTE
CHS has continued system-wide efforts to complete past due health assessments, in an effort to
improve inter-facility transfer of inmates to Department Of Corrections, and to decrease the
number of inmates needing a health assessment. Future improvement emphasis will be on the
completion of the health assessments in the earlier days of incarceration (within 14 days of
booking)
CHS documentation forms have been reviewed and revised to improve the collection of health
information. Methods of data collection and reporting have been reviewed.
Previously reported May 2006:
CHS focused effort at Durango jail to complete the health history, vital signs, and lab/diagnostic
testing portion of the 14 day health assessment.
Medical Providers changed practice for every inmate requesting sick call to include assessment
and treatment of the condition requiring sick call and to also include the physical exam, when
applicable. CHS continues to actively recruit and retain medical providers and nursing
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
Page 3 of 4
MC Confidential (June 08) 001104
personnel. CHS revised the training curriculum for Nurses to perform physical exams. CHS
plans to expand the training program with the recruitment of nurses.
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
Page 4 of4
MC Confidential (June 08)
001105
Maricopa County
Correctional Health Services
3250 W. Lower Buckeye Rd.
Suite
Dorinne L. Gray
Director, Quality/Utilization
Phoenix, Arizona 85009
Phone: (602) 876-7109
Fa:,:: (602) 506-2577
Management & Clinical Diagnostics
February 16,2007
Judith Stanley
National Commission on Correctional Health Care
1145 West Diversey Parkway
Chicago Illinois 60614
This document responds to the NCCHC's accreditation report review of findings dated
December 11, 2006, in which NCCHC requested subsequent documentation of compliance
with applicable Esseritial·and Important Standards on or before Fe1;>ruary 22 1 2007..
Maricopa County Correctional Health Services ril~ntains a robust comprehensive program for
continual quality improvement. Enclosed in report format and graphical representation, is
Maricopa County Sheriff s Office and Correctional Health Services corrective action and
evidence of compliance with NCCHC standards.:'
Maricopa County Correctional Health Services anticipates the remaining standards, J-E-04, JE-OS, and J-E-09, will be found in full compliance at the next NCCHC review meeting.
Thank you for the opportunity to respond to the December 11, 2006 findings.
Best regards,
Dorinne L. Gr
Manager of Quality I Utilization Management & Clinical Diagnostics
Maricopa County Correctional Health Services
MC Confidential (June 08) 001106
MARICOPA COUNTY
CORRECTIONAL HEALTH SERVICES
3250 W. Lower Buckeye Rd., Suite 2100
Phoenix, AZ 85009
(602) 876-7109
FAX (602) 442-8659
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
In their November 17,2006 meeting, the Accreditation Committee of the National Commission
on Correctional Health Care (NCCHC) voted to continue Maricopa County Sheriffs OfficeDetention Bureau on Continuing Accreditation Upon Verification with the qualification that
compliance with all of the Essential Standards and at least 85% of the applicable Important
Standards be demonstrated in a report to the NCCHC on or before February 22, 2007.
As reported in the NCCHC Accreditation Report Revised 12/11/2006, the following standards
.
required corrective action:
Essential Standards in Partial Compliance
J~E-04 Health Assessment
Important Standards in Partial Compliance*
*note: Prior to this rep~rt, 35 of37 applicable important standards (94.6%) have been cleared
and/or found in comp'liance by NCCHC, which exceeds the required 85%.
J-E-05 Mental Health Screening and Evaluation
J-E-09 Segregated Inmates
Maricopa County CHS Report of Accreditation Compliance
J-E-04 Health Assessment
Previously reported May 2006:
CHS focused effort at Durango jail to complete the health history, vital signs, and lab/diagnostic
testing portion of the 14 day health assessment.
Medical Providers changed practice for every inmate requesting sick call to include assessment
and treatment of the condition requiring sick call and to also include the physical exam, when
applicable. CHS continues to actively recruit and retain medical providers and nursing
personnel. CHS revised the training curriculum for Nurses to perform physical exams. CHS
plans to expand the training program with the recruitment of nurses.
Previously reported September 2006:
CHS hired 8 Traveler nurses to perform physical exams, working 12 hour shifts at both LBJ and
4th Avenue locations. Nurses are scheduled to provide 24/7 coverage at 4th Avenue Intake in an
effort to complete health assessments upon inmate's entrance to the jail system. CHS will
continue to hire up to a total of 15 Traveler nurses, as needed for improvement efforts, along
with ~>ngoing recruitment of regular staff. CBS staffing plan, based on Maricopa County
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
Page 1 of5
MC Confidential (June 08) 001107
".
Managing for Results program, was approved by the Maricopa County Office of Management
and Budget, and the Maricopa County Board of Supervisors. The approved staffing plan
provides the following increases in positions: Medical Records Technicians - 6 new FTEs,
Mental Health Professionals - 10 new FTEs, MDs (Medical) - 7 new FTEs, MDs (psychiatrist) . 3 new FTEs, CQrrectiona1 Health Techs - 13 new FIEs, Licensed Practical Nurses - 7 new
FTEs, Registered Nurses - 26 new FTEs, Health Unit Coordinators - 31 new FTEs, Nursing
Supervisors - 4 new FTEs, Quality Coordinator - 1 new FTE
CBS has continued system-wide efforts to complete past due health assessments, in an effort to
improve inter-facility transfer of inmates to Department Of Corrections, and to decrease the
number of inmates needing a health assessment. Future improvement emphasis will be on the
completion of the health assessments in the earlier days of incarceration (within 14 days of
booking)
CBS documentation forms have been reviewed and revised to improve the collection of health
information. Methods of data collection and reporting have been reviewed.
February 2007:
CHS' new initiatives for health assessments have continued from September 2006 to present.
Health Assessments have been brought current and are being maintained current at all Maricopa
County Jail facilities. An extensive effort to validate and make current the documentation of
physical exam, serology, and tuberculin skin testing completion dates in JMS Gail management
system) was completed. Thorough training on the use of JMS was developed and implemented.
The ongoing process for maintaining compliance with 14 day Health Assessments; i~ to schedule
trained 'nurses to perform health assessm'ents at LBJ 5 days per week; at Intake 24 hours per dayl7
days per week, at Durango 3 days per week and at 4th Avenue 2 days per week, utilizing a "power
squad" methodology. Maricopa County Sheriff's Office has contributed to the success of this
project by providing sufficient detention officer staff to accompany medical personnel for power
squads. Medical providers are completing health assessments during sick call at all facilities. To
ensure the health assessments are completed within 14 days, inmates needing physical exams are
placed on the sick call roster for completion of their physical exain at day 8-9 of incarceration.
Additional training for healthcare support staff to verify existence of prior incarcerations
(especially within the last twelve months) through patient identification numbers is currently
being rolled out.
The health assessment completion rate rose to 91.6% in January 2007, and 92.6% in midFebruary 2007. Maricopa County Correctional Health Services contends the intent of J-E-04
Health Assessment is met, and that CHS is in compliance with this standard.
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
Page 2 of5
MC Confidential (June 08)
001108
Maricopa County Correctional Health 5 rvic s
Health Assessment Completion ~ All Facilities
JMS data, All inmates with LOS >/= 10 15 days, n=avg. approx. 9000 each roonlh
Con dential Pursuant to A.R.S. 36-2401, et. se
"100 "
*
8
90
-I-
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80
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~
70
60 + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1
50 +--------,-----.,------,------,------,.....--------r--'
Aug-06
Sep-06
Oct-06
Nov-D6
Dec-D6
Jan-07
Feb-07
J-:E-05 Mental Health Screening and Evaluation
Previously reported September 2006:
Mental Health Screening is completed on all detainees at time of booking. All persons are then
compared to Value Options database (Maricopa County state-contracted Regional Behavioral
Health Authority for Medicaid, non-Medicaid and Title XXI eligible residents). CHS is notified
of persons receiving services from Value Options; mental health information is obtained from
case managers; and continuity of care is achieved. At the time of classification, inmates are
further screened for violent behavior, victimization, special education placement, andlor sex
offenses. CHS Mental Health Professionals are notified via the electronic Jail Management
System or referral of inmates with positive mental health screens needing further evaluation.
Mental Health Professionals (MHP's) perform a face-to-face assessment on these inmates in the
intake area. MHP's obtain outside records and treatment plans for those that are seriously
mentally ill, track inmate movement, and alert the clinic, where the inmate will be housed, to the
status of the inmate. MHP's at the housing facility perform a Mental Health Assessment within
14 days. The CHS Mental Health Assessment Form was developed and implemented in April
2006.
September 2006: The dynamic process stated above is ongoing with sustained effectiveness.
February 2007:
In June 2006, the NCCHC accreditation committee requested one additional month of data
demonstrating compliance with J-E-05, Mental Health Screening and Evaluation standard.
Maricopa County CHS submitted further data in September 2006. In the NCCHC revised report
dated 12-11-06, there was no mention of evidence of compliance that was submitted. Maricopa
County Correctional Health Services respectfully submits additional documentation of
compliance, totaling 4 months, as evidence that this standard should be found in full compliance.
Compliance that Mental Health Screening and Evaluations were completed within 14 Days of
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
Page 3 of5
MC Confidential (June 08) 001109
·
'.
booking are as follows: May 2006 = 100%, July 2006 = 93.3%, August 2006 = 94.1%,
December 2006 = 94.1 %. Maricopa County CHS intends to continue quarterly monitoring of
this standard as part of the Continuous Quality Improvement Program.
Maricopa CountyCorrectionalHeahh Services
Mental Heahh Screen &Evaluatio n
AllFacilities 2006
ConfidentialPursuant to ARS 36-2401et. seq.
100
100
100 100
100
100
90
80
70
60
50
40
30
20
10
o
Mental Helath, SCreen
' Mental Health Evaluation
,I_ May-06 • Jul-06 i:::J Aug-06 tJ Dec'-06 'I
J-E-OO Segregated Inmates
Previously reported September 2006:
Plan developed to revise policy and documentation practice.
Process in place: Inmates in segregation are checked by detention every 25 minutes.
Segregation checks by nursing staff are entered on the housing roster. Any inmate with a
healthcare complaint is offered an Inmate Request for Medical Services form. Any inmate with
any issue of questionable urgency is brought to the attention of the clinic RN, so that timely
triage and sick call evaluation can be completed. A nursing note is documented in the individual
inmate's medical record, progress note section.
February 2007:
The CHS policy and procedure entitled Segregated Inmates was revised on 12/15/06 and implemented
2/15/07, which addresses:
• MCSO notification to medical staff of initial inmate placement in segregation
• Review of inmate health information to determine contraindications to segregation
• Frequency of medical staff monitoring of segregated inmates based on degree of isolation in
accordance with NCCHC standards
• Documentation methodology
• Reference to MCSO policy and procedure for segregated inmate safety and well being through
detention security walks
• Reference to MCSO policy and procedure for segregated inmate access to programs and services
• Treatment of segregated inmates with non-urgent, urgent, and emergency health care needs
Confidential Pursuant to A.R.S. §§ 36-2401 to 36-2404
Page 4 of 5
MC Confidential (June 08) 001110
",
•
"
.
In June 2006, the NCCHC accreditation committee requested confinnation that the CHS plan was
implemented in order to be found in compliance. Maricopa County Correctional Health Services has
revised and implemented its Policy & Procedure and processes to comply with the NCCHC standards as
stated above. This report serves as the requested confirmation. Madcop!l County CHS contends this
standard is in full compliance.
Confidential Pursuant to A.R.S. §§ 36·2401 to 36-2404
Page 5 of5
MC Confidential (June 08)
001111
Maricopa County
Correctional Health Services
3250 W. Lower Buckeye Rd.
Suite
Dorinne L. Gray
Director, Quality/Utilization
Management & Clinical Diagnostics
Phoenix, Arizona 85009
Phone; (602) 876-7109
Fax; (602) 506-2577
September 29,2006
Judith Stanley
National Commission on Correctional Health Care
1145 West Diversey Parkway
Chicago Illinois 60614
This document responds to the NCCHC's accreditation report review of findings dated July
20, 2006, in which NCCHe requested subsequent documentation of compliance with
. app~icable Essential and Important Standards.onorbefore Octob~r 15,2006..
Maricopa County Correctional Health Services maintains a robust comprehensive program for
continual quality improvement. Enclosed in tabular format and graphical representation, is
Maricopa County Sh~riffs Office and Correctional Health Services corrective action and
evidence of compliance with NCCHC standards.
Maricopa County Correctional Health Services anticipates areas needing corrective action will
be cleared at the next NCCHC review meeting on November 17, 2006. Thank you for the
opportunity to respond to the July 20, 2006 findings.
Best regards,
Dorinne L. a
Director of Qu lity / Uti lzation Management & Clinical Diagnostics
Maricopa County Correctional Health Services
MC Confidential (June 08) 001112
Maricopa County Correctional'Health ServiceS
September 2006 Response to the NCCHC Accreditation SurveY.-conducted December 2005, NCCHC final Report dated February 24, 2006
Ell I
'Standard
I Compliance
PENDING COMPLIANCE ASSESSMENT
E
I J-E-04 Health Assessment
I
Partial
Confidential Pursuant to A.RS. 36-2401, et. seq.
I NCCHC Recommendation I'
CHS Resolution
HA be completed within 14 days
Immunization provided as
necessary
While this represents significant
progress, for full compliance, a
compliance rate of at least 90%
is required, provided the 10%
non-compliance is due to random
events and not aspecific pattern.
The facility remains in partial
compliance. (NCCHC June
2006).
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Medical Providers have changed practice for
every inmate requesting sick call to include
assessment and treatment of the condition
'requiring sick call and to also include the
,physical exam, when applicable. CHS
continues to actively recruit and retain medical
',providers and nursing personnel. CHS has
r~vised the training curriculum for Nurses to
,perfonm physical exams. CHS plans to
expand the training program with the
recruitment of nurses.
September 2006:
CHS has hired 8Traveler nurses to
perform physical exams, working 12 hour
shifts at both LBJ and 4lh Avenue
'locations. Nurses are scheduled to
provide 24/7 coverage at 4lh Avenue Intake
In'an effort to complete health
assessments upon inmate's entrance to
'the jail system. CHS will continue to hire
lip to a total of 15 Traveler nurses, as
n!'leded for improvement efforts, along with
'ongoing recruitment of regular staff. CHS
staffing plan, based on Maricopa County
Managing for Results program, has been
'approved by the Maricopa County Office of
Management and Budget, and'the
Maricopa County Board of Supervisors.
The approved staffing plan provides the
,following increases in positions:
Medical Records Technicians - 6 new FTEs
Mental Health Professionals -10 new FTEs
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May 2006:
'Focused effort at Durango jail to complete the
health history, vital signs, and lab/diagnostic
testing portion of the 14 day health
'assessment.
11/9/2006
CHS Evidence of Compliance
Significant improvement In the percent of
Health Histories, vital signs, and
lab/diagnostic tests completed within
fourteen days at Durango: February 2006 =
65%, May 2006 = 82%, June = 79%, July
= 82%, August = 77%
Compliance with health assessment
completion (all components of health
assessment, all inmates. based on JMS)
has improved: January 2006 =69.4%,
March 2006 = 70.7% (revised Sept. 2006)
The method for getermining health
assessment data using the MCSO Jail
Management System (JMS) was found to
have inherent variations and
inaccuracies.
CHS perfonned a random chart audit of
152 charts In all facilities on Inmates
booked between January and August
2006. Please note, audit denominator
data does not account for inmates that
may not have had a medical record
generated, (i.e. passed through intake
without TST, serology testing, or
physical exam AND who had never
requested medical services).
Results of Health Assessment Overall
Completion, chart audit August 2006:
Recording of Vital Signs = 97.4%
Collection of health history 98.0%
TB testing = 99.3%
Communicable Disease testing =
98.0%
Physical Exam =95.4%
HA completed within 14 days =
=
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Corifidential Pursuant to 4.ft.S. 36-2401, et. seq
Ell
Standard
Compliance
NCCHC Recommendation
CHS Resolution
MOs.(Medical) - 7 new FTEs
MOs (Psychiatrist) - 3 new FTEs
Correctional Health Techs - 13 new FTEs
Licensed Practical Nurses - 7 new FTEs
Registered Nurses - 26 new FTEs
Health Unit Coordinators - 31 new FTEs
Nursing Supervisors - 4 new FTEs
Quality Coordinator - 1 new FTE
CHS Evidence of Compliance
48.7%
CHS has continued system-wide efforts to
templete past due health assessments, in
an effort to improve lnter·facility transfer of
inmates to Department Of Corrections, and
to decrease the number of inmates
needing a health assessment. Future
improvement emphasis will be on the
completion of the health assessments in
the earlier days of incarceration (within 14
days of booking)
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C.HS documentation forms have been
reviewed and revised to improve the
collection of health Information.
.Methods of data collection and reporting
have been reviewed.
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Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.R.S. 36-2401, et. seq.
Ell I
I
Standard
Compliance I NCCHC Recommendation I. .
CHS Rii3otution
- - T CHS EvTdence of ComDliance
Maricopa County Correctional Health Services
Health Assessment Completion - All Facilities
lrunates booked 1/06 • 8/06 with LOS >/= to 15 days
Medical Chart Audit Conducted August 2006, n=152
Confidential Pursuant to ARS 36-2401 et.seq.
C
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100.0
'iI 80.0
T. _. I 97.4 I .
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Recording of
Vital Signs
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Collection of
Health History
TB Testing
MH evaluations completed within
. Communicable
Disease testing
Physical
Examination
Completed
within 14 days
of arrival
September 2006: Mental Health Screening is
'completed on all detainees at time of booking.
Need two months of data
All persons are then compared to Value
Options database (Maricopa County stateIn subsequent documentation. the contracted Regional Behavioral Health
Authority for Medicaid, non-Medicaid and Title
facility submitted results of their
corrective action since the
XXI eligible residents). CHS is notified of
February 2006 Accreditation
persons receiving services from Value
Committee meeting. It reports
Options; mental health information is obtained
results of the CQI stUdy of mental from case managers; and continuity of care is
health evaluations completed at· . achieved. At the time of classification,
all locations in May 2006 to be at
inmates are further screened for violent
100%. While this represents
'behavior, victimization, special education
significant progress,
'placement, and/or sex offenses. CHS Mental
confirmation of at least one
.Health Professionals are notified via the
14 days
CQI Audit. all locations 2006:
Mental Health Screens:
May =100%, July =100%, August =
100%
Mental Health Evaluations within 14
days: May 100%, July = 93%,
=
=
August 94% .
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3
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.K8. 36-2401, et. se....
Ell
Standard
CHS Resollition .
NCCHC Recommendation
more month of compliance is
needed. The facility remains in
partial compliance. (NCCHC
June 2006).
'CHS Evidence of Compliance
electronic Jail Management System or referral
of inmates with positive mental health screens
needing further evaluation. Mental Health
Professionals (MHP's) perform aface-to-face
assessment on these inmates in the intake
area. MHP's obtain outside records and
treatment plans for those that are seriously
mentally ill, track inmate movement, and alert
the clinic, where the inmate will be housed, to
t~e status of the inmate. MHP's at the
housing facility perform a Mental Health
. Assessment within 14 days. The CHS Mental
Health Assessment Form was developed and
implemented in April 2006.
.September 2006: The dynamic process
stated above is ongoing with sustained
effectiveness.
Maricopa CountyCorrectionalHealth Services
Mental Health Screen &Evaluatio n
AU Facilities 2006
Cor1fTdentia/ Pursuant to ARS 36-240Iet. seq.
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100
100
100
100
100
90
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70
60
50
40
30
20
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Mental He lath Screen
Mental Health Evaluatio n
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4
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.R.S. 36-2401, et. sea.
Ell
Standard
Comp~ance I NCCHe Recommendation I
CHS Resolution
. C.t'1S"·E'Iid~nce of Compliance
E
J-E-07 Non-Emergency Health
Care Requests & Services
Partial
I
I Estrella:
Triage tank orders within 24 hours
Estrella May 2006 :
Process for triage and scheduling of sick call
· reviewed and revised
NO NCCHC RESPONSE
DOCUMENTED, June 2006. Per September 2006:
LBJ OP has implemented a robust process
phone conversation with Judy
· fbr face·to·face nurse triage. A nurse
Stanley, CHS must document
compliance at LBJ OP.
dedicated to this process has been hired
and trained. At time of triage, any inmate
determined to be priority level one (needs
to be seen within 24 hours) are seen by a
. '.. provider in the main LBJ OP medical clinic
that day, or within 24 hours. Any inmate
determined to need emergency medical
.treatment is transported to the Emergency
· Room. CHS is working closely with MCSO
.detention officers to ensure flawless
~elivery of sick call and triage. Triage and
.sick call processes at Estrella are ongoing
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.~ 80
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50
40
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11/9/2006
CQI Audit LBJ OP 2006:
Medical Requests lriaged within 24 hours:
August 100%
Applicable inmates scheduled for sick call
within 24 hours: August = 100%
Applicable inmates received sick call
services as scheduled within 24 hours:
August = 100%
=
100
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Medical Requests Triaged
within 24 hours
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=
Maricopa County Correctional Health SeIVices
Non-Emergency Health Care Requests & Services
Estrella
Confidential Pursuant to ARS 36·2401 eL seq.
Maricopa County Correctional Health Services
Non-Emergency Health Care Requests &Services
LBJ OP August 2006
Confidential PlIrsuonllo ARS 36-2401 el. seq.
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CQI Audit Estrella 2006:
Medical Requests triaged within 24 hours:
April = 100%, May 93%, August = 100%
Applicable inmates scheduled for sick call
within 24 hours:
April =100%, May 2006 =100%, August
=100%
Applicable inmates received sick call
services as scheduled within 24 hours:
.April = 100%, May 2006 = 100%, August
= 100%
Applicable Inmates
Scheduled for Sick Call
within 24 Hours
Applicable Inmates
Received Sick Call within
24 Hours
Medical Requests Triaged Applicable Inmates
Applicable Inmates
within 24 hours
Scheduled for Sick Call Received Sick Callwithin
within 24 Hours
24 Hours
5
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.R.S..36-2401, et. seq
Ell
I
Standard
J-E-09 Segregated Inmates
Compliance
Partial
NCCHC Recom~ndation
4th Avenue - extreme isolation
inmates to be seen daily;
segregated inmates to be seen
3X per week (staffing sited)
CHS Resolution
.Plan developed to revise policy and
documentation practice.
J-H-04 Availability of health
record
Partial
Record is not always available at
the time of the medical or mental
health encounter - staffing cited
NO NCCHC RESPONSE, June
2006.
8:
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of Compliance
Process in place: Inmates in
segregation are checked by detention
every 25 minutes. Segregation checks
by nursing staff are entered on the
housing roster. Any Inmate with a
healthcare complaint is offered an
Inmate Request for Medical Services
form. Any inmate with any Issue of
questionable urgency Is brought to the
attention of the clinic RN, so that timely
triage and sick call evaluation can be
completed. A nursing note is
documented In the individual inmate's
medical record, progress note section.
In subsequent documentation, the
facility reports developing a plan
to provide the daily health checks
in the maximum security
segregation ("Super Max") cells.
Confirmation that the plan has
been implemented is required
for full compliance (NCCHC June
2006).
I
CHS..Evidence
Plan developed
·CHS continues to pursue EMR. CHS has
hired 4 additional Medical Record Technicians
·since January 2006. As of May 24, 2006, only
.1·Medical Record Tech vacancy remains.
·CHS implemented a process to transfer
medical records to on-site specialty clinics on
·day of clinic so that medical records are
ai.iailable to the provider prior to appointment.
COl audit all sites 2006:
Medical record available' at time of
the encounter:
May 2006 = 100%
August 2006 =97.6%
September 2006 = 98.6%
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As delineated in the CHS staffing plan,
CHS has increased the number of Medical
Record Technician FTE's by 6full-time
positions.
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has been published. The first bidders'
.conference will be on October 18,2006.
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6
Maricopa County Correctionai Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.R.S 36-2401, et. seq.
Ell I
Standard
I ComQliance I NCCHC Recommendation I
__ ~SHS Resolution
I G.H.S,E'=Videlice of Coml)liance
Maricopa County Correctional Health Services
Medical Record Available at Time ofFncounter
All Facilities 2006
Confidential Pursuant to ARS 36-2401
100
100
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See individual standards
'CHS has implemented strategies to
aggressively recruit and retain necessary staff.
CHS has completed athorough evaluation of
the tasks to deliver necessary health care and
The other standards cleared by 'tlie staffing needs to complete those tasks. A
corrective action subsequent to report of this evaluation is being developed
the survey indicate that the
and will be presented to the Maricopa County
facility is now in compliance , Office of Management and Budget.
with the intent of this standard
(NCCHC June 2006).
This standard will be met when
Sick Call, Triage, Chronic Care
and Consultant Care standards
are met
Sick CallI Triage standards met. See J-E07 Evidence of Compliance
Management of Chronic Disease intent of
standard met. See J-G-02
Consultant Car~ intent of standard met:
Utilization Management processes referrals
for Consultant Care on adaily basis M-F.
Appointments for authorized consultant
care are scheduled per priority designated
by referring provider. Statistics are kept
regarding appointment status and
monitored by the Quality Improvement
Committee and Executive Leadership.
Statistics were available to NCCHC
Surveyors at time of survey.
Between January 2006 and May 2006,
Maricopa County CHS has hired 2
7
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24,2006
Confidential
Pursuant to A.R.S. 36-2401, NCCHC Recommendation
CHS Resolution
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J-O-01 Pharmaceutical Operation
J-O-03 Clinic Space, Equipment &
Supplies
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Care
11/9/2006
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Subsequent to the February
2006 Accreditation Committee
meeting, the facility submitted
the results of CQI studies that
confirmed their corrective
action has improveCl the
medication renewal process.
The facility reports that timely
renewals for April 2006 were at
92% compliance; and for May
2006, at 97%. The facility is in
compliance with the
standard. (NCCHC June
2006).
In documentation of corrective
action taken after the survey,
the survey reported that sharps
counts were implemented at
the 4lb Avenue Jail.
Subsequent audits indicate that
in February, March and April
2006, compliance with weekly
sharps count was 100% at 4th
Avenue Intake, and 100% at 41h
Avenue Outpatient Clinic in
May. The facility is in
compliance with the std.
(NCCHC June 2006).
-
· Medication Renewal Process Medication process redesigned to discontinue
use of dual MAR. All medication
administration documentation has been
·unified to one MAR, which is maintained by
nurses, The method for notifying' the provider
·of upcoming medication expiration has been
standardized throughout the jail system.
Sharps counts implemented at 4th Avenue jail
..
The facility needs certifiCation, . . .
from SAMHSA. or must obtain an
exemption
CHS' Evidence of Compliance
Psychiatrists, 1 Forensic Psychologist, 3
Mental Health Professionals, 2 Psych RNs,
1 Psychometrist, 7 Correctional Health
Technicians,4 Health Unit Clerks, 1 Health
Care Administrator, 4 LPNs, 9 RNs, 1
Nursing Supervisor, 1 Physician Assistant,
1 Service
.
Worker, and 4 Medical Record Technicians.
cal Audit April 2006:
Medication renewed timely =92%
cal Audit May 20.06:
Medication renewed timely =97%
Continued monitoring:
Medication renewed timely:
july 2006 =89%
August 2006 =.100%
cal Audit 4th Avenue Intake, Sharps count
completed at feast weekly 2006:
January =100%; February = 100%; March
= 100%; April 10P%
CQI Audit 4th Avenue Outpatient Clinic,
Sharps count completed at least weekly
2006:
May =100%
=
Continued Monitoring 4th Avenue Intake:
Sharps count completed at least weekly
2006:
May =100%; June =100%, July = 100%;
August =100%
CHS maintains it does not prescribe
methadone to pregnant inmates to treat
substance abuse disorders. Methadone is
8
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC fmal Report dated February 24, 2006
Confidential
Pursuant to A.R.S. 36-2401
-
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Standard
J-E-12 Continuity of Care
Compliance
Y
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11/9/2006
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NCCHC Recommendation
NCCHC has been copied on
correspondence between the
SAMHSA representative and
the facility regarding the need
for OTP clinic accreditation
leading to federal
certification...However, the
dialogue continues and the
facility remains in compliance
with this standard in every
other aspect. The intent of
the standard is met.
(NCCHC June 2006).
Care ordered by prOViders is
transcribed and prOVided as
ordered
CHS Resolution
CHS:Evidence 'of Compliance
only administered to prevent spontaneous
abortion of the developing fetus, thus the
administration of methadone is regulated by
the physician's DEA number.
'Process for transcription, implementation and
documentation of provider orders was
reviewed. Documentation education delivered
iii February 2006.
The process for transcription,
implementation and
documentation of provider
..
orders was reviewed and reo
education given to involved
health staff during February
2006. In April, a 901 audit
confirmed significant progress
and confirmation that actioris take had addressed the issues.
The review included all clinical
sites. The facility reports that
97% of the orders were
transcribed in a timely manner
and 90% were initiated in a
timely manner. The audit was
repeated in May with 97% and
96% results respectively. The
intent of the standard is now
met (NCCHC June 2006).
Inmates who have serious health ·Keep-on-person medication procedure in
needs are oiven a supply of
place
CQI Audit April 2006 - All Clinical sites,
includes laboratory, medication, other
diagnostic testing, and treatment orders:
Orders transcribed timely =97%
Orders initiated timely =90%
COl Audit May 2006 - All Clinical sites,
includes laboratory, medication, other
diagnostic testing, and treatment orders:
Orders transcribed timely =97%
Orders initiated timely = 96%
Continued Monnoring:
COl Audit July 2006 - All Clinical sites:
Orders transcribed timely = 97%
Orders initiated timely =89%
COl Audit August 06- All Clinical sites:
Orders transcribed timely =92%
Orders initiated timely = 90%
Maricopa County has implemented one of
the most liberal Keep-on-Person proorams
9
Maricopa County Correctional'Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC fmal Report dated February 24,2006
-_
Ell
Standard
Compliance
••
---- ••• ---.
-
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__ • • •
--
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-_._~
NCCHC Recommendation
necessary medications sufficient
to last until the inmate is seen by
community providers.
_-
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....
--.l.
. CHS Resolution
Reviewed prescription practice with providers
The facility is meeting the
intent of this standard.
(NCCHC June 2006).
,
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J-G-01 SNTP
Y
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Use of treatment plans for
medical problems
Mental Health plans to outline and
guide treatment were missing
The intent of the standard is
met (NCCHe June 2006).
Medical treatment plan forms re-implemented;
Providers re-educated.
MH SNTP form revised, educated and
im'plemented April 2006.
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J-G-02 Management of Chronic
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CHS Evideil,ce of Compliance
in the nation, which is an important element
in our service. Inmates, who receive keepon-person medications and are released,
are permitted to take all remaining
medications with them. Inmates, who
receive direct-observation medications and
are due to be released, will have
prescriptions written for their medications,
upon request by the inmate. CHS works in
partnership with Value Options Case
Managers for inmates with serious mental
health needs to ensure continuity of care at
release. The VO Case manager receives
notification of the Inmate release and the
patient is handed over to Value Options,
who continues prescribed medications.
COl Audit April 2006 inpatient psych unit:
The SNTP includes treatment goals,
methods to meet goals and expected
completion dates = 89%; The needs of the
inmate are substantially met, consistent
with their SNTP = 100%;
Combined score = 95%
E
J-G-03 Infirmary Care
11/9/2006
Y
Effective system of tracking
chronic disease
Regularly scheduled clinics
Consistent use of chronic care
f10wsheet
Care consistent with current
national guidelines
The intent of the standard is
met (NCCHC June 2006).
Admitting notes to include
diagnosis, medication, diet,
activity, diagnostic tests required,
CHSutilized a consultant firm to develop a
database to track chronic care inmates.
Chronic care database allows the capability to
monitor frequency of appointments in line with
guidelines, so that appointments may be
regularly scheduled as necessary.
Chronic care form re-implemented; Providers
educated to complete and consistent use,
Plan developed for identification of high-risk
patients for influenza vaccine,
Re-implemented use of in-patient admission
order form to include diagnosis, medication,
diet, activity, diagnostic tests required, and
Audit scheduled every 6 months, next audit
October 2006
Influenza vaccine ordered May 2006.
Database designed.
Continued Monitoring April- Sept 2006,
Infirmary:
Admission orders include -
10
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC flnal Report dated February 24, 2006
"1.
Confidential Pursuant to A.R.S. 36-2401
Ell
Standard
Compliance
-
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frequency of vital sign monitoring
and frequency of vital sign
Discussed documentation of discharge plan I
monitoring
notes with provider
In-patient record to inCI(Jde ..
.P.erry & Potter Nursing manual on unit
discharge plan or discharge
notes.
Providers to round on patients per
policy
Manual of nursing care to be
available
The facility is in compliance
with the standard. (NCCHC
June 2006).
I-h
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..... i<.
CHS Resolution
NCCHC Recommendation
eMS Evidence of Compliance
Diagnosis =
April-100%
May ·100%
Aug-93%
Sept-100%
VS frequency =
April- 94%
May- 94%
Aug-BO%
Sept-100%
Activity =
April-97%
May- 94%
Aug-93%
Sept-100%
Diet =
April-100%
May-100%
Aug-93%
Sept-100%
Lab I diagnostic testing =
April- nla
May-100%
Aug-100%
Sept- nla
Medications =
April- 90%
May-100%
Aug-93%
Sept-100%
DIG plan documented =
April-100%
May-100%
Aug -100%
Sept- nla
Discharge Order =
April- 100%
May-100%
Aug -100%
Sept- nla
11
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant t(J A.R.S.. 36-2401, et. seq
Ell
Compliance NCCHC Recommendation
Standard
CHS. ReSQlution
QI:J~:~vidence of Compliance
Physician round per policy =
April- 97%
May-100%
Aug-100%
Sept-100%
Nursing round per policy =
April-100%
May -100%
Aug-100%
Sept-100%
E
J-G-05 Suicide Prevention
Y
Documentation required that
shows Corrective action is
identified and implemented for
2005 suicides
· None Required - documentation available
Documentation available. All Corrective
Actions completed and implemented.
Continued Monitoring:
No suicides have occurred 1-1-06 through
9-18-06.
The intent of the standard is
met (NCCHC June 2006).
COMPLIANT PER NCCHC FEBRUARY 2006
8::
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J-A-01 Access to Care
J-A-02 Health Authority
J-A-03 Medical Autonomy
J-A-04 Administrative meetings
J-A-05 Policies & Procedures
J-A-06 COl Program
J-A-O? Emergency Response
Y
y
y
y
y
y
Y
E
J-A-08 Communication of Special
Needs Patients
J-A-09 Privacy of Care
J-A-1O Inmate Death
J-A-11 Grievance Mechanism
y
None Required
y
y
y
None Required
·None Required
None Required
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None Required
None Required
·None Required
None Required
·None Required
None Required
E
E
E
E
E
E
E
11/9/2006
See J-E-O?
Involve correctional staff and
community agenciesIn
Emergency Response Plan
Monitor grievances by types,
sites, time of day, etc. as part of
COl program
Mock emergency scenarios are conducted
in Training Academy; MCSO officers
involved in Mass Disaster Drills, Man-Down
Drills and critiques of both.
External grievances monitored by type and
site. CHS receives reports from MCSO on
all grievances by descriptor and location.
MCSO is looking into possibility of updating
their system to allow for enhanced
monitorinq and trendinq capabilities.
12
Maricopa County Correction~l Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
..
Ell
Standard
Compliance
I
E
J-A-12 Sexual Assault reportinq
J-B-01Infection Control Program
Y
y
- -----,
- .. - -.-_.-.- -- ------_. --
NCCHC Recommendation
Comment: MRSA - high
prevalence, significant local
attention
._-,-_._---
CHS rtesolution
None Required
None Required
.
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J-B-02Environmental Health &
Safety
Y
Cleaning schedules doubled. Showers
renovated. Issues corrected.
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y
0-
E
J-B-03 Kitchen Sanitation
J-B-04 Ectoparasite Control
J-C-01 Credentialino
J-C-02 Clinical Performance
Enhancement
J-C-03 Continuino Education
J-C-04 TFaining for Correction
J-G-05 Medication Administration
Trainina
J-C-OB Inmate Workers
J-C-OB Health Care Liaison
J-e-09 Orientation
J-D-02 Medication Services
J-D-04 Diaonostic Services
J-E-01 Information on health
Y
Y
None Required
None Required
.None Required
None Required
Y
Y
Y
None Required
None Required
None Required
y
.None Required
None Required
None Required
None Required
None Required
None Required
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N/A
y
Y
Y
Y
GHS:Evide.ncQ of Compliance
Infection Control data do not support the
conclusion that "there is a high prevalence
of this disease at this jail". Infection Control
monitors all available laboratory reports,
and all hospitalized inmate reports for
positive MRSA cultures In CHS patients.
Medical records of patients with positive
MRSA cultures are reviewed, and a
determination is made regarding probable
community versus jail acquisition of
infection. Reports are presented to the
quarterly CHS Infection Control
Subcommittee, which include aline listing
of specific cases and graphic representation
of monthly MRSA rate. Approximately 40 50% of identified MRSA cases are
determined to be community-acquired.
Occasional inquiries have been received
from local news media. However, this is
not frequent nor a "focus of significant local
attention."
CHS submitted subsequent documentation
to NCCHC. NCCHC has found the facility
to be in compliance with the standard
13
Maricopa County Correctional Health Services
September 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
C
.--- ..
----, -----J
Ell
Standard
Compliance
E
E
E
E
I
services
J·E-02 Receiving Screening
J-E-03 Transfer Screening
J-E-OB Oral Care
J-E-08 EmefQency Services
J-E-10 Patient Escort
y
y
Y
Y
Y
I
I
J-E-11 Nursing Protocols
J-F-01 Health Education
Y
Y
I
I
I
I
E
J-F-02 Nutrition &Medical Diets
J-F-03 Exercise
J-F·04 Personal Hygiene
J-F-05 Use of Tobacco
J-G-04 Mental Health Services
J-G-06 Intoxication & Withdrawal
J-G-07 Pregnant Inmate care
J-G-OB Inmates with Alcohol or
other drug problems
Y
y
y
y
E
E
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J·G-09 Sexual Assault procedure
J·G-10 Pregnancy counseling
J·G-110rlhoses & aids
J·G-12 Care of terminally ill
J·H-01 Health record format
J·H·02 Confidentiality of records
J·H-03 Access to custody info
J·H-05 Transfer of records
J·H-06 Retention of records
J-J·01 Use of restraint & seclusion
J·I-02 Emergency Psychotropics
J-)-03 Forensic information
J-I·04 End of Life decision making
J-I-05 Informed Consent
J-I-06 Right to Refuse treatment
J-I-07 Medical or other research
-
Y
Y
Y
Y
y
Y
y
Y
Y
Y
Y
y
y
y
y
Y
Y
Y
Y
--
-
COl study to determine if delayed
access to diabetic pt due to escort
not available is a system-wide
problem
4th Ave & LBJ - i opportunities
for the GP to receive health educ.
Y
8:
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NCCHC Recommendation
Enhance substance abuse
program at 4th Ave &LBJ.
Estrella has strona proaram
Would likely beneijt from EMR
-
CH$ Resolution
CH$"Evidei1ce of Compliance
· None Required
None Required
None Required
·None Required
None Required
·None Required
·None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
. .None Required
.None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
o
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11/9/2006
14
•
Maricopa County
Correctional Health Services
Administration
May 26, 2006
234 N. Centro! Ave.
5"'F1"""
Phoenix, Arizona 85004
Phone: (601) 506-2906
F"", (601) 506-2577
Ms. Judith Stanley
National Commission on Correctional Health Care
1145 West Diversity Parkway
Chicago, III 60614
Re: May 2006 Response to the NCCHC Accreditation Survey conducted
December 2005, NCCHC Final Report dated February 24, 2006
Dear Ms. Stanley:
This letter responds to the NCCHC Final Report described above.
NCCHC reports that Maricopa County meets 28 of the 35 essential Standards. 1
The attached audit summary shows that Maricopa County has complied with the
intent of all remaining Essential Standards. Statistically valid audits of Maricopa
Countis compliance indi~tors demonstrate· that it has achieved 90% to 100%·
compliance in 6 of the remaining Essentiaf Standards: In" addition, Ci-is has .
demonstrated improvement in achieving compliance with J-E-04, Health
Assessments. CHS invites the Commission's attention to the improvements listed
in the Evidence of Compli;:lnce column in the attached Resolution Document.
NCCHC reports that Maricopa County meets 29 Important Standards. Given the
85% goal for meeting Important Standards, Maricopa County must comply with an
additional 3 Important Standards, for a total of 32. The attached Resolution
Document shows that Maricopa County meets at least 4 additional Important
Standards, particularly J-D-03 (Clinic Space, Equipment and Supplies); J-E-05
(Mental Health Screen and Evaluation; J-E-13 (Discharge Planning); and J-H-04
(Availability of Health Records). Furthermore, Maricopa County has demonstrated
improvement in achieving compliance with J-G-02 (Management of Chronic
Disease).
The NCCHC survey report contains a number of statements that are not
supported by the facts. In my previous discussions with NCCHC leadership, i
explained how the survey and report impact Maricopa County's risk management
and litigation interests. This means that Maricopa County has a significant financial
stake in the accuracy of NCCHC pronouncements.
The listing of errata in this letter is not exhaustive and Maricopa County reserves
the right to challenge, contradict or disclaim other incorrect or unsubstantiated
statements by NCCHC at any time. Maricopa County requests that NCCHC
correct the report to reflect the following:
1 The
original survey found compliance with 27 Essential standards. NCCHC later found
compliance with J-B-02, Environmental Health and Safety, based upon documentation
submitted by the Maricopa County Sheriffs Office.
MC Confidential (June 08) 001127
Ms. Judith Stanley
Response to NCCHC Findings
May 26,2006
Page 2 of3
County governance should be properly noted•
. Th~ Maricopa County correctional health services are under the aegis of ·the
Maricopa County Manager, not a city manager. The CHS Director reports to the
Deputy County Manager, not the deputy city manager. References to the "CEO"
should be the "CHS Director."
More importantly, the responsible health authority, Correctional Health Services, is
a department of Maricopa County, not a separate corporation.
The report should accurately state the chronological record.
State that the NCCHC Accreditation Committee met in 2006, instead of 2005 and
that the response is due in 2006, instead of 2005.
NCCHC should state the correct standards when asking for correctlv
action.
For example, the report demands corrective action, citing J-E-13(2)(b), which
applies to follow-up services with community providers. However, the narrative
direction for corrective action requires CHS to supply a sufficient amount of
medication to discharged inmates, which is a different standard under J-E-13(2)(a).
Maricopa County's. Infection .control data contradic;t the report's conclusion·
.that "there is a high prevalence of this disease at this jail."
...
.
Maricopa County searches for positive MRSA cultures in all laboratory results from
Sonora Quest, the Maricopa County Public Health Laboratory, and all hospital
.reports collected by CHS Utilization Management. For the calendar year 2005, .
. Maricopa County identified a total of 40 inmates with MRSA. Approximately 15 of
those inmates acquired the infection in the community. rather than in the jail.
The report does not correctly describe·the facilities. Correct descriptions are
below in regular type.
The main campus consists of Estrella Jail, Estrella Support (Tents). Lower
Buckeye Jail (LBJ), Towers Jail and Durango Jail.
The 4 n Avenue jail processes all male and female inmates with the exception of
self surrenders. The jail performs many functions that are not related to intake,
such as maximum security housing, IA Court, Bonds and Forfeitures, and
probation violations.
LBJ has serviced since April 2005 a 60-bed capacity infirmary and a 260-bed
inpatient psychiatric facility.
The reference to "Estrella Support Jail" should be "Estrella Jail". Estrella jail does
not perform intake functions. It also does not house male inmates. The report's
discussion regarding corrective action under J-A-01 and J-E-07 confuses Estrella
Support Jail with Estrella Jail.
"Estrella Tent City" is known as "Estrella Support (Tent City)". Also, Estrella
Support (Tent City) is adjacent to the Estrella Jail, not Estrella Support.
The report misstates staff titles of persons interviewed.
MC Confidential (June 08) 001128
Ms. Judith Stanley
Response to NCCHC Findings
May26,2006
Page 30f3
Reference to "2 unit directors of nurses" should be "2 Nurse Supervisors."
Reference to the "director of mental health services, two psychiatrists, the
outpatient mental health director" should be "the inpatient mental health
professional supervisor, two psychiatrists, the outpatient mental he.alth professional
supervisor."
The Director of Mental Health performs psychological autopsy. not the chief
psychologist.
The report misstates the process and documentation regarding disaster drills.
The survey team members were given unlimited access to file cabinets replete with
documentation proving an annual disaster drill was held at each facility as reqUired.
The documentation also showed that all required man-down drills were performed in
every facility and included participation by both MCSO officers and CHS health staff.
Nevertheless, the report states that this documentation was unavailable. The report
.cites to interviews of 25 of the over 2000 detention officers as confirming that mandown drills have not occurred at 4th avenue jail, and that documentation was not
available that man-down drills were performed at other jails.
The report should correctly describe Maricopa County's grievance procedure.
The Clinical liaison I Risk Manager and Director of Quality Management review all
of initial
and institutional
grievances~
external grievances
and..aggregate
data
.
.
.
'.
..,
.
.'.
.
Nursing, mental health or dental staff typically performs the initial review of
grievances.
The nurse supervisor, MHP supervisor or dentist responds to
institutional grievances. External grievances are always reviewed and trended by
the Clinical liaison I Risk Manager and Director of Quality Management.
The report should correctly describe the inmate co-pay system.
The detention bureau provides each inmate with a copy of "Inmate Rules and
Regulations," which sets out rules of the jail and describes the co-pay system. The
information is provided at intake during the pre-booking health screening process.
Co-pay is $10.00, not $5.00. We would be pleased to provide a copy of these rules
if the survey team failed to obtain them.
If you have any questions regarding this response, please do not hesitate to contact
me at (602) 690-7610.
Best regards,
lsI
Lindy Funkhouser, Director
Maricopa County Department
of Correctional Health Services
MC Confidential (June 08) 001129
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Maricopa County Correctional Health Services
May 2006 Response to the NCCHC Accreditation Survey conducted
December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.R.S. 36-2401, et. seq.
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Medication Renewed Timely
PJI Facilities 2006
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70
60
50
(
40
30
20
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April
May
_ _ _ _ _ _ _ _ _ _ _ _ _- ' - - -
.
••••• _
•• _._
. _• • • • • • _
••••••
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Source: Maricopa·County 2006 QI Audit
Results
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J-D-03 Clinic Space) Equipment ~ndS~pplies-
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SHARPS Inventory weekJ.y compliance - 4th Ave Intake
Tune Period:1/23/06 to 412106
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70.0% +1- - I
60.0% +1---1
50.0% -+-1- - - I
40.0% 1
1
30.0%
20.0% +1--,
10.0% +1-0.0% +1_-'
Week 1 Week 2 Week 3 Week 4' Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
.•.
Source: Maricopa County 2006 QI Audit
Res'ults
-- - --_.- -_ _._._------.
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Source: Maricopa County 2006 QI Audit
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Maricopa County Correctional Health Services
Mental Health Sc.reen & Evaluation
All Facilities May 2006
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IVIental Health Evaluation
._-_.,--_ -..-...........
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Source: Maricopa County 2006 QI Audit
Results
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Maricopa County Correctional Health Services
Non-Emergency Health'Care Requests & Services
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• May
3
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Medical Requests
Triaged within 24
Applicable Inmates
Applicable Inmates
Scheduled for Sick Call
Received Sick Call
hours
within 24 Hours
within 24 Hours
---'~"'-"-~.-
Source: Maricopa'County 2006 QI Audit
. Results
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Continuity of Care
All Fa ci lities
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Transcnbed
TImely
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May-De
Apr-De
.._, --_., -.- ._.,
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Source: Maricopa County 2006 QI Audit
Results
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Maricopa County Correctional Health Services
Special Needs' Treatment Plan
April 2006
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Source: Maricopa County 2006 QI Audit
Results
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Infirmary Care
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'Results
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Medical Record Available at Time ofEncomter
May 06
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80.0%
60.0%
40.0%
20.0%
0.0%
Durango
Towers.
LBJ
4th Ave
Psych
--------------------------=---------------_._--.. - . __._.. _--Source: Maricopa County 2006 Q I Audit
Results
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conducted December 2005, NCCHC final Report dated
February 24, 2006
Maricopa County Correctional Health
Services
Confidential Pursuant to A.R.S. 36-2401, et. seq.
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Maricopa County Correctional Health Services
Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.KS. 36-2401, et. seq.
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Standard
J·A.Q1 Access to Care
J·A.Q2 Health Authority
J·A.Q3 Medical AutonoolY
J·A.Q4 Administrative meetings
J.A-05 Policies &Procedures
J.A.QS cal ProQram
J·A.Q7 Emergency Response
ComDUance
Y
NCCHe Recoinmendatii:m
see J-E.Q7
Y
Y
y
Y
y
Y
Involve correctional staff and community
agencies in Emergency Response Plan
CHS Resolution
None Required
None Required
None ReQuired
None Required
None ReQuired
None ReQuired
None Required
Y
None Required
I
I
I
J·A.Qa Communlcation of Special
Needs Patients
J.A.Q9 Privacy of Care
J·A·10 Inmate Death
J.A·11 Grievance Mechanism
Y
Y
y
None Required
None ReQuired
None ReqUired
I
E
J·A·12 Sexual Assault reoortina
J·S.Q1 Infection Control Program
Y
E
6/1/2006
Monitorgnevancesby.types, sites, time
of day, etc. as part of cal program
None ReQuired
None Required
Y
Comment: MRSA _. high prevalence,
significant local a~ention
.
CHS Evidence of Compliance
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Training Academy; Meso officers involved
Mass Disaster Drills, Man-Down Drills and
critiques of both.
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External grievances monitored by type and
site. CHS receives reports from MCSO on !
grievances by descriptor and location. MCE
is looking into possibility of updating their
system to allow for enhanced monitoring an·
trending capabilities.
Infection Control data do not support the
conclusion that "there is a high prevalence c
this cisease at this jail". Infection Control
monitors all available laboratory reports, anc
all hospitalized Inmate reports for positive
MRSA cultures In CHS patients. Medcal
records of patients with positive MRSA
cultures are reviewed, and a determination i
made regarding probable community versus
jail acquisition of infection. Reports are
presented to the quarterly CHS Infection
Control Subcommittee, which include a line
listing of specific cases and graphic
representation of monthly MRSA rate.
2
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Maricopa County Correctional Health Services
May 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
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Confidential Pursuant to A.R.S. 36-2401, et. seq.
En
Standard
Compliance
CHS Resolution
NCCHe Recommendation
-.
E
I
I
E
I
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E
E
E
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J·B-02 Environmental Health &
Safety
Y
J-B-03 Kitchen Sanitation
J·B-04 Eotoparasite Control
J·C-01 Credentlallng
J-C-02 Clinical Performance
Enhancement
J-C-03 Continuing Education
J·C-04 Traininafor Correction
J-C-05 Medication Administration
Tralning
J·C-06 Inmate Worners
J-C-07 Staffing Plan
Y
Y
y
Cleaning schedules doubled.
Showers renovated. Issues
corrected.
None Reauired
None Required
None Required
None Required
..
Y
y
Partial
This standard will be .rnet when Sick Call,
Triage, Chronic Care and Consultant
Care standards are met
.
6/1/2006
CHS Evidence of Compliance
Approximately 40 - 50% of Identified MRSA
cases are determined to be communityacquired.
Occasional inquiries have been received fro
local news media. However, this is not
frequent nor a "focus of significant local
attention:
CHS submitted subsequent documentation'
NCCHC. NCCHC has found the facility tc
be in compliance with-the standard
None Required
See incividual standards
CHS has implemented strategies to
aggressively recruit and retain
necessary staff.
CHS has completed athorough
evaluation of the tasks to deliver
necessary health care and the
staffing needs to complete those
tasks. Areport of this evaluation is
being developed and will be
presented to the Maricopa County
Office of Management and BUdget.
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None Reauired
None Required
Y
Y
y
o
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Sick CallI Triage standards met See J-E-O
Evidence of Compliance
Management of Chronic Disease intent of
standard met. See J-G.Q2
Consultant Care intent of standard met
Utilization Management processes referrals
for Consultant Care on a dally basis M·F.
Appointments for authorized consultant care
are scheduled per priority designated by
referring provider. Statistics are kept
regarding appointment status and monitorec
by the Quality Improvement Committee and
Executive Leadership. Statistics were
available to NCCHC Surveyors at time of
survey.
Between January 2006 and May 2006,
Maricopa County CHS has hired 2
3
(Y)
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Maricopa County Correctional Health Services
May 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.R.S. 36-2401, et. seq.
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Compliance
NeCHC RecOmmendation
CHS Resolution
CHS Evidence of Compliance
Psychiatrists, 1Forensic Psychologis~ 3
Mental Health Professionals, 2 Psych RNs,
Psychometrist, 7 Correctional Health
Technicians, 4 Health Unit Clerks, 1Health
Care Administrator, 4LPNs, 9 RNs, 1Nursil
Supervisor, 1Physician Assistant, 1 Service
Worker, and 4 Medcal Record Technicians.
I
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J-C..Q8 Health Care Uaison
J·C..Q9 Orientation
J·O-D1 Pharmaceutical Operation
J·O-D2 Medication Services
J·O..Q3 Clinic Space, Equipment &
Supplies
None Required
None Required
Medication Renewal Process Medication process redesigned to
discontinue use of dual MAR All
medication administration
documentation has been unified to
one MAR, which is maintained by
nurses. The method for notifying
the provider of upcoming medication
expiration has been standardized
throughout the jail system.
None Required
Sharps counts implemented at41h
N/A
Y
Partial
Y
Partial
Avenu~jail
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J·D..Q4 Diaonostio Services
J·D..Q5 Hospital and Specialty
Care
6/1/2006
y
Partial
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cal Audit April 2006:
Medication renewed timely =92%
cal Audit May 2006:
Medication renewed timely = 97%
cal Audit41h Avenue Intake, Sharps count
completed at least weekly 2006:
January = 100%; February = 100%;
March = 100%; April = 100% ;
cal Audit 4111 Avenue Outpatient Clinic,
Sharps count completed at least weekly
2006:
May = 100%
None Required
The facility needs certification from
SAMHSA, or must obtain an exemption
(1)
l=:
CHS maintains it does not prescribe
methadone to pregnant inmates to treat
substance abuse dsorders. Methadone is
only administered to prevent spontaneous
abortion of the developing fetus, thus the
administration of methadone is regulated by
the physician's DEA number.
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May 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
ConfidentialPursuant to A.R.S. 36-2401, et. seq.
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o
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StandaFd
J-E-01 Information on health
Compfiance
NeCHC Recommendation
Y
CHS Resolution
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CHS Evidence of Compliance
None Required
I-)
services
E
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J.E..Q2 ReceivinQ SCreenlna
J·E..Q3 Transfer SCreeolno
J-E-04 Health Assessment
J·E-05 Mental Health Screen &
Evaluation
6/1/2006
y
Y
Partial
Partial
HA be completed within 14 days
Immunization provided as necessary
None Required
None Required
Focused effort at Durango jail to
complete the health history, vital
. signs. and latVdiagnostic testing
portion of the 14 day health .
assessment.
Medical Providers have changed
practice for every inmate requesting
sick call to include assessment and
treatment of the condition requiring
sick call and to also include the
physical exam, when applicable.
CHS continues to actively recruit
and retain medical providers and
nursing personnel. CHS has
revised the training curriculum for
Nurses to perform physical exams.
CHS plans to expand the training
program with the recruitment of
nurses.
MH evaluations completed within 14 days Mental Health Screening is
completed on all detainees and is
Need two months of data
required prior to acceptance for
booking. Mental Health
Professionals are notified by the
electronic Jail Management System
of all inmates with positive mental
health screens. Mental Health
..
Professionals (MHP's) perform a
face-ta-face assessment on these
inmates in the intake area. MHP's
..
..
obtain outside records and
treatment plans for those that are
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Significant improvement in the percent of
Health Histories, vital signs, and Iabldagno!
tests completed within fourteen days at
Durango: February 2006 65%, May 200
=82%
=
Compliance with health assessment
completed within 14 days (all components a
health assessment all inmates) has improvI
January 2006 76.1%, March 2006 =
77.3%
=
COl Audit. all locations 2006:
Mental Health Screens, May 100%
Mental Health EvaluatIons, May 100%
=
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May 2006 Response to the NCCHC Accreditation Survey cOnducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.R.S. 36-2401, et. seq.
Standard.
En
Compliance
CHS Resolution
NeCHC Recommendation
seriously mentally ill, track inmate
movement and alert the clinic,
where the inmate will be housed, to
the status of the inmate. MHPs at
the housing facility perfonn aMental
Health Assessment within 14 days.
The CHS Mental Health
Assessment Form was developed
and implemented in April 2006.
..
E
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J·E-DS Oral Care
J.E-D7 Non-Emergency Health
Care Requests & Servtces
Y
Partial
CHS Evidence of Compliance
.
Estrella:
Triage tank orders wiihin 24 hours
None Required
Estrella:
Process for triage and scheduling of
sick call reviewed and revised
I
J·E-1O Patient Escort
6/112006
Y
Partial
Y
4th Avenue - extreme isolation inmates to
be seen daily; segtegated inmates to be
seen 3X Perweek (staffing sited)
CQI study to determine if delayed access
to diabetic patient due to escort not
available is a system-wide problem
None Required
Plan developed to revise policy and
documentation practice.
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Medical Requests triaged within 24
hours = 100%
Applicable Inmates scheduled for sic
call within 24 hours = 100%
Applicable Inmates received sIck call
services as scheduled within 24 hour
=90%
=
J·E-Qa Ememency Services
J·E-Q9 Segregated Inmates
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CQI Audit Estrella May 2006:
Medical Requests triaged wlthln24
hours = 93%
Applicable Inmates scheduled for sic
call within 24 hours 1000/0
Applicable Inmates received sick call
services as scheduled within 24 hour
= 100%
E
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Plan developed
None Required
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May 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
ConjidentialPiJrst!qnt toA.1J..S. 36-2401, et. seq.
Stand~
J-E·11 Nursing Protocols
J-E·12 Contlmily of Care
Compliance
y
Partial
NCCfiC Recommendation
Care ordered by providers is transcribed
and provided as Ordered
CHS Resolution
None ReQuired
Process for transcription,
implementation and documentation
of provider orders was reviewed.
Documentation education delivered
in February 2006.
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COl Audit April 2006 - All Clinical sites,
includes laboratory, medication, othSr
diagnostic testing, and treatment orders:
Orders transcribed timely =97%
Orders Initiated timely 90%
=
includes laboratory, medication, other
diagnostic testing, and treatment orders:
Orders transcribed timely =97%
Orders Initiated timely =96%
:
I
J·E·13 Discharge Planning
Partial
Inmates who have serious health needs
are given a supply of necessary
medications sufficient to last untllthe
inmate is seen by community providers.
Keep-on-person medication
procedure in place
Reviewed prescription practice with
providers
.
I
J.F.Q1 Health Education
y
I
I
I
J.F.Q2 Nutrition &Medcal Diets
J-F.Q3 Exercise
J-F-04 Personal Hygiene
Y
y
y
6/1/2006
41!l Ave &LBJ - more Opportunities be
given for the general population to
receive health education
Maricopa Counly has implemented one of tt
moslliberal Keep-on-Person programs in th
nation, which is an Important elemen! in our
service. Inmates, who receive keep-onperson medications and are released; are
permitted to take !ill. remaining mecications
with them. Inmates, who receive directobservation mecications and are due to be
released, will have prescriptions written for
their medications upon request by the inma!
CHS works in partnership with Value Option
Case Managers for inmates with serious
mental health needs to ensure continuity of
care at release. The VO Case manager
receives notification of the inmate release al
the patient is handed over to Value Options,
who continues prescribed medications.
None ReqUired
None Required
None Required
None Required
7
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May 2006 Response to the NeCHC Accreditation Survey conducted December 2Q05, NCCHC final Report dated February 24, 2006
Confidential Pursuant to A.RS. 36-2401. et. seq.
Ell
Standard'
I
E
J·F-QS Use of Tobacco
J·G-01 SNTP
Compliance
Y
Partial
NCCHe Re~mmendation
Use of treatment plans for medical
problems
Mental Health plans 10 outline and guide
treatment were missing
CHS Resolution
None Required
Medical treatment plan forms reimplemented; Providers reeducated.
MH SNTP form revised. educated
and implemented April 2006.
ex>
o
CHS Evidence of Compliance
COl Audit April 2006 inpatient psych unit:
The SNTP Includes treatment goals,
methods to meet goals and expected
completion dates =89%; The needs of th
inmate are substantially met, consistent
with their SNTP =100%;
Combined score 95%
Influenza vaccine ordered May 2006.
Database designed.
=
I
J-G-Q2 Management of Chronic
Disease
Partial
Effective system of trackiQ9,chronic
..
disease
Regularly scheduled clinics
Consistent use of chronic care flcwsheet
Care consistent with current national
guidelines
CHS utilized a consultant firm to
develop a database to track chronic
care inmates. Chronic care
database allows the capability'to
monitor frequency of appointments
in line with guidelines, so that
appointments may be regularly
scheduled as necessary.
Chronic care form re-implemented;
Providers educated to complete and
consistent use,
Plan developed for identification of
high-risk patients for influenza
vaccine.
Admitting notes to include diagnosis,
,medication. diet, activity. ciagnostic tests
required, and frequency of vital sign
monitoring
In-patient record to include discharge
plan or discharge notes.
Providers to round on patients par policy
Manual of nursing ~re to be available
Re-implemented use of in-patient
admission order form to include
diagnosis. medcation, ciet activity.
diagnostic tests required, and
frequency of vital sign monitoring
Discussed documentation of
discharge plan I notes with provider
Peny &Potter Nursing manual on
unit
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Partial
'
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6/1/2006
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COl audit April 2006, Infirmary:
Admission orders include Diagnosis 100%
VS frequency 94%
ActiVity 97%
Diet 100%
Labs / diagnostic testing none
applicable
Medications ordered & on MAR 9(0)
Discharge plan documented 100%
Discharge Order = 1000!o
Physician round per policy 97%
Nursing round per policy 100%
=
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Maricopa County Correctional Health Services
May 2006 Response to the NCCHC Accreditation Survey conducted December 2005, NCCHC final Report dated February 24, 2006
Confidential Puriuant to A.RS. 36-2401, et. seq.
. Standard
EJI
CompJiance
NeCHe RecOmmendation
CHS Resolution
OJ
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CHS Evidence of Compliance
=
=
=
J-G..Q4 Mental Health SeNices
J-G-OS Suicide Prevention
E
E
I
J-G..()S Intoxication &Withdrawal
J-G..Q7 Pregnant Inmate care
J-G..Q8 Inmates with Alcohol or
other clrua Problems
J-G..Q9 Sexual Assault procedure
J·G-10 Pregnancy counseling
J-G-11 Orthoses &aids
J-G-12 Care of tenninally III
J·H.Q1 Health record format
J-H.Q2 Confidentiality of records
J-H..Q3 Access to custody info
J-H..Q4 Availability of health
record
I
I
I
I
E
E
I
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6/1/2006
Y
Partial
Documentation required that shows
Corrective action is identified and
Irrplemented for 2005 suicides
Y
y
y
y
Y
y
y
y
y
y
Partial
..
Enhance substance· abuse program'at 4.111
Ave &LBJ. Estrella has strong program
~
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cal audit May 2006, Infinnary:
Admission orders Include Diagnosis = 100%
VS frequency =94%
Activity = 94%
Diet 10oolo
Labs I diagnostic testing = 100%
Medications ordered &on MAR = 100
Discharge plan documented 100%
Discharge Order 100%
Physician round per policy = 100%
Nursing round per polley =100%
E
E
Q)
None Required
None Required - documentation
available
Documentation available, All Corrective
Actions completed and implemented,
None Required
None ReQUired
None Required
None Required
None Required
None Required
None Required
None Required
SYStem would Iikelv benefit from EMR
None Required
None Required
Record is not always. available at the time CHS continues to pursue EMR.
of the medical or mental health encounter CHS has hired 4additional Medical
Record Technicians since January
- staffing cited
200S. As of May 24, 2006, only 1
Medical Record Tech vacancy
remains,
cal audit all sites 2006:
Medical record available at time of thl
encounter, May 2006 = 10oolo
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Maricopa County Correctional Health Services
May 2006 Response to the NCCHe Accreditation Survey·conducted Deaember 2005, NCCHC final Report dated February 24, 2006
Confidential PursiJant to A.R.S. 36-2401, et. seq.
o
o
co
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an
StanQlard
,
Compli~nce
NeCHC Recommendation
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J·H-05 Transfer of records
J-H-06 Retention of records
J·I-01 Use of restraint & seclusion
J·I-02 Ememencv Psvchotrooics
J·I.Q3 Forensic Information
J·I.Q4 End of Life decision maklna
J·I-05 Informed Consent
J-I.Q6 RIght to Refuse treatment
J·I.Q7 Medical or other research
Y
Y
Y
y
Y
Y
Y
Y
y
..
"
"
CHS Resolution
CHS Evidence of Compliance
CHS implemented aprocess to
transfer medeal records to on-site
specialty clinics on day of clinic so
that medical records are available to
the provider prior to aPPOintment
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
None Required
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Maricopa County
Correctional Health Services
. 111 W. Monroe, Suite 900
Phoenix, Arizona 8500~
Phone: (602) 506-2906
Fax:
(602) 506-2577
CONFIDENTIAL
February 20, 2006
Judith Stanley
National Commission on Correctional Health Care
1145 West Diversey Parkway
Chicago, Illinois 60614
This letter responds to the NCCHC's accreditation survey report draft ("Draft") dated
February 7, 2006. The Draft contains findings and recommendations of the most
recent accreditation review meeting with the Maricopa County Sheriff s Office and
Correctional Health Services ("County"). TI..is letter responds to the findings and .
appraises NCCHe of Maricopa County's plan of action to address areas of deficiency.
The County thanks the auditors for a very thorough review. Their comments were
very perceptive and valuable for the County's ongoing process of restructuring
correctional health care in the Coul.lty jails..Since the exit interView, ~taffhas been
.. addressing areas 'of ~bnceinthattIie: sUrvey team expressed 'during the audit pro·cess.
This letter is to inform NCCHC of the County's progress and future plans. This letter
also clarifies some items regarding the County's practices.
Listed be.lDw in tabular format are standards sited in the draft of February 7,2006, as
weB as our plans to address the area of concern for each standard that is sited to bring
us into full compliance:
J-A-07
Emergency
Response Plan
The County is surprised that the Draft finds partial compliance with
this standard, since the County's pre-audit checklist indicated full
compliance. Moreover, the exit conference did not cite this standard
as an area of concern. The County's record of emergency drills also
indicates compliance with this standard. Appendix 1 is a summary
sheet of emergency drill dates for the calendar year 2005 along with
evaluation write-upsJor the emergency responses. This information
was available during the audit. Please review the documentation of
compliance and provide additional guidance as appropriate. The
emergency drill evaluations have been widely circulated at staff
meetings and the County has developed administrative corrective
action plans as a result of these disaster drills.
The County agrees that correctional officers should be included in a
mass disaster drill and expects to have such a drill later this year.
J-B-OI
The Draft finds partial compliance with this standard based on a
MC Confidential (June 08) 001150
Mancopa County
Corrcction:U Health Service.
111 W. Monroe, ::iUlte 900
Phoeni.". Arizona 85003
Phone: (602) 5ll6-2906
F:Lx: (602) 506-2577
Judith Stanley
National Commission on
Correctional Health Care
February 20,2006
Page 2 of8
Infection Control
Program
statement that clinical staff does not culture abscesses for MRSA.
This statement is inaccurate. The County's 1vlRSA program is quite
active given the high prevalence of this condition. The County treats
the more complex MRSA patients through the Maricopa Medical
Center. .As part of that treatment many of the cultures that are
obtained for patients with complicated wounds are obtained at the
hospital. The County shares in that clinical data and uses the
information to manage these complex patients.
The evolving knowledge base with regard to methicillin resistant
staphylococcus aureus includes recognition that there are two very
distinctive clinical entities involved. These entities are genetically
separate and are treated very differently based on their virulence.
Hospital Acquired MRSA (HA-MRSA) does require very
sophisticated management including culture and sensitivity to
optimize treatment. The County actively participates in this program
and, uses the data t~ :provide appropriate'treatmeilt plans for 'patients.,
.
.
~
."..".....',..
. .
. '
!
Community Acquired MRSA (CA-MRSA) is a distinctly different
clinical entity from Hospital Acquired MRSA. The County's clinical
guidelines with respect to infections have been developed with the
assistance offellowship-trained infectious disease physicians in the
County's practice environment. Those guidelines currently do not
recommend culturing of skin abscesses at initial presentation. If the
wounds do not respond to initial irrigation, debridement and
appropriate wound care then culturing is appropriate and is performed
within the County's facility.
The County's infectious disease nurse monitors the culture results of
patients with wounds and maintains an ongoing surveillance of this
disease entity. MRSA has been the focus of significant attention
locally. The County frequently uses the disease surveillance data and
clinical observations to monitor any significant deviations in the
prevalence ofthese infections within our jail population. Historical
MRSA surveillance data is presented in Appendix 2.
Perhaps the audit team did not have sufficient time to fully investigate
the scope of the County's disease surveillance for MRSA. A
complicating factor might be that the surveillance system occurs in
conjunction with the local hospital. The County maintains that it
fully complies with the standard and practices at the cutting edge of
the evidence in the infectious disease treatment commW1ity.
MC Confidential (June 08) 001151
Judith Stanley
M:U1Clll'" County
CorrtCI"m.J lle.lth Semce$
111 W. Mnnroe. Suit,· <)IKI
Phoenix., An~()n. 85003
Phone: (602) 506-2906
)0":1.<: (602} 50(,·2577
National Commission on
Correctional Health Care
February 20, 2006
Page 30f8
J~B-02
Environmental
Health ;md
Safety
J-C-04
Training for
Correctional
Officers
J-C-07
Staffing Plan
The findings under this standard have been forwarded to the
Mfuicopa County Sheriff's Office. Their Facilities Division and the
Sheriff's Office have addressed these issues and a report indicating
their compliance is contained in Appendix 3.
The Maricopa County Sheriff's Office is aware of this standard and is
proactively addressing the CPR training. Evidence of compliance
with this standard is included in Appendix 4.
The County has devoted considerable activity to improving staffing
levels. The County has initiated a concerted hiring effort, supported
by an improved salary structure. Staffing gains, to date, since the
audit are summarized below:
• 6 RN's
• 4 LPN's
• 4 medical records clerks
• ,1 0 cori:~ctiQnaf healthcare tec1lliici,ans
• 2 psychiatrists
2 mental health professionals
• 6 new medical providers requested
Q
Staffmg is the County~s top priority and many of the corrective action
plans identified in this document are dependent upon that effort's
success. This effort is ongoing and the County will periodically
update NCCHC on its progress. Evidence of the County's staffing
and recruitment plan is in Appendix 5.
1-.-------.
J-D-01
Pharmaceutical
Operations
The County agrees that the medication renewal process must be
improved. The Draft indicates that corrective action is not required
for this standard.
The County has redesigned the medication process since the auditors
were on site. The County discontinued the use of dual medication
administration records (MAR). All records have been unified into one
MAR, which is maintained now exclusively by nurses. This
improvement will enhance continuity of care in the administration
and renewal of medications. This revision began on February 1,
2006, and the improvements in the process are evident. The County
will perform a quality assurance study on the medication renewal
process after the new procedures have run for several weeks. The
County expects to document full compliance shortly.
MC Confidential (June 08) 001152
Maricopa County
Judith Stanley
National Commission on
Correctional Health Care
February 20, 2006
Page 4 of8
Corr~cti()n"1 Health
SL"TVicc."
11\ W. Monroe. SUttc 'JOO
Phoenix, An:!ona 85003
Phone: (602) 506-2906
1',,-,,: (602) 50(,..2577
J-E-04
Health
Assessment
The County acknowledges ongoing difficulty with this standard. The
limitations in the past have been staffing. The County is improving
staffing, as noted in the comments to J-C-07. The County expects to
implement a sustainable solution once the additional staff is on board
and oriented. The County plans to perform health assessments in the
Booking area because of the movement dynamics within the
Maricopa County Jail System as a whole.
The solution for fixing the health assessment requires multiple
changes within our operation. Those changes have been identified
and are enumerated below: .
1. Increased clinical staffing (ongoing).
2. Appropriate training and credentialing of staff to perform
assessments (curriculum designed, staffwill be trained once
they are hired).
3. .Adequate officer support to facilitate the ·flow thro\lgh the. ..
. . Booking Clinic (the h..iring of additional corr"ecti ona] health·
technicians to perform the intake screening w~ll enable the
officers to be freed from the pre-intake area to assist with
clinic flow in the back. This process will begin on March 1,
2006, and the County expects to have the officers freed up
within one months' time).
4. Better data to eliminate repeat exams. A study of the health
assessment process demonstrates that many patients are
receiving duplicate exams while others are receiving none.
The County is working to control the infoDnation and to
generate more reliable data.
5. Improve the documentation process. The County is
redesigning the health assessment to be more efficient and
user-friendly. The goal is to improve productivity and remove
unnecessary documentation.
.The corrective action suggests that additional clarification is needed
for the STD and TB testing programs. The County designed the
current STD and TB testing program in co~iunctjon with the County
Health Department and the Arizona State Health Department. These
agencies are fully aware of the County's screening activities and
symptomatic testing. The agencies assisted in identifying the highest
risk populations and designing the current program. The County
MC Confidential (June 08) 001153
Mancop" County
Corrcctiollnl Health Sen·icc.
III W. Monroe. SUltC 'J()()
Phoenix, Ari>.ona 8S(](J}
Judith Stanley
National Commission on
Correctional Health Care
Phone: (602) SOG-2906
Fox: (602) 506-2577
February 20,2006
Page 5 of8
respectfully requests that NCCHC remove this corrective action since
the issue has been addressed.
The County is revising its corrective action plan for immunizations.
The immunizations will be provided through chronic care clinics.
Immunizations are available through the County's pharmacy vendor.
The flu season is currently over in Arizona and flu vaccines will not
be pertinent until next season. The County does not foresee any
difficulty in implementing this plan. The County will initiate the
process of identifying asthmatics and supplying them with
Pneumovax immunization as part of the forthcoming chronic care
plan.
J-E-05
Mental Health
Screening and
Evaluation'
The Mental Health Screening and Evaluation is tied to the health
assessment process that the County is designing. Many of the
limitations in the health assessment also pertain to the mental health
screening and evaluation.. The action plan for mental health assessment.will
identical t(dhe acti(Ynplanfor-heaHh assessment. The County will document compliance as the program takes shape.
b.e
_._-------
J--E-07
l'lonemergency
Healt.hcare
Requests and
Services
CBS agrees with the auditors' findings. The County has formulated a
plan to fully comply wit~1 this standard. The County will devote new
nursing and provider staff to this process. The COlmty will triage all
patients within 24 hours of a sick call request. The triage acuity that
is assigned will drive the schedule so that the sickest patients will be
seen first. The County will produce an aging repo'lt of the time
between submission of sick call requests and a provider encounter.
This will assist greatly in modifying staffing to ensure that patients
are seen in a timely manner for medical> mental health and dental
encounters.
The County is revising the process of rotating clinics. The variance in
access to care has particularly been a problem at the Lower Buckeye
Jail. The plan is to centralize the LBJ outpatient clinic and all
prisoners who need to be seen, regardless of their housing location,
will be brought to that clinic for their sick call encounter. This
change will occur within the next two to four weeks. The County
expects to achieve full compliance with the standard.
The County will submit additional evidence of our compliance as
these processes come online.
J-E-09
th
The 4 Avenue Jail l1as become operational within the past 12
MC Confidential (June 08) 001154
Judith Stanley
National Commission on
MosicllP' County
Correcn"n,l Health Serv,ces
111 W. Monm<:. SUIre 900
Phoeni:<. Arizonll 85003
Phone: «(,02) 506-2906
Fll.-":: (602) 506-2577
Correctional Health Care
February 20, 2006
Page 60f8_
Segregated
Inmates
months. The County has had to revise monitoring of segregated
inmates to comply with this standard and to work within the
correctional daily schedule. Some of the County's modifications
occurred since the audit and Appendix 6 contains documentation of
the new practices. The County believes that it is in full compliance
with the requirement to check segregated inmates 3 times per week.
Joanne Dorman assisted the County in pre-survey preparations. She
.reviewed_our isolation practices and determined through consultation
with Judith Stanley that none of our areas qualified as «extreme
isolation" because of the ability of prisoners to interact with each
other through the windows between cells.
J-E-12
Continuity of
Care During
- -Incarceration
"I-E-l3
Discharge
Planning
Compliance with this standard relates to clinical staffing. The County
is increasing staffing with the goal of cowplying with this standard.
The County will conduct CQI reviews of this standard and forward
that infonnation to NCCHC.
The- County maiiltains tllat its disd1arge-plaJ.lIiirig-nleets theihtended
goals of this standard. The County maintains that it directs resources
toward patients with significant health needs. For example:
,.
The infectious disease staff follows all patients with
communicable diseases and coordinates hand-off care with the
Maricopa County Public Health Department.
•
The County internally tracks patients who are identified as
Seriously Mentally III by the community mental health vendor
(Value Options). Care is coordinated through on-site visits
from Value Options case workers prior to prisoner release
This degree of discharge plam1ing for the mentally ill exceeds
other jails.
•
The County coordinates discharge planning for HIV patients
with the Maricopa County Public Health Department. HIV
caseworkers come to the jail, visit with the patients, and malce
plans for discharge medications, housing, food, and healthcare
benefits.
•
The County has two full-time caseworkers who provide
discharge planning for any hospitalized patient. Patients are
transitioned to assisted living environments, skilled nursing
environments, rehabilitation units, or the jail infirmary.
MC Confidential (June 08) 001155
Mnnwp" County
Judith Stanley
National Commission on
Cnrrcct",ml Health &;TV1CCS
111 W, MontelL'. SUite l)(Hl
An,,,,m,,
Ph"eni.".
8500:\
Phone: (602) 506-2906
Fa,,; (602) 501>-2577
Correctional Health Care
February 20, 2006
page 7 of8
•
The COlUlty supplements resources for the seriously mentally
ill via the County's Restoration to Competency Program. This
program comdinates and tracks care of mentally incompetent
patients. The program fosters good discharge planning to
ensure that these fragile patients receive optimal care as they
move from inpatient to step-down status, and into general
population. Planning is critical as patients move from the
Arizona State Hospital back to the jail environment.
The Draft does not fully appreciate the tight interdigitation of the
County's care with the available community resources. The County
maintains that its discharge planning is robust for individuals with
serious health needs.
J-0-01
Special Needs
Treatment Plans
, I
,
.
The County is redesigning the chronic care encounters for medical
and mental health patients. The plan is to add providers for dedicated
chronic care clinics at all facilities: Patients will then be identified.
and:sC:h~dO:Ied 'into'"these dediCated'clinics and the sl;e'ciai 'needs: '
treatment plans for these patients will be initiated and followed.
Compliance with this standard will be forthcoming as this program is
launched. Additional data will be provided to NCCHC as it becomes
available.
f-.
J-G-.Q3
lnfilmary Care
The County uses the Perry arid Potter.Nursing textbook as its manual
of nursing care. This text was selected by a committee of nurses and
has been in place for over a year. Copies of this manual are located in
all clinical areas.
Internal policies and practices are being addressed to standardize the
charting practices in all inpatient units. The County will complete
CQI studies focused on compliance with this standard. The studies
will be sent to NCCHC as they are completed.
The provider staffmg enhancements will address the weekend
coverage of the infirmaries. Once staff positions are hired, providers
will be expected to round daily (weekends included) in the medical
and mental health infim1aries.
J-G-06
Intoxication and
Withdrawal
Scott Chavez provided the County with the federal code related to
this standard. The County researched this issue with its pharmacists
and providers. The best available information demonstrates that
national guidelines are evolving for methadone treatment for pregnan1
women. The available federal law is not clear. The core issue
Me Confidential (June 08) 001156
Judith Stanley
National Commission on
Correctional Health Care
February 20, 2006
Page 8 of8
Manc()p;1 Ccmnty
Corr~cl;"nol Health
Scrvlces
111 W. Monroe, Suit" 900
Pho~~,Ari7.ona85003
Phone: (602) 506-2906
p",,: (602) 506-2577
focuses on the reason for using methadone and the identity of the
patient. T'ne County does not admiJP.ster methadone for substance
abuse therapy of pregnant women. The <;ounty administers
mefuadone to prevent a spontaneous abortion. The fetus, not the
mother, is the patient. Therefore, the guidelines for OTP therapy and
the need for CSAT certification do not apply.
,
.
The County maintains that administration of methadone to prevent
spontaneous abortion isregu!ated by a physician's DEA number, not
a substance abuse DEA number. This practice accords with hospital
and correctional healthcare practices nationwide. More developed
federal guidelines are necessary before NCCHC requires corrective
action. The County respectfully requests full credit for standard J-G06.
.
Thank you for the opportunity to respond to the Draft. TIle COUllty believes that it has
achieved cODlpliaq'ce in.several m:eas ~d is hopd;'u.I that those will be ~l~ared pdor to
tlle final accreditation report. The County is working diligently to perfonn action
plans that will clear the m'eas needing corrective action.
If you have any questions regarding this response, please do not hesitate to contact me
at (602) 690-7610.
Best regards,
Lindy Fu mouser, Director
Maricopa County Department
of Correctional Health
Services
MC Confidential (June 08) 001157
AP·PENDIX'·l
MC Confidential (June 08) 001158
Maricopa County
Correctional Health Services
234 N. CL-ntral Ave, 5th Fl.
Phoenix, AIi~ona 85004
Phone: (602) 50(;"2906
Fax:
(602) 506-2577 .
TO: NCCHC
The source documents for these emergency drill summaries are
voluminous and will be made available upon request at Maricopa
County's Lower Buckeye Jail, Administration Building, Suite 2100, in
Phoenix Arizona.'
.
Me Confidential (June 08)
001159
EmergehCY D.rill Dafes
CY 2005'
'.
Date
Facility
Shift
CHS Observers
Remarks:
Man - Down
Madison - Closed
1
2
RN Smitherman
Man - pawn. Inmate fell off his bunk and complaining of back pain.
Madison
Man· Down
3
Madison - Closed
Mass Casualty
2
Madison - Closed
Man - Down Non-Responsive inmate, CPR.
1
Rigo Quiroz, LPN
01/22/05
Estrella
M~n - Down Inmate fell down stairs causing back Iniury.
None
2
06/26/05
Estrella
Man· Down Actual Event; Attempted suicide by strangulation.
None
3
08/25/05
Estrella
Mass Casualty Fire in F dorm, cause a cigarette tossed into laundN.
Ruth PhilJiben, Teresa Cannon
2
10/27/05
Estrella
Man· Down Slip and fall on the parade deck.
RN Kathi Harris
Durango
1
11/29/05
RN Carol Taborda, LPN Lisa Saunders Man - Down Stabbing in rest room.
2
Durango
07/08/05
Man.- Down Inmate collapse to the floor.
RN Adaku Friday
3
07/01/05
Durango
Mass Casualty Strange 6dor and smoke comlna out of vents, 20 inmates affected.
Ruth Philliben, LeAnn Bethel
11/30105
Durango
2
Man.- Down Inmate found on floor, fall from top bunk.
Towers
1
Ruth Philliben, RN, HCA
08/22/05
2
03/07/05
Towers
Toni Malinchalk, RN
Man - Down Actual Ev~nt: Inmate clammed shut cell door cutting off 3 fingers.
06/10/05
Towers
3
Howard Wilkinson, RN; W. Clark, LPN Man· Down Attempted suicide by hanging.
07/23/05
Towers
2 (1,3)
Robert Lake RN, Ruth Philliben, RN HC Mass Casualty Power Outage, Pod C disruptive/altercation.
04/22/05
ESB-Tents
2
Robert Spears.,RN; Janet Smith, LPN
Mandown Due to electrical shock; lighting a cigarette from electical outlet.
8/22/05
ESB-Tents
1
Robert Speares RN, Jan Flaes LPN
Man - Down Inmate lying on floor in dayroom not coherent, violent with staff.
06/30/05
RNs Roberts and Goettman
ESB-Tents
3
Man - Down Attempted suicide by ham~ing and lacerated wrists.
05/06/05
1
Wanda LaPoint, RN HCA
Mass Casualty Micro burst in the Tent area. Tents destroYed, 10 injured.
ESB-Tents
XXXXXXXXX ( Opened April 2005) XXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXX)()txXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
07/19/05
Lower Buckeye
1
Laurie S1. Louis, RN; E Sheima, RN
Man - Down Actual Event; CHS RN slipped and Iniured himself.
07/17/05
Lower Buckeye
Louie Dira, RN
2
Man - Down Officer down due to asthma attack inside P5 crossover.
08/06/05
Lower Buckeye
3
LeAnn Bethel
Mah - Down Inmate found unconscious lying face down In a larQe pool of blood.
Lower Buckeye
08/29/05
2
Mass Casualty Phone call regarding suspicious package and explosion in P-6.
Roberto Escobar, RN
07/12/05
4th Avenue
Wanda LaPoint, RN HCA
1
Ma.ri· Down Inmate in SMU-20 set mattress on fire. Second inmate acting out.
07/11/05
4th Avenue
2
Wanda LaPoint, RN HCA
Man - Down Inmate lying on floor of his cell with blood around his head.
07/13/05
4th Avenue
3
Laura Roberts, RN
Man - Down Inmate in holding tank found with cut wrist and unresponsive.
12/01/05
4th Avenue
1
Wanda LaPoint, RN HCA
Mass Casualty Hazardous gas tanker involved in a collicion @ 4th & Madison.
01/17/05
3::
n
n
o
~
H1
1-'-
p..
(j)
~
rt
1-'-
P!
f-'
y
C
~
(j)
o
co
o
o
I-'
f-'
OJ
o
As of: 12/7/2005
Green: Completed
Black: Scheduled
Red: Not yet scheduled or accomplished
lUi!!!1
,••• I
46 p'
CHS/MCSO Disaster Drill Exercises
" .II
CY2005
OBSERVERS RECOMMENDATIONS
Madison: Man Down, Shift 2,1/17/05
Response/Recommendations:
MCSO:
Detention staff secured the pod. They had the inmate lay in initial position until medical arrived.
Once medical staff determined the inmate needed to be placed in a neck brace and back board,
officers assisted medical staff as directed such as moving him to a position to allow him to be placed
on the back board. Detention staff then escorted the inmate to the hospital.
CHS, RN Smitherman:
RNSmitherman and a CNA arrived on scenewith the gurney, backboard and "man down"bag. RN.
$milh,erm;:lri"did ah .initiC))· assessment, th'en placec\"arieck.brace QD inmate:. She then I.og rolled"the
inmate into a position so he could be placed on backboard. This was done with the help of the' .
CNA and detention staff, Once in the clinic the medical staff made the arrangements for the inmate
to be transported.
a
.:' Debriefing/Recommendations:
Action Plan:
Estrella:
Man Down", Shift 3,1/22/05
* (Actual Incident)
MCSO, No Input;
CHS, Rigo Quiroz, LPN
Man Down - Non-Responsive Inmate. All officers responded in a timely manner and offered to
assist with CPR. The initial radio call was a general call for assistance for an inmate down.
DebriefinglRecommendations:
1.
It would be helpful in the future if radio call for assistance would be more informative (ie
fall from top bunk, head injury, cutting on self, eel.) This would enable the medical staff to
respond with more equipment and facilitate everyones critical role.
2. A triage area should have adequate lighting, accessibility and space to perform all
necessary activities to enhance performance by responding personnel.
Action Plan:
02/21/06
MC Confidential (June 08) 001161
Towers: Man Down Drill! Shift 2, 3/7105
MCSO
- Officer Bagshaw A8039, called for Medical assistance, and Officer Sutton G. A8191 placed the
detached finger tips into a bag and then that bag was placed into a bog containing ice. They were
transported to medical by Officer Coble. A8640 who assisted in gathering the severed fingers and by
wrapping the injured hand with a towel and instructing Cobb to apply constant pressure. Officer
Means A9146 kept Cobb's attention focused and instructed him to sing, talk whatever to maintain
consciousness.
.
CHS
- RN Malinchalk arrived with LPN Candy they were will prepared with'the "Man Down" cart, as will as
providing the ice, and bags to transport the severed fingers. Phownix Fire was called at 1710 hours
per PAC Avalos; they arrived at about 1720 hours. RN Malinchalk called to verify which hospital had a
had surgeon so sho could direct the ALS ambulance to that Emergency room. Cobb was transported
via ambula~ce #431, escourted by Officer Botello A8410 to St. Josephs hospital at 1735 hours.
Debriefing/Recommendations:
To include small, clear, Bio-Hazard bags in the Emergency Kits in each tower.
.Action Plan:·
Estrella Support Clinic!: Man Down Drill, Shift 1, 4/22/05
Response:
MCSO,:
Mandown and request tor medical assistance was dearly stated on the radio. There was no officer
in the clinic for approx 30 seconds, so the medical staff could not leave the locked clinic to respond
to the emergency. The officer unlocked the clinic door specifically told the RN the nature of the
emergency (shock from an electrical outlet). Detention did not move the inmate.
CHS:
The RN instructed the MA to contact Estrella clinic for backup and to remain in the clinic. An LPN
and MA accompanied the RN to the designated site. The RN asked,if "someone had a wheelchair
or streacher". Sgt Coler was very good about instructing one of his officers to obtain a streacher
and backboard af1d bring it to the site.
DebriefinglRecommendations:
1. Must have an officer present at all times to allow the nurse out of the clinic to respond to
emergencies.
2. Need a Stryker cotlstreacher with large wheels. The wheels on the current cot got stuck
all the way to the clinic due to the thick layer of gravel in the yard. Some tents are so far
out into the yard that it would take a long time and several very strong officers to carry a
letter to the clinic.
Action Plan:
2
02/21/06
MC Confidential (June 08) 001162
Estr lIa Support Clinic: Mass Casualty, Shift 2, 5/6/05
Response:
MCSO:
Patients were brought to the clinic. Officers were present while the· patients were evaluated. MCSO
transportation t?rrived within the 30 minute window allowed by the on call provider.
CHS:
Phone call to staffing office was a little unclear, calls were made to the clinic by the HCA to clarify
the situation. Estrella Clinic nurse manager sent Hector Molina, LPN, to assist with the routine clinic
work (completing accuchecks and administering Insulin). The staffing office called the Durango
clinic and had Vicki Woods, MA, sent to assist with the clerical work (creating charts, answering the
phones, ect.).
DebriefingIRecommendations:
1. HCA will assess/evaluate the situation with the staff involved to determine if having the LPN
deal with the more critical patients was the o.ptimal use of nursing resources.
Action Plan:
Towers: Man Down, Shift 3, 6/10/2005
MCSO;
3 dayshift detention officers were reporting to work. One officer began to enter to control tower and
noticed the inmate swinning from the top tier rails in the corner of the pod. He called out to the 2
other officers and they entered the pod. One officer grabbed the inmate's legs and reduced tension
on the sheet. The second officer retrieved the "911" tool and went up the stairs to cut the noose.
The inmate struggled against the officers.
CHS, Name;
Response by Medical: W. Clark, LPN applied a C-collar to the patient. H. Wilkinson, RN started an
IV. The patient was conscious and responsive. Phoenix fire was called.
DebriefinglRecomrnendations:
Detention: The officer stated that he used the "911" tool for about 20 seconds to saw the noose.
He became tired and a second officer took over. The tool was very dull. The officer stated
that the "911" tool in Tower 6 is also dull.
Medical: The clinic is routinely staffed for 12 hours only (0700-1930 hours) An LPN frequently
works the 11-7 shift. In IV line could not have been started if the incident had occurred on the
night shift
Action Pian:
3
02/21/06
MC Confidential (June 08)
001163
Estrella Jail: Man Down Drill, Shift 2. 6/26105
Inmate Michell walking down steps had fallen causing back pain and left unable to move. Cause of the
incident was the .inmate stepping onto a plastic lunch bag on the steps.
MCSO
- From the time the initial call was placed by Security Control four officers, medical team and Sgt
Responded to the scene within sixty seconds. The first officer on the scene ordered the inmates in
the pod to lockdown and secured the area. The other officers arrived to assist securing the area.
House officers advised to stop all radio transmission until the emergency was cleared. Sg1. Tenny
notified security control and advised the officers to contact MCSO radio to contact Phoenix Fire.
CHS·
Medial arrived with backboard and C- collar to examine without moving the inmate. It was
determined that Phoenix Fire Paramedics needed to be contacted due to the unknown nature of the
inmates condition. Medical Staff stayed with the inmate until they arrived keeping her from moving.
The paramedics arrived and examined the inmate, placed her in a C-collar then placed her onto a
backboard for. transportation to the hospital.
Debriefing/Recommendations:
Medical and responding offic.ers were not aware that an inmate had fallen off the steps and
medical help arrived without the proper equipment to treat the injured. Medical staff had to
retrievethe ,,!dditional supplies from the Estrella clinic.· The house .officers needed to clearly.
..
advis·e respo·nding the type df medical·errlEirgehcy.··
Action Plan:
Durango: Man Down Drill, Shift 3, 7/1/05
MCSO
Inmate was observed to collapse and fall to the floor. Officer quickly radioed for assistance and
numerous officers responded and secured the area.
CHS
Medicals response time was 4 minutes from initial radio call at 0100. Nurse arrived with guerney and
medical emergency pack.
Debriefing/Recommendations:
- None
Action Plan:
4
02/21/06
Me Confidential (June 08)
001164
Durango: Man Down Drill, Shift 2,7/8105
MCSO
- Inmate exited from restroom with a towel draped over his left arm. Officers immediately locked down
the inmates and notified other officers of the situation. Supervisors were immediately notified.
CHS
"
- Officers radioed for medical assistance and LPN arrived on the scene and removed the inmate to
medical. RN 'assessed the inr:nate and made the decision to send him to MMC for evaluation and
treatment.
Debriefing/Recommendations:
None
Action Plan:
4th Ave. Jail: Man Down Drill, Shift 2, 7/11/05
Unresponsive inmate lying on cell floor, to be discovered
MCSO;
. . "qfficers."entered the c~ll fir.st and .the iniTIate was secured with handcuffs ahd leg shackles.. 'The S9t:: .
controlled the number of officers in the cell and surrounding area. One of the officers asked the
nursing staff if a gurney was needed, It was brought to the site along with a backboard.
CHS;
J. VanEvery, RN assessed the pat.ient. P. Brooks, LPN took vital signs. Instruction was given to
detention to log roll the patient, pyt him on a backboard and place him on the gurney.
Debriefing/Recommendations:
The nursing staff did not put on stab proof vests. Was this indicated in this situation? To
be discussed with detention supervision.
The nursing staff did not have an ambu bag or c-collar with the man down bag. There
were no straps on the gurney. Nursing/medical staff need to determine the necessity of
having a bag, collar, and/or straps on each gurney.
The clinic currently does not have a disaster bag for a mass casualty.
Gurney is difficult to raise and lower. Detention officers present practiced (after the drill)
raising and lowering the gurney with a patient on the cot.
Action Plan:
5
02/21/06
MC Confidential (June 08) 001165
th
4
Ave. Jail: Man Down Drill, Shift 1, 7/12105
Response:
MCSO;
- Officers entered the smoke filled area with 8CBA's. Nursing was advised to remain in the main hall.
Two inmates were brought out to the hall for evaluation, Officers re~ponded to medical questions
appropriately.
CHS;
- D. Rogers, RN assessed the patients. P. Smith, LPN stood by for assistance. R. Hinzman, MA
retrieved the vital sign monitor and checked the patients. T. Colpitts arrived at the scene from
the clinic. She immediately went to the 8gt in charge and asked questions about the inmates
and sustained injuries. She then proceeded to each patient and completed a brief history. The
first inmate was placed on the gurney and wheeled to the clinic. Instruction was given to
detention staff about the workings of the gurney. The second inmate was walked to the clinic.
T. Colpitts did instruct R. Hinzman to contact CHS administration and other nursing staff in the
facility for assistance.
Debriefing/Recommendations:
,. The nursing staft did not put on stab proof vests. Was this inpicated in this situation? To be
discussed with detention supervision'.
.
.
"
• Ther.e were no straps on the gu~neY.· N'ursing/medical staff need to deter~ine the necessity
of haVing straps on each gurney.
• The clinic currently does not have a disaster bag for a mass casualty.
GurQey is difficult to raise and lower. Detention officers present practiced (after the drill)
•
raising and lowering the gurney with a patient on the cot.
• Nursing/medical needs to consider an SVN machine in each mini clinic for breathing
treatments.
th
W. laPoint, HCA waited 5 minutes for the elevator to get to the 4 floor. (2 minutes for the
elevator to arrive at the basement and appx 3 minutes for the door to open).
Action Plan:
6
0212J/06
MC Confidential (June 08) 001166
Fourth Avenue Jail: Man Down Drill, Shift 3, 7/13/05
Inmate found in the medical holding tank who appeared to have cut his wrists and was unresponsive.
The cutting device was on t~e floor in plain sight.
MCSO
- MUltiple officers responded to the area, more than were needed. Sgt Heathcock directed several
officers to return to their dUty posts. The responding house offic~rs were ready to go in and remove
the inmate wearing nothing more than latex gloves. The offic~rs had to be given a verbal command to
put on PPE. After putting on the PPE the officers took extra care to cover the inmate's cuts with
towels to attempt to stop the bleeding. Officers were a little hesitant to put on protective equipment
and some officers entered the area not fully protected. Officers conducted. proper first aid. They also
properly secured the cutting device. Sgt Layton saw officers remove contaminated PPE without using
proper techniques.
CHS
- None
Debriefing/Recommendations:
The PPE kits are secured with nylon zip ties. These ties cannot be removed by hand, they
must be cut off. Officers askeq the nurse if she had scissors to cut off the- zip tie to the PPE
kits.. Finding scissors', cHppers or some other tool- to cut.off the zipties may b.e difficult and .
may certainly delay officers from accessing the PPE. I recommend thatahothet type 'ortiEr be
used to secure these boxes. The beaded nylon ties that are commonly used on fire
extinguishers will work well. A reversible zip tie that can be loosened by pressing a tab will
also work.
Action Plan:
Lower Buckeye Jail: Man Down Drill, Shift 2,7/17/05
Officer down due to asthma attack inside P5 crossover.
MCSO
- Detention staff was prompt to arrive and safely able to secure the scene making it safe for officers and
medical staff. Because the call came through as an Officer Down call several Sgt.s and officers from
LBJ responded as well.
CHS
- Psych Medical staff was stationed in the house and were there in seconds. Psych medical placed
Helseth on oxygen. LBJ medical staff responded and brought down the machine to give Helseth a
breathing treatment, they also responded in very good time for the size of the facility and from their
area that they deployed from.
Debriefing/Recommendations:
Add gurney training to the mandatory First Aid Training.
Write a memorandum to Training and Development to add gurney training to the mandatory
First Aid Training conducted by Meso Training staff.
Action Plan:
7
02/21/06
MC Confidential (June 08) 001167
Towers = Mass Casualtv*, Shift 2 (1,3), 7/23105-7124/05
~ (Actual Incident)
. Scenario:
•
Power outage 7/23/05 @ 1845. Nurse Manager notified. No backup generator outlet located in
clinic area. Clinic wlo power I function.
Inmates in Tower 4, C Pod became disruptive secondary to heat, led to altercation @ 2200: Pod
Pepper Sprayed @ 2200 by MCSO
Night shift MCSO decontaminated pod and showered inmates, unknown change of clothing
12 inmate mandowns on night shift related to Pepper Spray starting 2300
•
Inmates cIa heat and humidity in pods: Night RN requested ice water for pods shortly after the
altercation.
MCSO contacted facilities maintenance to repair swamp cooler not working in two pods: Tower 4: C
&0
•
•
•
Day shift requested ice water for pods beginning @ 0830 and notified nurse manager
MCSO Response to nursing staff was that it was against health department rules to provide ice
water in containers wlo spigots and that they were unable to reach kitchen to obtain ice water in
appropriate containers (am of 7/24/05)
1 inmate brought to medical @ 1200 related to dehydration I heat exhaustion: transported to ER via
911
Potential for heat exhaustion 1 heat stroke high in these pods: 1200 RN called HCA for assistance:
2 RN's deployed from other clinics to help assess
•
RNs & MA to pod to triage victims
...
..
HCA notified Manager: 1;>oth went to sce"ne to assi.st with .inmate evaluation 1 triage for.potential. heat
. victims 1300· .
.. .
.
.
•
•
•
•
Day shift staff in pods obtained exposure to Pepper Spray: some with physical consequences
Ice water provided to pod C by detention around 1600
Fans installed around same time
Was the working relationship between Medical and Detention staff smooth, effective, and
professional, achieving the goal of a positive outcome?
There is no 'formal mechanism for identifying this type of situation as a potential disaster. CHS
identified the potential for medical complications secondary to prolonged heat exposure (heat
exhaustion, dehydration, medication complications etc).
,
Once the potential for disaster was identified by CHS and communicated with MCSO 8gt on duty,
ice was obtained and provided for inmates.
MCSO prOVided assistance in triaging inmates in Tower 4, Pod C.
Worked together to respond to respiratory difficulties rlt Pepper Spray
DebriefingJRecommendations:
Develop CHS 1 MeSO mechanism for identification of and response to heat exposure
Clarify CHS I MCSO protocol for multi-inmate Exposure to Pepper Spray
Action Plan:
8
02/2J/06
MC Confidential (June 08)
001168
Lower Buckeye Jail: Man Down Drilll, Shift III, 8106105
MCSO: Officer Brown
- Officers responded safely, secured the scene prior to medicals arrival. ASsisted in getting EMS in and
out of the facility in a timely fashion.
CHS, None
Debriefing/Recommendations:
Spoke to 2 officers at 2 core about the incident. Briefed Security Control Officers about the
need for them to call communications instead of calling 911 themselves. Gave everyone the
extension of Radio (61030).
Action Plan: .
Towers: Man Down Drill, Shift I, 8122105
MCSO, None;
- Response by Detention
"CHS, Ruth PhiJliben, RN, HCA
- b SpIne; Backboard applied: "Transported to"clinic via gurney. Eval by RN and MD. -IV Normal Saline. "
" transported to rviMC ER for evalualio"n."
" ".
""
Debrll:lfing/Recommendations:
-None
Action Plan: •
ESBlTent5: Man Down Drill, Shift 1; 8/22105
MCSO
- Radio call made by Officer Terresa Goodwin that an inmate was down in the dayroom. Inmate was
lying on floor not coherent to his surroundings. While being evaluated became violent with staff and
refused to follow orders.
CHS
- Medical staff responded promptly giving detention support in safely transporting the inmate to the
medical clinic so the inmate could be treated. Upon arriving at the clinic medical staff stayed on scene
and followed their protocol to insure the inmate received the treatment needed.
Debriefing/Recommendations:
The only thing that would have made the scenario smoother would be if Estrella Support
Building had a restraint chair on site. A restraint chair had to be retrieved from Estrella Jail.
Action Plan:
Agencies involved were notified of the recommendation with request to evaluate and obtain chair if
feasible.
9
02/21/06
MC Confidential (June 08) 001169
Estrella Jail: Man Down Drill, Shift 3, 8/25105
Attempted suicide with strap around the neck.
. MCSO
- Inmates in Tower A 200 summoned officer that something was srong in the pod. As officer entered
pod her was called to cell 205 where he found an inmate covered with a blanket. When he removed
the blanket he saw that the inmate had a strap around her neck. At that point he called for officer
assistance in A Tower. Control then relayed the call for officer assistance in Tower A and asked if
medical assistance was needed and called the clinic.
CHS
- When the medical staff arrived they were prepared to deal with the situation. They responded with a
stretcher and the needed items to do a quick assessment on the inmate prior to taking to the clinic.
Officer went with the inmate to the Estrella Clinic where it was determined that the injuries were not
serious and was sent to LBJ to be evaluated by councilors.'
Debriefing/Recommendations:
.
In this situation, an authorized item (Velcro strap from a splint/boot) was placed around the
inmate
.
S neck by the inmate in an effort to commit suicide. This revealed a potential problem. with
this type splint device that would allow the strap to be removed from the boot.
. Action Plan:
10
02/2]/06
MC Confidential (June 08) 001170
Lower Buckeye Jail: .Mass Casualty Drill, Shift 2, 8/29105
Response:
MCSO, Sgt. James Seibert
Sgt Rosales responded as soon as the radio call came out. He directed his officers to the scene.
The Officers responded with their air packs and fire extinguishers. They entered the house and
began their search, they immediately started removing the inmates from the smoke filled room and
took them to the triage area.
Overall the drill was a tremendous success. The supervisors and officers along with CHS did an
outstanding job working together. The FMO's we're right there after the drill filling all the air packs
that were utilized dUring the drill. Sgt Rosales did a nice job; his radio transmissions were precise
and accurate. The officers assigned to the Medical Services Division are to be commended; they
responded and carried out the drill in a professional manner. The Drill was executed with no injuries
to the officers or volunteers. One officer during the evacuation was overcome with "heat
exhaustion". He was seen by medical and was released back to work after the drill· was completed.
CHS, Roberto Escobar
Medical Staff on scene; RN Escobar, Dr. Drapeau, MD and other RN's along with Medical
Assistants responded with their equipment, set up the triage area and promptly assessed the
inmates as they were brought to them from the housing unit.
Debriefing/Reco~mendations;.
' . . .'.
.'
.
It was mentioned during the briefing a few areas of improvement needed to be addressed.
The Incident Commander could have responded directly to the housing unit instead of
directing an Officer to radio him as to what was happening.
CHS willlJ.ot set up the triage area in the middle of the hallway that needs to be kept open.
We had two equipment malfunctions; one airpack was missing the face mask, one fire
extinguisher was missing a pin. FMS Hector Osuna took the fire extinguisher out of service
and replaced the air pack and mask.
We need to work on being a little more diligent and expedite the task at hand. It was
discussed that an initial assessment of the situation should be made and then formulate a
plan of action. With this plan in place it will help expedite any future emergencies
Action Plan:
11
02/2]/06
MC Confidential (June 08) 001171
Estrella Jail: Mass Casualty Drill, Shift 2,10/27105
MCSO
- From the time the initial call was placed by Security Control, eight officers responded to the scene
within ninety seconds. The first officers on scene arrived with air-packs and fire extingUishers and
went straight into the dorm. They entered and began to direct the inmates out of the dorm. The house
officer had gotten the inmates up, put her air-pack on and secured the logbook, roster and keys (the
door cards were not secured). Other officers remained in the hallway during the evacuation process
and directed the inmates to the rec yard. There were ten inmates identified as "injured" and were
directed to a triage area for evaluation. The entire evacuation process took less than four minutes.
Once all inmates were safely placed in the recreation yard, two officers entered the house to look for
anyone who ad been left behind. An additional officer began an ID headcount of all the inmates in the
'
recreation yard.
CHS
- The Security Officer delayed in notifying Medical. When they were notified medical responded in a
. timely manner. The only issue that came up in the response was the arrival directly a "F" dorm.
Detention staff should have diiected them to a "safer" area initially. A medical liaison officer would
have prevented this from occurring. The medical staff responded with the proper equipment to triage
and treat injuries.
Debriefing/Recommendations:
The Security Control Officer should have included Medical in their radio transmission to
. "ensure .p·roper response.. . : . "
.'
. ' .. '
.
..... . . .
Officers failed to'arrive at the scene with air' packs and fire extinguishers. As~cond call was
made to remind them to bring the necessary equipment. This hindered their actions in so far.
as entering the affected area.
Wen the "injured" inmates were evacuated some of them were directed to the recreation yard
rather than the triage area.
Action Plan:
The Nurse Manager and Jail Commander were contacted concerning the need for additional radios
in the area set to iTIonitor channel 1, the detention channel. The information returned indicated that
the problem with this partiCUlar exercise was not related to the lack of radios but to the initial radio
calls not clearly indicating that medical should be involved and where to report to. These officers
were debriefed on correct radio transmissions and what to include.
Durango: Man Down, Shift 1, 11/29/05
Meso
- Inmate was returning to Durango Jail from LBJ medical when he slipped off his crutch on the parade
deck and landed on his tail bone. Officer witnessed the inmate fall and responded. Officers spoke with the
inmate until medical arrived keeping him still on the ground.
CHS
- RN and Officer assisted the inmate into a wheel chair. There were no problems identified and the
transition was smooth getting the inmate to medical. The inmate was awake, responsive and able to
communicate his injuries. He was taken to the Durango Medical Clinic for further evaluation. He was seen
by the Provider and returned to his housing unit.
Debriefing/Recommendations:
- None
Action Plan:
12
02/21/06
MC Confidential (June 08) 001172
Durango: Mass Casultv Drill, Shift 2,11/30105
MCSO
- Responding officers donned MSA air packs and responded with fire fighting equipment. Security
Control simulated the calling of Phoenix Fire and dispatched an officer to open the perimeter gates when
they arrived. Incident supervisor established a Command Post and placed the facility on security override
at 1615 hours. The officers were paired up as they entered the warehouse to evacuate the inmates.
CHS
- Injured inmates were taken to the triage area set up south of the 0-8 and the other inmates were
secured in the Recreation Yard. Officers searched the dorm for any injured or unconscious inmates.
Officer spoke to each inmate in the recreation yard asking if they needed medical attention. The officer
working the dorm also did not give the names and booking numbers of the inmates which would have
allowed the medical staff to pull the inmates medical files.
~.
Debriefing/Recommendations:
The inmates were removed from the affected area, but there was come confusion as to what
to do with them once they were outside.
Holding and triage areas were set up but there was a failure in communication that caused a
delay in securing the inmates.
The inmates were allowed to wander around while the officers conducting the ID headcount
and ill the triage a·rea.
.
.. Officers ante'red the affected area :without ~irpacks afte·r the' imn.ates ha.d been ev.acuated but .
before the area was cleared.
.
.
Action Plan:
13
02/21/00
MC Confidential (June 08) 001173
Durango: Mass Casualty Drill, Shift 1,12/1105
MCSO
.
th
- A hazardous gas tanker was· involved in a collision at the corner of 4 Ave. and Madison. Strong
odors were smelled in Level2A Radio call requested a supervisor to report to House 2A, announced
it was a drill and inmates were "acting weird". An "Incident Commander" was designated. Medical
staff was held in an unaffected area until such time that detention staff donning airpacs were able to
remove the downed inmates from the affected unit. Once turned over to medical staff the inmates
were moved to designated triage areas in the hallway outside of Level 2 Medical and a secondary
triage area in basement medical. As the inmates in need of medical attention· were being removed the
rest of the inmates were being staged for a partial evacuation. The unaffected inmates were then .
moved from 2-A-100 to 2-0-200 and secured in the recreation yard until such time it was safe to return
to the assigned housing unit.
CHS
- Medical staff heard th.e call on the radio. The Nurse Manager gave instruction to the nursing staff and
the Provider communicated with him. to the Sergeant. Additional staff arrived from the mini clinics and
the Providers received additional instruction from the Doctor on scene. The nursing and medical staff
were very clear on the health care chain of command. There was an initial problem. with p'atients
blocking the exit to the housing unit. The injured were then transported to the mini din,ic, but nursing
staff were prevented from entering the clinic to assess the patients.
.Debriefing/Recommendations:
D~t~ntiol) to deh;r!nine if the elevators can be iliated on overriqe to summon the .elevator .
after a radio call·by medical:
.
,
..
.......,...
Detention to brief staff on the reduction of radio transmissions during an emergency to
essential information only.
Detention to advise medical staff of evacuation route and signs to be made to post in the
main clinic and mini clinics.
Detention to instruct their staff on location of stairs to the levels.
Detention will instruct their staff to evacuate the "well" inmates first.
Medical to order fluorescent vests; one for the medical staff member in charge and one for
the detention officer in charge.
Medical to instruct FTO's on use of the Stryker cots. There was some difficulty raising and
lowering cots with patients on board.
Need mechanism for documenting on each patient and keep information with the patient for
the providers to continually review.
Action Plan:
14
02/21/06
MC Confidential (June 08) 001174
APPENDIX 2
MC Confidential (June 08)
001175
,....f;·
CORRECTIONAL HEALTH SERVICES
INFECTION CONTROL .COMMITTEE MEETING.
Confidential pursuant."to ~RS 36-2401 et seq.
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C·orifidentiaf pursuant to ARS 36·
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Comulunicable Disease Exposures - Inmate Exposures
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Confidential pursuant to
I
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2401 et sea.
A~S
36-2401 et seq.
Maricopa County COfre~tional Health Services
Total # 'of T6 Cases
All Clinics Per ~ 0,000 Mandays
to A RS36-1
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Infection ContrQI
MRSACases
Confidential pursuant to·A.RS 36-2401 et seq.
Month
January
January
February
February
March
March
March
April
April
April
April
May
May
May
May
June
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591M
421M
181M
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331M
241M
261F
261M
191F
47/M
311M
19/F
Clinic
IProbableLocation MRSA Acquired/Comments
Madison Psych. !Jail
. ICommunity-Skin graft at Good Sal"Tlprior to booking
Durango
IJail
Towers
Foot
Towers
IJaii
Lt. index finger
Towers
IJaii
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Estrella Support IJail
Rt. Elbow
Towers
IJail
Finger
Estrella
'Community. Had ear tubes when booked.
Ear
ICommunity•. Had wound and sutures at bookin
Rt. Leg wound Estrella
Durango
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Rt. Thumb
Durango Psych
ICommunity. CIO abd. pain when booked
Urine
Forearm
Estrella
'Jail
Bacteremia
Estrella
IPossibly Jail._ Septic ioint.
IPossibly jail. Had lung problems when booked.
Durango
Nose
Ear
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Ears
Estrella
IJail
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.
.
Maricopa County Correctional Health Services ., : ";:
2401 et seq.
Reported MRSA~ses
MRSA by Month-All Clinics'Per 10,000 Mandays
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Confidential pursuant to:ARS 36-2401 et seq.
,);,~~~Fi~t
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"":; .'<?lnfideDtial.pUrsuant to ARS 36-2401 et seq
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Court Ordered ·RPR.s. ~ ,~, %Tests Completed
Confidential pursuant toARS 36-2401 et seq.
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.
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for JanuaryfFebruary, 2005
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Infection CO:ntroIEmployee ;Exposure
Confidential pursuant to ARS 36-2401 et seq.
CHS Staff
DatEi ~.f IhQig~iU;r~·,:.tji:i~-A1~'[~~~;:1f?lt~·· Clinic~;';~~l~: .Devic.~ ty~}:.[~::·:::"~:::';·~~: ·~·:~~~Fr.~;-i;~~;;'!M:{!lUiru:t:'1~-~-Y~~S-::~,;#;]J6/11/2003
8/15/2003
9/13/2003
10/15/2003
1212212003
1/30/2004
71212004
8/412004
IMedical Assistant
I
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Lancet
'·1 Pricked by an uncapped lancet.
Scissors
IAttempting to remove jammedstaple With scissors.
Syringe Needle' -I Pricked when recapping needle
Syringe Needle INeedle penetratedIn<:!ex firrgeLafter administering insulin to inmate.
I
Lancet. -I Inmate pulled hand back while nurse performed accu-check.
I
NtA
IBlood spill on ftnqers of right hand.
125 Gauge NeedlelAccidental needlesticls to hand_whUeperfoming medical procedure.
I Butterfly Needle /Inmate fainted, pulled hand back and was pricked by needle.
IMadison OP
ITowers Clinic
I Medical Assistant I Madison Outpatient
IRegistered Nurse I Madi~on Intake
ILicensed PracticalNfvladison Intake
IMedical Assistant IMadison OP
IPhysician
ITowers Clinic
IMedical Assistant IMadison Intake
IRegistered Nurse
3/13/2005
Physician Assistant IDuranqo OP
Needle
6/1212005
Physician Assistant IEstrella Clinic
Needle
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4/20/2004
7/26/2005
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IMedical Assistant
IMedical Assistant
IDuran~o Juvy
IDurango OP
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Needle
. IStuck by contaminated needle while disposlnQ.
Butterfly Needle IPulled out needle from inmate and stuckleftthulTlb;did bleed
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Correctional Health Services
Infection Control
Communicable Disease Report
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36-2401 et seq.
..
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Disease
Tuberculosis Cases (New--Confirmed)
Varicella
Hepatitis A
Hepatitis B
Hepatitis C
HIV/AIDS
Syphilis, Early
Syp h ilis, Late
Chlamydia
Gonorrhea
Totals
Disease
Tu bercu losis Cases (N ew--Confirm ed)
Varicella
Hepatitis A
Hepatitis B
Hepatitis C
HIV/AIDS
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3
8
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Total for Quarter
0
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0
0
a
1
21
5
3
7
40
12
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0
13
1
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13
Nov
Oct
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Chlamydia
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Totals
CD
o
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C
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0
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9
9
'28
40
16
83
. 94
Dec
2
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3
11
Total for Quarter
1
1
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1
11
6
4
0
5
11
28
11
73
5
20
12
59
38
245
3
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36
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etreq.
So"""""
. .,Martcopa Countj C<>rrectJOnaI_ith
R3ported Communicable l:Aseases
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July
/August" )Septerrber
01 "
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October
8:
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Inmate Exposures
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I
Total # of Inni ate Expos ures
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Communicable Disease Exposures - Total CHS/Registry Staff
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SepteniJer
01
01
October INbverrber IDecerrber ITotal for Quarter
21 ..
11
51
1/
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Maricopa' County Correctional Health Services
Confidential pursuant to ARS 36·
2401 et seq.
sta'!f
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All Clinics Per 1,OQO ADP
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. ;.
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Confidential purs uant to ARS 36·
2401etseq.
Ii
Total # of TB' Cases
AU Clinic$ Per
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February 7,2006
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::;-;., ··Hd.V.05· .;- .Th"lC.<-'i'{;Dec 05
~'. .:";·"··:~·.:L::~·~]':: . .·:>·: ; ~ .:.:~~~~ r/:~·;~· :~~~::~;7~~:;:;¥t~:·~·:~~i:.·~ .~i1}~·;t~11~:t<~~r :.~' ,,:~~ ~.~:.:r::::.
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R1tttT1fbl*r" "'jrJt"W
I
:
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Correctional.Health Services
Infection Control
Communicable Disease Report
Chickenpox
Confidential pursuant to ARS 36-2401 et seq.
','
..
.~g"11-~l~8~;:~~~~~~#,rfi~7;~~~~~~
~,:~;llt1;9H~
:It.es:s:·~;2Z~'7LO,5.t~Iitl;2124/'O,5~;;?_:;:
i~h;g~c::;~~ci~~';~t91;~~~f~$i~J~~~"~~~:,_.
Total Exposed ~ Inmates
Total Exposed ~ Staff (CHS & Registry)
Total Exposed- Inmates.& Staff'
291
5
296
23
Released to other agencies
Released to Self·PH
Positive (Immune) Test results'
Refused Testing
Negative (Non-Immune) Test Results--Quarantined
Known cases transmitted from index cases
Known pregnant 1M exposed.
8:
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Correctional ,Health Services
Infection Control
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Chickenpox
Confidential pursuant to ARS 36-2401 et seq.
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Total Exposed - Inmates
Total Exposed - Staff (CHS & Regi$try)
Total Exposed - Inmates &Staff
77
4
81
3::
n
Released to other agencies
Released to Self-PH
Positive (1m m une) Test r'esults
Refused Testin g
Equivocal Test Results--~uaranUl1ed
Negative (Non-Immune) Test Results--Quarantined,
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Known pregnant 1M exposed .
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July
July
August
August
August
Sept.
Sept.
Sept.
Sept.
SeDt.
Sept.
October
October
October
October
October
October
October
November
November
November
December
December
December
361M
281M
471M
361M
271M
221M
181M
391M
211M
421F
261M
471M
451M
301M
361M
191M
251M
451F
281M
4aIF
231M
511M
42/F
201M
Leg Wound
ITowers
Bil.legs, R arm IDurango
legs at MMC 14th Ave IIA
Ear
ILBJ
Lt. Buttock
ITowers
Facial cellulitis 'Towers
Rt. Forearm
1LBJ
Rt. Elbow
ILBJ
Lt. Knee
ILBJ
Groin, axilla
IEstrella
Nasal
ILBJ
R arm abscess 14th Ave. Outpt.
Nasal culture 1LBJ Outpt.
Nasal culture ITowers
Blood cx MMC ILBJ Outpt.
Nasal culture ITowers
R Hand
ITowers
Leg wound
IEstrella
Nasal culture ILBJ Outpt.
L Hand wound IEstrella
Blood
IInfirmary
R leg wound 14th Ave. Outpt.
Head/scalp
IEstrella
R infraorbital 14th Ave. Outpt.
Community. Laceration Rt. ankl~ whenboQke(j (Jumped out window)
Jail. Multiple absCesses
Community. Abscesses both legs when b(){)ked, per pt., MRSA
Community. C/O ear drainage x 1 yr. when booked
Jail. 11M squeezed abscess on buttock
Jail. Booked March '2004, to MMC Sept. 2005, facial cellulitis, MRSA
Jail. Rt. Forearm abscess, not present when booked
Community. Elbow'infected at time of booking.
Jail. Booked July 2005, Adm. MMC Sept. 2005 with knee cellulitis
Community. Multiple ,abscesses when booked, SIP skin graft
Jail. Booked April 2005, Hx.mastoid cellulitis, but no prevo cultures
Community =-AbsceSses; hx "skinpopPir'lg"_@ !ime of booking
Jail - hx osteo R finger
Jail; hx of head & abd wounds
Community - adm.,To MMC 1 day after booking; hx of IVDA
Jail - hx of spider bite; multiple abscesses; Nsg ruptured abd abscess w/pressure
Jail
Community ..hx of L leg fx w/pins @ time of bookin
Community - On H&P multiple MRSA infections; suspect carrier
Community-broke, drug pipe in h?nd~prior to booking
Hospital acquired; tit PICC line' .'
Community - multiple abscesses @ time of bookin
Jail
eom,munity - R infraorbital abscess sip removal of metal plate from previous MVA surgery
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2401 et seq.
to ARS 36-2401 et seq.
.
.
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---------~~---..:..---~------,Ii···
Maricopa County Correctional Health servfces",:
, ReportedMRSACases
;'
MRSA by Month·AIlClinfcs Per 10,000 ADP
.
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Prepared by Quality
February 7, 2006
ow.
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Correctional Health Services
Infection C;ontrol
Court Ordered RPRs - .0/0 Tests' Completed
ConfIdential pursuant to· ARS 36-2401 et seq.
Correctionall-2alh Services
".
.
". . '..
Infection Control
lib data available for the mOrith of January, 2004-fIb data available
February, 2004- ~cember, 200S
~ for JoouarylFebruary, 2005
Court Ordered RPRs - % Tests Completed :.; .......,---'::""'---;,:;~,;;"":. . , . . - - - - -_ _--,--.J
'~----..J.,.
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Total
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90%
80%
10%
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40%
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20%
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Correctional Health Services
Infection .Control
Employee Exposure
Confidential pursuant to. ARS 36-2401 et seq.
CHS Staff
O<l.~e .bf l.tibJdeilfl F )~~:~. Title '{P"
6/11/2003
8/15/2003
9/13/2003
10/15/2003
12/22/2003
1/30/2004
71212004
8/4/2004
, .;' 1"~2~ifd(r;f.
DDevi~~ltl·~ ~~'1 ~:~.~~~~~~~::~~?~~:~~:J.:~~. ::~·~;~·;·:i~~~~~:::~:·.~af1~ilf11fJE~t~:~:_·:i~;.~~·~·~~':J~~·~~r;'i~~:'·~
:.
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3/13/2005
Physician Assistant IDurango OP
Needle
o
6/1212005
10/5/2005
Needle
TB SyrinQe
10/27/2005
Physician Assistant IEstrella Clinic
Medical Assistant IP-4
Licensed Practical
Nurse
Ip-4
11/612005
Registered Nurse
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Needle stick after.suturin!=l when disposinQ sharps
Putting needle in sharps container
Putting needle in sharps container
TB SyrinQe
Pricked in Rt FA with TB syringe/was depositinQ blood draw needle into sharps container.
22 gauge Eclipse
needle
needle stick· finQer while closing safety cap; contaminated needlelblood noted under glove
CD
rt
f-'.
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Lancet
IPricked by an.uncapped lancet.
IMedical Assistant I Madison OP
Scissors
IAttempting to remove jammed staple with scissors.
IRegistered Nurse !Towers Clinic
IMedical Assistant IMadison OutpatiE Syringe Needle !Pricked when··recapping needle
Syringe Needle INeedle penetrated index finger after administering insulin to inmate.
IRegistered Nurse I Madison Intake
Lancet
IInmate pulled hand back while nurse performed accu-eheck.
ILicensed Practical NMadison Intake
N1A
IBlood spill on .fingers of riQht hand.
IMedical Assistant IMadison OP
25 Gauge Needle IAccidental needl8?tick to hancj Vl'hile pejioming medical prOQedure.
IPhysician
ITowers Clinic
Butterfly Needle IInmate fainted; pulled hand back and was pricked by needle.
IMedical Assistant IMadison Intake
in
IDurango OP
I--'
Registry Staff
Cj
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IMedical Assistant
4/20/2004-- ., Medical ASSIStant 7/26/2005
IMedical Assistant
I Durango JUVy
I
I
I
I . Durango of:' I
LBJ
Butterfly Needle .lStuck by contaminated needle while drawing bIocJ<L
NeMle
IStuck by contaminated needle while disposing.
Butterfly Needle IPuliedout ne8dtefrominmate and stuckleftthunlb; did bleed
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APPENDIX 3
MC Confidential (June 08) 001203
Lindy Funkhouser - HCMX
From:
Cheryl McCall - SHERIFFX
Sent:
Tuesday, February 21, 2006 8:35 AM
To:
Lindy Funkhouser - HCMX
Cc:
Larry Hutcheson - SHERIFFX; Kundavaram Reddy - SHERIFFX; Nancy O'Neill- SHERIFFX
SUbject: RE: Attorney-client communication regarding NCCHC survey response
Good Momlng,
It appears that MCSO Food Service is in COmplilll1Ce wit~ all standards, both in section J-F-02 Nutrition and
. Medical Diets, and in section J-B-03 Kitchen Sanitation and Food Handlers.
The only thing I see for J-F-02 that needs to be changed is the following:
The statement that says the "food services manager i~ a dietician", which is notccirrect.
A correct statement would be the following:
The Assistant Food Service Manager has a: Registered Dietician on staff. The dietician is
responsible for overseeing the nutritional component of meals served.
For J-B-03, the description of food service could be changed to:
. B. .MANAGING A SAFE AND
HEALTHY ENVIR·ONi1JiNT·
~i1QJJ~1]
Meals are prepared jn a massive modern kitchen complex at the Lower Buckeye complex. The kitchen
has state-of-the-art equipment and is efficient and effective. Facility staff and inmate-workers are
employed in the food services opcnltiol1s. Once prepared, food is placed on individual, seaJ"cd food trays
that are· loaded into special insulated carts. The carts are loaded onto refrigerated trailers for transpOli to
jail facilities. At the facilities, carts are loaded into docking stations which refrigerate the trays until an
automatic cycle begins before meal time. During this cycle, trays are both heated and chilled, k.eeping
food h01 on one side, and cold 011 the other. The survey team noted a very efficient food service in place.
That is all that I saw that needed to be changed. See below for original text:
F. HEALTH PROMOTION AND DISEASE PREVENTION
1. General Comments
Medical diets are currently being prepared for patients with specific dietary needs. The food services manager is
a dietitian and oversees the nutritional component of meals served.
J-F-02 Nutrition and Medical Diets (1).
I X ]compliance [ 1partial compliance [ )non-compliance.
Corrective action [X ] is not required. [ ) is required for Compliance Indicator(s):
B. MANAGING A SAFE AND HEALTHY ENVIRONMENT
Kitchen
Meals are prepared in a massive modern kitchen complex at LBJ. The kitchen has state-of-the-art equipment and
is efficient and effective. Facility staff and inmate-workers are employed in the food services operations. Once
prepared, food is prepared on individual food lrays that arc loadc:d inlo special insulated containers and then 0010
(0 giunl trucks which distribute 1h~ trays to the inl11at~ living areas. Th~ insulated containers for the trays keep hot·
2/21/2006
MC Confidential (June 08) 001204
("oods hm on 01le: ~icie. slld cold thing-, cold on tile: Dtller. The survey team noted a very efficient food service in
place.
Meals are served twice a day; the interval between the evening meal and morning meal does not exceed 14 hours.
The morning distribution is served between 7 am and 8 am. Inmates who are working also receive a "sack lunch"
at this time. The evening meal is served between 5 pm and 6 pm. Diabetics, those who are pregnant and those
whose health requires more frequent or additional meals or food are provided for. Surveyors noticed that there
were no complaints regarding the food serVices from the inmates.
The only other kitchen is at Durango. This kitchen is old, yet staff and inmates are attentive to daily cleaning and
maintenance. There are plans to stop using the Durango kitchen.'
J-B-03 Kitchen Sanitation and Food Handlers (I).
[ X ]compliance ( ] partial compliance [ ]non-compliance.
Corrective action [X ] is not required. [ ] is required for Compliance Indicator(s):
Let me know if you need additional information.
Cheryl McCall
2/21/2006
MC Confidential (June 08)
001205
APPENDIX 4
MC Confidential (June 08) 001206
Lindy Funkhouser - HCMX
From:
Frank Kelch - SHERIFFX
Sent:
Tuesday, February 21, 2006 11 :26 AM
To:
Lindy Funkhouser - HCMX
Subject: Our response to the report
Undy,
:"'isted below you shall find our r.esponse to the two issues that were brought up by the inspectors during the NCCHC Inspection.
j·C-04 Training for Correctional Officers.
• Checking the statistics for the training for CPR and First Aid, the Sheriffs Office is well within the standards set forth by the
standard. Listed below you shall discover the statistics for the number of staff assigned compared to the number who were not up
10 date on their CPR and First Aid training. In each case we were well ab0~e the 75 percentage allowed.
...·
. ,;,:'
Month
Number of Officers Assigned
Percentage of
Number of-Staff not in compliance
Staff in compliance
:l~,
November
1866
155
91.69 %
December
1854
131
92.93 %
January
1873
.131
93.01 %
'1881
131
93.04%
Febru"ary
,J-B-02 Environmental health and Safety Issues
Upon receipt ofthe detailed inspection repOli, Our Institutional Services Division did a complete re-inspection
and did find some of the same issues that were brought up within the inspection. Since that time we have doubled the
cleaning schedule of the showers and have ordered some renovations to the showers in the Estrella Building which is
near completion as of this writing. We are also seeking some additional funding to address the shower areas within the
Towers Jail. The dusty conditions concerning the floors have been addressed and corrective action has been noted on
various re-inspections.
This should address those two issues Lindy. If you have any questions feel free to call me
Frank
2/21/2006
MC Confidential (June 08) 001207
APPENDIX 5
MC Confidential (June 08) 001208
Maricopa County
Correctional Health Services
234 N. Centrnl Ave, 5rh Fl.
Phoenix., Arizona 85004
Phone: (602) 506-2906
Fax:. (602) 506-2577
Appendix 5 Cover Memorandum
,~
To:
NeCHC
From:
Lindy Funkhouser
Director, Correctional Health Services
0~~~
Attached to this cover memorandum are documents that evidence Correctional Health
Services' (CHS) recruitment plan.
Attachment "1" is the salary 'structure for CHS nurses. This salary structure became
effective in Nove~ber 2005. Employees began to see these increases in their midDecember paychecks.
Attachment "2" is a report of incoming certifications of eligible candidates for
employment. This report is one of several that the CHS Director reviews with the
CHS Human Relations staff every two weeks. This meeting also reviews the current
list of open and funded positions in CBS. The Director reviews the status of every
open position and, if necessary, develops an action plan for filling the position. The .
. meeting: also revi.ews all. positions under administrative action in the event the' action: ..,
results in a vacancy.
Attachment "3" lists the job fair opportunities that CHS plans to attend as a registered
employer. CHS plans to coo~dinat~ with special Sheriff's Office recruitments to
broaden its reach in the community.
Attachment "4" is the CHS request to the County Office of Management and Budget
for additional funding for recruitment and retention initiatives. The attachment lists
the initiatives. Please note that the request is not effective unless and until it is
reviewed by OMB and approved by the Maricopa County Board of Supervisors.
MC Confidential (June 08) 001209
Placement in Range Salary Range Structure
In accordance with Maricopa County Total Compensation Department's philosophy,
Cqrrectional Health Services hires· individuals into the nursing market range at. the
appropriate salary based on their total years ofjobreiated experience. For example, a RN
with 5 years of experience would be compensated at $25.33 per hour, while a RN with 10
years of experience would be compensated at $31.72 per hour.
Total Compensation recently c9mpressed the nursing salary ranges from 25 years to a
total of 12 years. The following working titles are included within the nurse market
range; Clinical Nurse Educator, Discharge Case Manager, Night Shift Supervisor, and
Psych Registered Nurse.
.
Total Compensation also provided salary ranges for Licensed Practical Nurse, Nursing
Supervisor and Nurse PractitionerlPhysician's Assistants using the saJI:le placement in
range strategy.
.
These salary ranges were effective November 5, 2005 and will be reviewed on an annual
basis by Total Compensation.
Years of
..Experi·ence
0
1
2
3
4
5
6
7
8
9
10
11
12
..
LPN
.Nurse
. ($).
. ($)
13.54
14.08
14.64
15.23
15.84
16-.4J
17.13
17.82
18.53
19.27
20.04
20.84
21:62
20.23
21.16
22.13
23.15
24.. 22
25.33
26.50
27.72
28.99
30.32
31.72
33.18
34.71
Nursing
.. : .·SuperVisor
27.27
28.28
29.33
30.41
31.54
32.70
33.91
35.17
36.47
37.82
39.22
40.67
42.18
(n .
Nurse
-Practition~r($) -,
".
31.51
32.79
34.13
35.52
36.96
38.47
40.03
41.66
43.36
45.12
46.96
48.87
50.88
MC Confidential (June 08) 001210
Incoming Certifications of Eligible Candidates for Employment
Position Title
Health Unit Coordinator
. Supervisor
Wanda LaPoint
Date Cert List(s)
Issued
1/23/06
Correctional Health Tech. Lin Maschner
1/19/06
Mental Health
Professional
Dr. Joseph
1/24/06
Mental Health
Professional (Temp)
Dr. Joseph
1/24/06
Medic'al I~ventory and
Stock Tech
..
Margaret Green
2/6/06
Nurse Practitioner
Dr. Joseph
1/26/06
--
LPN
Ruth Philliben
1/30/2006,2/13/06
RN
Ruth Philliben
1/30/2006,2/13/06
Nurse Recruiter
Lin Maschner
2/13/06
Admin. Assistant
Lin Maschner
2/21/06
-'
MC Confidential (June 08) 001211
N
rl
Marrcopa County
Correctf6nal Health Servic s
FY 2005/2006 Job Fairs
Dat~
.'. ·;T·~~~f~'(1~~'~!~.
:!.
.:11/2/2006
9113/2005
Tuesday
N
rl
o
o
I
Jobing.Com
(747 N. 22nd
Street
/PhoeniX, P-Z'602 200-6818
85016
Nursing
Spectrum/Nurs 12655 Villa Creek
eWeek
Drive, Suite 250
ASU Student
l12/11/2C06
Nurses
Saturday
Assoclation
I
Dallas, TX
75234
j7001 E. Williams IMesa, Az
Field Road
85212
1100 W.
2/25/2006 Maricopa
County Sheriffs Washington, 19
Saturday
Office,
Floor
Nursing
4/26/2006
Spectrum/Nurs 12655 Villa Creek
Wednesday
eWeek
Drive, Suite 250
~
'.~
~.:
I
Pointe South
Baseline Road &
Mountain Pavilion 1-10
Cost
o
Q)
~
$1,524
g
rl
111 N. 3rd St.,
http://events.nursingspe
Phx 85004
Phx Civic Plaza
972 488-00911
ctrum.com
http://WW'W.asu.ed/stude
ASU Main
Campus, Tempe,
1480-727-1550 480-727-1556'1 ntaff~irs/careerJEmpReg jASU Student
INurslngCareerDaylnfo. Union
P-Z
htm
I
co
.
1800-8688944 Ext 135
1~~g~2Ix, All 876-1 000
Dallas, TX
75234
...: ....:.
I
.
I
WWN. iobing. com
~ .~
.Atldress
. ';- ::. " ::.: ..:" ..
Sheriffs Office
Training Center
http://events.nursingspe
1800-868ctrum.com
I Phx Civic Plaza
8944 Ext 135 1'972488-0091
35th Ave & Lower
Buckeye Road
111 N. 3rd St.,
Phx 85004
ro
$1,995
'r!
.j.J
~
(1)
'D
$350
.r!
lH
$0
u
u
~
o
;2:;
$2,200
((3
-
Maricopa .County
'Correctional Health Services
234 N. Cent:r:ll Ave.
Date: February 21,2006
Suite 5000
Phoenix, lIZ 85004
Phone: 602-506·5580
Pax: 602·506-25/7
To:
Chris Bradley, Deputy Budget Director
From: Lisa Gardner, CHS Finance
Subject: Nursing Incentives
:'
Manag~\ ?f-----
Vl"/
.
.
Per our previous discussions regarding CHS's desire to move forward with several
initiatives related to recruitment of our clinical staff, we would like the opportunity to
meet with 'you to talk in detail with respect to:
a.
b.
c.
d.
Recruitment bonus for RN night and weekend shifts
Retention bonus for select clinical market ranges
Utilization of "Jobing.com"
Uniform
aUowance
fo~. select c\.inical.market
ranges
:
. . ..
.
I will· forward to you a draft cost proposal for the remainder of this fiscal year and
next fiscal year, and also work with Neeraj to set up a meeting.
Please let me know i(you have any questions, and we look forward to discussing
these opportunities with you.
'
MC Confidential (June 08) 001213
CHS
Nursing Incentive Plan
.Total Estimate for:
Retention, Recruitment, and Uniform Allowance Plans
For the Fiscal Years Ended FY06 and FY07
FY06
Recruitment Plan - RN only
Uniform Allowance
Jobing.com
Retention ~Ian
Total
FY07
Total for 06 and 07
16,107
35.263
78,600'
38,542
152,943
35,263
-67,600
3,503
169.050
70,525
146,200
42,044
168,511
259,308
427.819
MC Confidential (June 08)
001214
CHS
Nursing Incentive Plan
Recruitment Plan - RN only
$5,000 Per new recruit
Assume
Total
Vacancies 30% turnover
All RN Posistions
30
39
30
39
Assume
75% are
eve/~ight
0.75
Eve/Night
Vacancies
Recommended
Sign On Bonus
Potential
Total Cost
29
5,000
145,000
29
145,000
Pilas -In Scenario
Approval by April 1, 2006
3::
n
n
Hire Phase in (25% success each month)
May
June
JUly FY07
Aug
o
Cost By Month
June
Aug
Sept
May
July
7
7,000
7,000
7
7,000
7,000
7
7,000
8
8,000
29
7,000
7,000
:::J
7,000
15,000
7,000
FY06
FY07
7,000
28,000
7,000
0
28,000
35,000
40,000
14,QOO
131,000
16,107
152,943
0
r-n
1-"
0..
CD
:::J
With Variable Benefit Rate at 15.05% fyOS and 16.75% fy07
rt
1-"
OJ
~
Assumptions:
Cj
C
:::J
Vacancy numbers as of 12/28/2005
o
75% of the vacancies are evening and night shifts
Will achieve 25% success each month after approval beginning in February 2006
Turnover rate of 30% in total was assumed
CD
CD
o
o
~
N
~
{Jl
CHS
Nursing Incentive Plan
Uniform Allowance
3 Uniforms per year
# of
Positions
CHT's. RNs, LPNs
MIST's. Rad Tech, MR Techs
HUCs
Dental Offices
180
19
26
6
Totals
231
Est
Positions
Turnover R wi turn
30%
10%
10%
10%
Est Cost
Per Year
234
21
29
7
125
125
125
125
. 29 j 250
2,613
.' 3,575
825
290
500
.36,263
Includes Filled and Vacant positions
::$
()
()
o
tl
t-h
f-"-
0-
m
tl
It
f-".
OJ
f-'
~
tl
m
o
CO
o
o
t--'
I\.)
f-'
01
Subtotal
Assumptions:
Turn over rate at 30% for RNs. LPNs, CHTs, 10% for all others
Include 25% additional on top of $1 OO/uniform to cover employee taxable benefit
Current
Expense
fy06
Total
Cost
fy07
Total
Cost
1,000
29,250
2,613
3,575
(175)
29,250
2,613
3,575
(175)
1,000
35,263
35,263
Retention/Longevity Bonus Program*
FY 2006 - YTD from date of hire
5 'r'ears of Continuous Service No of Emp
Nurse Manager
o
Rr'l
7 $
LPN
FY 2007 - Only current FY sleps
5 Years of Continuous Service
No of Emp
Amount
$
3,500.00
10 $
~OOQOO
$
8,500.00
Nurse Manager
$
Rlj
$
2 $
$
1,000.00
2,000.00
3,000.00
15 Years of Continuous Service
NLlfse Manager
RN
LPN
Subtotals for NM, RN,LPN
3::
::J
Hl
1-"
p..
(j)
::J
rt
HUC
CHT
OTH
HUC
PJ
Cj
C
::J
CHT
OTH
(j)
o
Subtotals for HUC,CHT,Other
$
$
1,000.00
$
$
$
3 $
$
Nur~e Manager
RN .
LPN
27 $
22,000.00
Subtotals for NM, RN,LPN
500.00
500.00
1,000.00
.
$
$
$
$
4 $
2,000.00
$
500,00
500,00
FY 2007
5 Years of Continuous Service
4 $
3 $
1 $
$
2,000.00
1,500.00
500.00
4,000.00
HUC
CHT.·
$
$
$
OTH
1,OO(),OO
10 Years of Continuous Service
$
$
$
HUC
$
CHT
aTK ..
$
$
$
15 Years of Continuous Service
HUC
500.00
500.00
$
LPN
"$
1-"
f-'
Nurse Manager
RN
.
1,500.00
4,500.00
4,500.00
10,500.00
1 $
3 $
10 Years of Continuous Service
CHT
OTH
$
$
15 'friars of Continuous ServiCe
FY 2006
5 Years of Continuous Service
n
n
o
Nurse Manager
RN'
LPt-J
19 years of Continuous Service
10 Years of Continuous Service
LPN
Amount
15 Years of Continuous Service
4 $
o $
6,000.00
1 $
1,500.00
$
7,500.00
13 $
11,500.00
40 $
33,500.00
HUC'
$
CHT
$
OTH
$
$
Subtotals f r HUC,CHT,Oth r
2 $
1,000,00
6 $
S,DOD,OD
CD
o
o
f-'
N
f-'
--.l
·Does NOT include variable benefits that will be paid on Ihase dollars
Nursing l'lCe'ltl·,'e.xls
RetentioniLongevity Bonus Program*
Cosls for Nurse Manager, RN & LPN for FY 06
$
22,000,00
Cosls for Nurse Manager, RN & LPN for FY 07
$
$
2,000.00
24,000,00
Costs for HUC, CHT, OTH for FY 06
$
11,500.00
Costs for HUC, CHT, OTH for FY 07
$
$
1,000.00
12,500,00
Tolal Costs for the next 2 fiscal years (FY 2005-2006 and FY 2006-2007)
$
36,500,00
3:
n
n
o
::s
H1
1--'-
0..
CD
::s
rt
1--"
OJ
i-'
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~
::s
CD
o
CO
o
o
f-l
I'V
i-'
CO
'Does NOT include variable bene fils thai will be paid on these dollars
Nursing Incentive. ~Is
Usa Gardner - CHSX
From:
Lindy F.unkhouser - HCMX
Sent:
Tuesday, February 14,20064:36 PM
To:·
Janice stratton - CHSX; Peggy Garza - CHSX
Cc:
Rebecca Nicholson - CHSX; Lisa Gardner - CHSX; Margaret Green - CHSX
Subject: RE: TV Prices
MCSO also is very interested in working with us on our recruitment efforts. We might want to coordinate our
messages, if possible.
---Original Message----From: Janice Stratton - CHSX
Sent: Tuesday, February 14,20064:20 PM
To: Peggy Garza CHSX; Lindy Funkhouser - HCMX
Cc: Rebecca Nicholson - CHSX; Lisa Gardner - CHSX
Subject: RE: TV Prices
J
My thought is that buying the 30 pack package is preferable because we want to get to the point fairly
soon to recruit positions by location and so would have numerous postings with RNs, LPNs, HUCs,
CHTs, etc. Right now we just posted RNs, LPNs, etc.
Janice Stratton
CHSHRM(J/uiger
.
PIrone:· 602506-5584
Fax: 602506-2160
-----Original Message----From: Peggy Garza - CHSX
Sent: Tuesday, February 14, 20064:02 PM
To: Lindy Funkhouser - HCMX
Cc: Rebecca Nicholson - CHSX; Janice Stratton - CHSX; Lisa Gardner - CHSX
Subject: RE: TV Prices
Importance: High
Lindy- I received the proposals from Jobing on cost of a 20 and 15 pack listing,-.Tb.e..20 pack cost
is $1588.16; 15 pack cost is $1482.00. In comparing the cost for a 30 pacili$1577.33~versus
the 20 pack ($15B8.33), there's a difference of $10.83. Does anyone have any comments?
·Thanks! -Peg
-----Original Message----From: Lindy Funkhouser - HCMX
Sent: Friday, February 10, 2006 10:45 AM.
To: Peggy Garza - CHSX; Rebecca Nicholson - CHSX
Cc: Lisa Gardner - CHSX; Janice Stratton - CHSX; Chris Bradley - OMBX; Neeraj
Deshpande - OMBX
Subject: RE: TV Prices
Thanks, Peggy.
-----Original Message----. From: Peggy Garza - CHSX
Sent: Friday, February 10, 2006 10:44 AM
To: Lindy Funkhouser - HCMX; Rebecca Nicholson - CHSX
2/21/2006
MC Confidential (June 08) 001219
Cc Lisa Gardner - CHSX; Janice Stratton - CHSX; Chris Bradley - OMBX; Neeraj
Deshpande - OMBX
Sobjece RE: TV Prices
Importance: High
Update: I made contact with Jobing on Wednesday, February 8 and inquired on
the co~t of a 20 and 15 pack listing. I also asked Wit was possible tei prepare a
proposal for months left of this fiscal year for the different packages. They ,
promised a response bye-mail by the end of the day today. - Peg
---Original Message--From: Lindy Funkhouser - HCMX
Sent: Friday, February 10, 2006 10:30 AM
To: Rebecca Nicholson - CHSX
Cc: Lisa Gardner - CHSX; Janice Stratton. - CHSXi Chris Bradley - OMBX;
Neeraj Deshpande - OMBXi Peggy Garza - CHSX
Subject: RE: TV Prices
Oops. I didn't catch that.
Then the breakdown should be as follows. I will fill in the blanks when I
hear from Peggy.
~
"Fees for at least 3 major job fairs
Trinkets
-frint Advertising (special displays,
. .etc.)
. ' . '.
..,
.
'''Jobing.com
. Display Materials and Graphics
Laptops for remote access to
PeopleSoft
=- .. Jobinq.com listings and management
TOTAL
-
-
-r
5,000 0
1,000
. 15.000 .
45,000
5,000
I,\.
,,,,., g.
I...
tJf1L
• 'I
6,000
[(1C U TBD
"
;
TBD
-----Original Message----from: Rebecca Nicholson - CHSX
Sent: Friday, February 10, 2006 itO:15 AM
To: Lindy Funkhouser - HCMX
Cc: Lisa Gardner - CHSX; Janice Stratton - CHSX
Subject: RE: lV Prices
Lindy,
Don't forget to add in the additional amount for the
Jobing.com listings and management. Peggy was to follow
up on the pricing for 20 listings. I have not received that
information from her; however, I believe the $45,000 was
for the video only.
Rebecca
----Original Message----From: Lindy Funkhouser - HCMX
Sent: Friday, February 10, 20069:19 AM
To: Lisa Gardner - CHSX
Cc: Chris Bradley - OMBX; Neeraj Deshpande - OMBX;
2/2112006
MC Confidential (June 08) 001220
Janice Stratton - CHSX; Margaret Green - CHSX;
Rebecca Nicholson - CHSX
Subject: FW: TV Prices
OMB has expressed an interest in setting up a budget
for CHS recruitment. I think the sensible approach is to
follow some· of the approaches that MeSO has found
usefUl, including the Jobing.com feature. In the interest
of putting something on the table, I have prepared the
following draft annual budget. Items in red are one-time
purchases.
Fees for at least 3 major job fairs
Trinkets
Print Advertising (special displays,
etc.)
.
Jobin~.com
Dlsplav Materials and Graphics
Laptops for remote access to
PeopleSoft
TOTAL
5,000
1,000
15.000
45,000
5,000
6,000
77,000
Let me "know what you think.
-----Original Message----- .
From: Rebecca Nicholson - CHSX
. Sent: Tuesday, February 07, 2..0064;40 PM
. To: Janice Strptton - CHSX; Peggy Garza - CHSX
Cc: Lindy Funkhouser - HClvJX
Subject: FVI/: TV Prices
Here's the electronic version of the videofTV quote from
Jobing.com
-----Original Mes·sage----From: Matt Furrey [mailto:mattJurrey@jobing.com]
Sent: Monday, February 06, 2006 1:35 PM
To: Rebecca Nicholson - CHSX
Subject: TV Prices
Hi Rebecca,
I wanted to get this information over to you on behalf of Kat.
Included is the TV pricing that you and Kat had discussed. If you
have any questions, please give Kat or I a call.
Thanks!!!
Have a great day and Go Jobing!
Matt Furrey
Industry Specialist
matt.f.lJrrey@jQbil19.~om
602-200-6800
www.Jobing.com
Tune into JobingTV - it's what's hot in Valley r cruiting!
btlP-:lliobingty.,jQPj!l9~.~Qml..R.elault
..asp-
2/21/2006
MC Confidential (June 08) 001221
Great Local Jobs for Great Local People - Check out our
Local PartnershipsI
http;/lcQmmunity.jop.ing.comfdefault.asp.?PageJP..=1 0002831
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2/21/2006
MC Confidential (June 08)
001222
APPENDIX 6
MC Confidential (June 08) 001223
Memornndum
Margaret Green. RN, BSN, MBA
Chief of Operations
Correctional Health Services
,..,
To:
All Nurse ManagerstnHealth Care Administrators
cc:
Unda Maschner, DO ; Undy Funkhouser, Director
From:
Margaret Green~
Date:
2/21/2006
Re:
Segregated Inmates
I
'
III follow-up to the NCCHC Survey Exit Conference; Maricopa County ~o[rectional
. H~alth Services has been evaluating the proce~s of monitoring inmates in ..
segregation. As per ti,iscussions in January thepblicy Segregated Inn~ates, J-E-:G9.
·hMheeil niodified to reflect tile change in documentation that ,¥as· determilled to:be .
necessary.
Meso will continue to provide each clinic with the list of inmates in segregation
each week. When an inmate is initially placed 'in segregation a "Segregation
ObsenJation" form is to be initiated and placed in the Segregation Log.
Please review this policy (attached) with staff at your next staff meeting to insure
full compliance.
MC Confidential (June 08) 001224
CORRECTIONAL HEALTH SERVICES
CLINICAL POLICIES
NCCHe Standard:
J-E-09 (Important)
Policy.Title:
SEGREGATED lNMATES
Applicability:
ALL cLiNIcs AND HEALTH CARE STAFF
-
Origination Date:
05/01104
Initiating Partyrream;
Margaret Green, RN; ChiefofOperatiQns
Last Revision Date:
Approved:
Next Review Date:
g~
Gerar<lo~:
02/01/06
11/29/06
2i2:;Li2.&'
F~hnnser,
Page:
10f2
llndy
Director, Correctional Health Services
".
Date:
I.
PURPOSE: To ensure that inmates who are confined to their housing unit or cell maintain
t.heir physical and mental health.
II.
POLICY:
A. Imnates who are segregated and have limited contact with staff or other inmates will be
monitored 3 days a week by medical or mental health staff as needed.
.
B. Inmates under with litt~e or no contact with other individuals are monitored daily by medical
staff and at least once a week by mental health staff.
C. MCSO will notify CHS when an inmate is placed in segregation. A licensed nurse will review
the inmate's health record to detenrune whether existing medical, dental, Of mental health
needs contraindicate the placement or require accommodation. Such review is documented in
the health record.
MC Confidential (June 08) 001225
PROCEDURES:
ill.
A. A roster of segregated inmates will be sent to the primer or delivered
to
each clinic per week.
B. The inmates will be monitored on a frequency basis determined by level of segregation.
1. Inmates·who are segregated and have limited contact· with sU:iff or other
inmates are monitored 3 days a week by medical or mental health staff.
2. Inmates under extreme isolation: (Note: Currently Maricopa County has no
inmates in "extreme isolation". MeSO does not use this type of housing.
Procedures will be developed in the event inmates are at some point placed
in "extreme isolation".)
C. Each inmate will be individually observed and asked ifhe/she has any health care requests.
D. The health staffwill document on the "Segregation Obsen1ation" form for each inmate on
the· roster indicating inmate mental and physical status of the inmate and any health
complaints. The health staff will initial the date. Ai the end of each month (or when the
inmate is· removed from segregation) the "Segregation Observation" form will be placed in
the inmates chart.
E. Documentation of emergent needs and intervention will be in the inmates chart.
..F:· Inrilat~s will be.en·couragelt to submit an Inm<;lte Medical Request F9rmJ6r')1on~einergent
. health related prob·!ems.·
'.'
.
G. Inmates detemlined to need health care will be referred to the appropriate clinical setting for
triage, examination and treatment. All clinical encounters will be documented in the inmate's
health record.
m.
EVALUATION REVIEW CRITERION:
This policy is to be reviewed annually.
IV.
REFERENCES
NeCHC Standard J-E-09.
v.
DEFINITIONS
Segregated inmates are those isolated from the general population and who receive services and
activities apart from the other inmates.
VI.
ATTACHMENTS
None
Policy Title: Segregated lmnates
Page 2 of2
MC Confidential (June 08) 001226
Maricopa County
Correctional Health Services
Segregation Observation
Name:
Booking Nrnnber:
Date ofBirth:
Imnate labd or Addressograph Stamp
Month:
..
year:
_
Wednesday
Monday
.' • 'J • ... ,'
Week
Housing Unit:
_
Fridav
o No Issues
o No Issues
o NoIssues
Comments:
.Comments:
Comments:
# 1
Initials
Week
Date
DOlte
Initials
Date
o No Issues
o NoIssues
o No Issues
Comments:
Comments:
Comments:
# 2
.
Initials
..
.
Date
o No Issue.~
Week
Initials
CODlIDents:
Initials
o No Issues
Date
Comments:
.
Initials
.
Date
o No Issues
Comments:
# 3
Initials
1----
Week
Date
Initials
Date
Initials
Date
o NoIssues
o No Issues
o No Issues
Comments:
Comments:
Comments:
# 4
..
ImtJals
Initials
SIgnature Starn))
Date
Initials
Date
..
InItials
Initials
Date
SIgnature Starnl)
CHS- Nurs- XXX
02-21-06
MC Confidential
(June 08) 001227