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1UMSIID ACCREDITATION l{EPORT ON .
T,HE HEALTH CARE ~vrCES AT

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MARICOPA COUNTY SHERlFF1S OFFICE-DETENTION BUREAU

Plloenix, AZ

Fe'broBIY 24. 2006
. (0612712~07 ReVision)

1I..i0llll1 CoMmissianol1 CarrcctiDlJ\1I H . Care
1145 W. Divamy Pkwy.
Cb~,IL60614-J318

(773) 8S0-146O

Me CQrlfldenllal (April 08)

0001

DEFOOOOOI

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Accredita!lon Survey Report #112 .
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:M"arlcopa Gouniy'Sheriffs Office - Detention 6ureau

Page 1

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Feliruary 24, 2006

.This jail was surveyed fur continuing CQmp~ance with tl:ie NCCHO ~OQ3 Standanis for Health
setvlces Tn JaBs on December 12~!6, 2005. The fac:Rity was first a~iled In 1965. .
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I. Executive Summary of Continuing Accreditation Survey FindIngs

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Compliance Datlslon Key

AccredllBI1lln b awarded to B rac/Hlynnillli In ~pil~nCe'hilh lhe appncubls20D3 NCCHe 8i~atrfs rorHeaHh Servfr:es

fit
ACQl'8d1taUon req1JWs t:Qmpllance wIlh 100% or the Bppl~le £!l~entlal 5lal1dards and at least afi~ of Ihe
appJIaIbIe Irnparlant &tandatdS. There aridi1llllyp:s" of nndl~s regartllnQ Indlvldual standlltlls:
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i." a!l!!1!liaiito:r all requlremanl& for Ihl! standan! are met; \he tn\enI of the ~\andard l~ mel; \10 t:llIrlieUve a~n h1
·requlred.
.

z. ParI!a! Cgmll!!arw&; alrf ~r of lndtc3tor.; BN nC6S!ng(or not In oQrnpllance; \hg Inhml or lhe sbmd~rd iii mel;
• CDl'I'8<llfva adIoll1s requlrtl}l.

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3. Noq-<jDmplran~: none DfUi!llndl~{li

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~ met; the lnbmloriIle.slandm Is rml mel, cOrrecllve acUOn ~ requlred.

4. rto! appllC'llbl!l: salfoeicplanillcry.

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6. Recomma~da!lon(Sl:
. SlJ!ige¢Ms ror CCll'I~nu"ihmprovema~
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. ~ ~Vll aalJon ~ requlTl;\I•. :

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foIo\e: NeCHe uct:redlta~ ~ do not·tine a raclllty·fac:tlta sarnlllSSUli more tlian OI'lCe. !!van lIlo~ lhll.lIOI'\ccmpIrsntprac;llca may falllll1dermc"! than lllll!! lIlanliarcl. Tl'ia 1ssUillst:llBdundertl1emust reIevanlslandartland t:rlISS.mei'lmClld to In otherlilandard's.
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Survey Flnctings:
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Of S6 the essential standards; 55 were app.np;:lbl~ to tpl~ facility.
Of these, 27 Ware (77%} found to lia [n complTanc:e:
Out t>f the 3B Important stal1dafds, 81 Were ~pRcablaro Ulls i'at.I\1ty.
Ofthesa, 29 (78%) were found to!Je 1!1 lloplpllsl'1cs.
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D~<:IsrDn;'The

at·~e1fp.~llJary·24,

Accreditation' Commlttae
'2005 meatiilQ,',v;plad III conUnue
the Accrealtalion of.the facJUly b!.!t pl\'l~ ,It onPrpbaUori. "The Cpmmittee wishes to gIve the.
faollity adequate tIme to correct the C!t.ed del1clen~. anll asks1hat correctlve aellon t!lken !lY .
1he fewUlfy be dtll:umetlted. and progress reported to the committee at lis next meelfrlg. on June

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-In documentation subml~ by the facilitY sUbseqtJent to the I:ebniary 2006 AccredJ1atlon
Commltfee meeting, the facility cleared an addlijonal six SSl1enlial standards and a Illtal.of34
(92%) of ~ Jmporlant standard~. This corrective action..was rey!ewed by the June 30 2006
AceredllElllori CommUtee whi.ch volel;l to upgrade the facll!ty to Conllnulng Aecreditption Upon
VerlfiaaflOll. Further corrective acHon wlll be reviewed by fh.e Aceredlta~on Cammillee at their
November 17, ;mae rrw.et!ng.

*1n d~antation suomltted'by the faclllty 6\Jbsequentiy. the facmty Cleared.all but Dna
.
. essential standard and a total of 35 (95%) ofihl!llmportantstandaTds. ThIs'colTBCllve actlon
was rBVlaWed by the November 17,2006 Acctedllmlon Committee which voted to conllnue the
facllity OIl ConUnu!ng Accrer:lftat1on Upon Vermcatlon. Further corrective aellon will be reviewed
by the Accrodftaifon Comm!tree at ltlefr March, 20Q7 m~g.
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Accreoitation Survey Report #1 ~2

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p;age2
,- f..eb~ry 2~J 2~

Marfcopa C0l!t'~ Sheriffs Office - Oetention ~au_

- *On March 16,2007, the Accreditation.Commi,tlee voted to conUnuB tAe facillty on Continuing
Accredltatlon'WIth Verificatlon (CAV) stallls fo.allow It time fu cornptete the required correcllve
action.
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.. On June 27, 2007•.the facility submitted documentation of cgrreetive action- that brought it into
CQIl1pllance with all of the applicable essen~al ttandarus and 95% of the ~fl",llcable fmportant
stand~s~ .ThE! faCIlity Is accretll~d.- '_

Standards Not Appiicable at this faeUlPL .
J;e-oa Health Oare Ualson
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~entlal' Siangartls Notin QompljanAA llnd RequIring Correoliva Aptian
Nonrr -•

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Essenllal. S1andarrlslrr Partial ComplIance and~egulrin9' Cot'ratffiVe Acf!an
_J~B-D2 Environmental Healttl and -Safely,£D212 6 cleared ;":see standard for spec:tlics)

J·P-01 PharmacetJtlcal Operatlons (06/06 ~~red -'sae sta'ndaitl.fcr ~pecfllca)
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J-E-C4 Health Assessment (06107: cilmpl1ailce l:'!sues o l e f f l ·
_ ___ _ _.
--J-E-07 NOlleniergenc:y Heallli'Cani(Reqtiests:aiid ~ieiVfc§s:(il7lci7 cleared ":s?s-stanaard for

-", '" .sp"!o!fillllJ, '-.

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J-E·12,Contlni.rJtY'Of C.are punng lncar~~at1on (06106 cleared - see ~i:ll;lrd for spectlics)
J-G-01 Special Needs Treatment PJans.(OOf06 clearefl- see stand<m:l for speolfics)
J-G-03lnfirmary ~ (OSJq6 cleared .:. s~e stand,!-rd for ~clflos) .
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, J.G.05Sulclde f'lrevel'itlon Prog~ (06106 cleared - lOlle standard for speolffcs) _

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lmpormot Stam;lartlli Not'ln Qot11l¥iince"ahd'Beguldmi:Correcl:!Ve Action
Npne

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ImpprtantStandards In partial Cmnpllabca and ReqUIring' Correel!ya Action
J-C.07 stafflng Plan (Q6106 c1!'lsr;ro -:' see ~~ 'fqr t,peclflcs) .

J-p-tJs ClInic Sp~1

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ERtllpm_etrt and ,Stlppn.es _(06/0~ eJe.'a!:ed - aee $1artdard for ~lllc:s) -

J..0.05 HGspita~ an? ~~c1altY, care (06/06 Cleated - sea standard for ~ecmcs)"
J.E.05 Marital Health Sareenrhg and" EVafual!on
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J..E-D9 Sagragaled Inmates ". .:
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J-E-13 DIscharge PlannIng (05/08 cleared-see,standarlHorspeclflcs)
J..G-02 Management of C~ronr!l Dlseasa (06~ cleared -sea standard I'?r 15pecmcs)
J·H-04 Avallablllly and Use of Health Record's (rf7trJ7.cleared - s.ee. standard for
specifics)
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Nots: The Detention Bure~u Is cD~prtsEid of se-.:-eral components: lntryls ~port, dE!scripllons,
comments,- and racomme9~atlons, apply to all compon~ of ~ J,all ~elJl \lnless olh~e _
noted. However. noncompbance Wllh a standard at one-fuelllty may affect. for ihe purposes of
aCCllldltat!on, the Detention Bureau as a Whale. Please note that this rBpcrtfo(:IJses prfman1y_on issues found that a,re in nietl of corremlon or enhancemern:. ,It Is moot effectl'le WIlen read In
conjuncllon Wllh ther StandBreJ~ manual.
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Facility Profile'
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Typa of F a . Jan
total AdmissIons for FY 2005:
Average dany poptIlaUan:

119,694
9,054-

Me Oonfidentlal (April OS)

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ACQ'edltalion Survey.Report #112
.
Marlcopa County Sheriff's Office -Detention. Bureau

February 24, 2.006

300 (24-hour period)
.
None. The fac1rrty has six Components functlonlng
as an integra~syslem.

Averas.e'dally lnl:ake:
Satellites:

A. Desgrtpllpn of Facility
this courrty Jan COn1plex, referred to by.the county as ttie Detention BUrl*lu. is located to nines
from the qowntown area of a large metropolitan clly In the" southwestern UnIted Stales: The
.Detenllon 8ureau1s comprised ofsaveral oomponents twO campuses:. the Inlake Campus
and the Maln Campus. On the Inlake Csmpu5 near the Cl;ltiler of town, which Is approxililately
1.0 mOss away from, the Maln Campus, fs the 4th Avenue Jail, Which oontalns the new "central
Intake" function and areEi fOr lhe- enh·system.ln the main campus are the Estrella Jail, Estrella
SupportTerit Clly), the LoWer Buckeye JaB (LBJ),the Towers ~a1\, and DI:lTat:'90 Jail, The'
components cfthis Integrated
Jail sysrem are
...
. as
. follows. . ..

on

IIrtbKE CAMPUS:

.

.4th A\jnf,la Jal~.~ 4l!1 ~~IJ~Il!)an·ls.a mk8lsei .h!ll~seC).llity jall capctble Ofhan'dnng aoo
. bi:i6lilngs eveiJY 12 heUls. ,P.JI malE! and fe/lJales.lnmalBli s'nterlrtg the Detentlon Bureau are
processed through this Jan (except for self-suiTanders), The lntaka Center is considered a
~arate program WIthIn the Jail, and has itS 'Own liedicated healtti personnel. In.addl1l9l1 to
ltlt!ake, ~Ilj~venu~ iJioluileB maXImum s..ectiiity Iiriu~lng; ',lA Oou~ 'Bends' alJd Fciifeitures, and
prQl;atIon violst!ons processIng ,The 41!t '6venue Jall'has ~ ,360 cells, including more than 200"
special manageTnemt cella'for .varloJ.lS~evers ,Df~l\!9regaUori. The a~aragB populatfon Is 1,900
lnmams who ara predominantly maxlrrlum c1asaifica\ilJll w\lh asmall !'lumber ¢-trosty·leliel

Inmates.
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.MAIN CAMPUS: .

Lower Syclmve Jail: The LBJ, a new Jail opened In 2.005, ha.s 12 ho\Jslng units (each wlth Z

pees CllPablei of holding 110 persons per pDj1~ and 4 dcnnlicrlas. One pod Is reserved for_
s!!tl~ housing t1l'1d 'spaelal hblds. There Is a 504 cell juven\leTemand faomty, a 86{lcell
adult maximum classiifcallcn sentenCed facility, 265 cell paychlEitrlo (acIDly and.iiI 4 he'd .
dcrmltolY adult mInImum security faclllly. Blnce April 2005, LBJ has contalried a 60 bed
capacity Infirmary ana a 260 bed Inpatient psychlatrl~ faclllly. ' On Elecember 12, 2005 this
fi:lo1llty-had a population Of 2,431 males (adult and lwenDe).

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ll1e laJ site Is t1Je
ofsaveral
fOncllohs. Meal preparation for all the faciDties Is
dona atthe very large ceiltral kitchen and new food processing. plant. LaundlY Is dOfle at 1he .
central laundrY complex. There (s an Inmate. library, canteen, property snd evldence,storage
faclUtles, and a cenlral power plant to support all these faclll1las. Haalth servlaes admlnlslralilln
rmd the Delel1Uon Bureau's programs and eduaallon adJ11inl5lratfons are also located In the LBJ
JaIl. AtLBJ, outpatlerJt care Is provfdecl as well as Infirmary care. The B(lOpe OT health service at
the Inlirmery.lnclUdes follow up oore for lransfars from area hospitals fo"OWlng surgical
.
procedure; and IftnesS. ·cr Injury that requires acute or IntensIve hQspltallzaticn. Inmates lnfeclsd
with communIcable dIsease are also housed fo the infjim~l[Y. Juveniles requiring SIJlckle watch
- are housed !n"fhe Inflrmary.
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Icootion

cem

MO eonfidential.(Apn1 08)
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DEFOOOO05

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AccteditaBon May Report #112
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MarIcopa counl¥ Sheriffs Office - Derenlicn Buraau

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P¥lge4
February 24, 2006

Towem: TQWeI'S Jan housing unltli are squa~ with a pod located In each comer. The peds are
single cell configuration on a comman day room. Each of the six, towel'S hf3s rour pods. Towers
has a segregation unit of 3.0 single calf beds. The JaU ha!i clinic space. a chapel, vlsltatlon space
and an Blrerelse yard. Towers houses maxlmum, medIum atld mInImum security adult mates as
weft assenrencedjuvenUe males. On lheday oi.th~ survey, the poplllatJon Was 931 males.
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Estrella Jail: Esl;rella Jail Includes inma~S'af all classifications Including minimum, mediul1l,
and maximum cUstody, On the day of the sl.livey there were 1,04"0 fnmates. Thera are 5 unlts
'(T~rs A, 8, C, D, M). One 14 b~,pod In TOV;{er,M housell,!wenlle fema'res (6 at the til'lle of
thes\llvey). In addlUon there are 8 dormltortes eacl:i'houslng 130 females. The JaU has clinic
spacs, kJ1chen'space, a chapel, VisllatlOI15pBCBl'prOgram space am;1 an Inlake araa. Altho~gh
mo'st or ~ Inmates are pre-tlial, there al'f'l Some senlenced .Inmates. There ware 50'inmates
. ,who were p~nant. At1he ~me of the survey Dorm H was net operaUonal due to nghtiRg and
shower I'G$toralion.
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. Estrella Suppor!: ITenl CIty); Tent C}ty Is comprised of.39 te~ts and two'donnllori~ adjacent to

the EStret1a Jan.,' The Tent Cily bOlr,;es senlens:ed and mlnrmum security mala and fEllJ'iale
, Inmates. The average papUlation I~ 9~ •. MQ~ ,it;l!lii;l\~.WQr.k In the foOl;! falll.alYl (aundJY or
,''£:haln gang".cletall: Inmates haile accJ3~ to .large day ~oms, lol!et Bnd shawer'fa9\lltles tone
male amI gna female).,
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, .Q.Im!bgQ: Durango.ls deslgna<! as '8 mlnlmljm·s~CWi\Yfuclllty and ~s sevelJ..pod.ular houSing
units. ant! ~ barracksSlyle dc;nTT\s. It contaIns a smalh:lln!cj a'chapel, !J!sliatlon'area, program
and exeri:lse yard. The,ADP for I:?urango Is"~ ,800. of which there are g;iO im,mtal health

area,'

pstlenls.

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There were appioxlmately 540 correctlonal officers o.n duty during three work sfUftS thrOughout
the Detention Bureau facJtllles, , "
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S, Jumale Fyou1e1ign Character!stlcs
On December'15"', !he'OeteliUon sUrea4''the only''?Omponetit slll.lated 'on the Inlake '~mp~s,
housed 66 Inmates In the Centra! Intake area and 1,El35Inmale$In general housing ana
sagregallon a~.
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The main 'campus'ls cDmposed Of an tl:1e other com~nants

of the Defunllo~ Bureau. There are
2,91 e Inmates at lBJ lnctudlng the 171 mala,mental health population and 166 male Juvennes;
947 male lnma\es at Towers; 1,028 female Inmates at Eslrella Supporl,tncludlng {I female
JuvenUes; 1,3~5Inmates at the Tent CIty; and, 1,505 Inmates at Durango.
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The faclllly mey wish In review !he NccHe p,0slUon st~tement; "Health SerVIces to Adolescents
In Adult C~onaf Fl!c1lll1es" for guidance In eating for the ]uvenlles. (The slalement can be
found in \,he SlandarrJa man~l or on NCCHC's webslte ~www.nechc,org.):'
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C. FacllllY Health SBtVlces

Detention Bursau heallh eervlces are provJdetl by !he county board of sup~sors uncrertha
aegIs of'the Maricopa Cc~ Menag':!r. Haalth servlces ara orsanl2:ad under a department of
Matlco~ CQunl:y;Correcllonal Heallh Services (CHS). Medical, dental, and mental heallh
MG Confidential (April OS) , "

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Accl'editallon SUf\ley R~po~ #112
Maricopa County StIeJiff's··Office·-Delentlon Bureau

Page 5

February 24, 2006 .

seNlces.ara provided umlerthts one health authority utilizing a combinatlon of county
.
employees and Independent con!ra~ora. In FY2005,.according to statistics prpvldad by fucillly
'Staff,.thera weru 31,6221ntlMdual health aaru requests. The. health services unit made 380,199
medlcall nursfng, psychlatiy, counseUng, dental, s~a1ty, and .Inlake appolnbnents, There
were 22,628 Inma~physical examinations pelfonned.
D. Heal!h Services Staffing

.

Health staffars orrslteal some falll1llles 24-hours a day, 7 days a week, while olher srtes a.re
slaffed forJlmlled hours. For the complete report on staffing typ!i!;;, (oc8tl0113, and coverage, see
Secllon C Personnel and Training.
.

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Survey.Proms

Co~lsted

~ltllc ~r~s~ Inm~k

The on:elte .suryey
of !guflng Jhe
housIng areas, segrega1l0r;l, and
reuteatlon ~~s at a11.six sftel;. Areas for,spaclallzed Qeallfi faclllt~ jN8ItI touresllnchidil)Q
Inl:a~e processIng at the 41l1.,A.,vel1.l:le; as well as lhe'lnfll'f!1S~:and Il1EIrital health·\l.nlt al LSJ. The
. food'procel>31ng plant a~~BJ'anO ih~ ~~her"'al Dull!ngo. ~ also revr~d.
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DOCllmenlatlo\1 raylewed Inaiudeid ~d1ca1 ~cortlSj PC!~t;les'and p.r0CE!du~; provlder neerISeS';
agmlnistratrve -staff, health staff, and quality Imp-rovement meellng mlnutas; slatIstical and. .
envIronmental Imipelllion. reports; and tralnlng records for health servlce·perSonnel and··
cerrect!onal'offical13: Approxlinritl'lly 62 medlcal reco>Qs, IncludIng 31 mental health re'cOrds, and
6 death TeCordS ware reviewed•. ' tnteMews were condur::b!I:l.ot! a structured and cOnfldentlal
basis .
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Central office staff InlB.N,leWB((lnclucjed lhe lnteflm director, director of rIsk man~gament, .
'medICal dIrector, chief of. ~peratrOl'Js, dlre~or of
ii1fln~gement, director qf nursjna,
lnfect10Tf conb'ol manager, tJ\reictbr of mental health aervlees,'c1inlcal riurse educator, medIcal
facUlties' and suppUes manager;'the regionalilidnfns c#nter managerl chief d!ilnllst, and the
Ulilfultlon reYiew nursa: tlther'lnfervfaws lit vsrtolJS.fa~ 'nclllded: llm:e he"allh care
admlnlstratcl'li, 12 RNs, the two ijiJn;e ·SupelVlSorS, the ectIng manager of the InllntiarY, twO
Inlfrmary patients, the Inp~lIent mental t1e!1!lh 'professlonal StJps,:"l5Or, two psj'l;hlabists. the
•outpatIent mental health superVIsor, two caunselofS, threa scetal workers, two PAs, three h~{th
unit cIerItS, thl'l3l1lteCords clerks, and elghfLPNs. Addlllonally. 25 eorreetlon officers ~nd 72
lnmates were tntarvl19wetfon a structured anCl ~nfidenliBI basIs. Inmates lntef\lklwed Included
.!hose wilt! are Spanish speaking only.
.

quauty

The facility was surveyed uJ,lder the Nc·eHe 2003 sts']dards for ""ealth Services in Jails by

R. Soott Chavez., PhD, MPA, pA-o. CCHP-A, NCCHe's Vice PresIdent (lead);
Donald Kern, MD, MPH, beHP, Special Consult?nt Of! Correetl~a1 Haaltl1 to fue

Depa.rtment of Health and Mental Hygiene, elly of New York, and NCCHe. BO£!rd
representatiVe, the AmerICan College of Preventlve Medlclne;'
.

Wiluam Reinbold, MD, ;6,sslSlanl Professor ofoPaychla{ry, DIrector of Forensic
Seellan of Loulslana state·Unlvemlly, Naw Orleans, and certlllad In General,
Forenstc ChIld and Adolescent Psych~bf..
.
Steven 6. ~pellcer, MD, FAOP"CCHP-i\, former Medlcal Dl\'!:lcl.or of the New Mexico
. . correc.Uaos D!!flartinent. and Independent correctlonal health consLlllant;
Me Confid~al (April 08)
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1SIccreartatlon 5~ Repott #112~r1ccpa County Sheriffs OffIce - Detenllon BureaIJ

PageS'
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Catharine M. KnOK, 'RN, MN, CCHP. 5talewfde orreclor of Nursing, WashlJllitoCi
Departnieul of Corrections;:.
.
Helen Martin, ~N, 8SN. CCHP. former Director of Nurses, Harrls ~ounly, Houslon.

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Dorina Rdcj\a. RN. PHN, MN, MHA,yCHP. Los Angele:;; Counly, S~ia19~nsul!Bnt
to Auditor Controller; and
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Major Ruth I, Wyatt, RN, CCHP, Health Service Admfnlstrator, Hlnds'County Sheriff
Departmen~ Ja~n, MIssissippi.
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lV, SURVEY'FINDIN\?S-.AND'C.QMMENTS',

Ar GOVERNANCE ANtr ADMINls-r:RATION
This seclldn dsals WIth the Qrganlia'ttan of the health slillVleas at the facltlly and the Interface of Cllrteatlcnal
and health !reI'Vk:es authorlUe$. Althgogh many" ffi!Jde!1l of orgimlzallorr arB valid, the o)Jlooma nsad!> to be
a alOrdInaIl!lc! ilyslem af Health caFe'for!he whcl~ IRdMdua1 In,wj]!ctl ~ lB c1earWho does Wha.t when, and
under whose aulllerlly. ppllcles and prQCeduras need 10 Include,&Ra specifiC operating' gqlill;llln~ The
rou~ fl?r9~1Ip9 ltt~ h~llh-seJvlaes~ara laJd.1nlhlssectfon, wlljloutcolT\P/lanca In lhesaamas,'
health servICeS staff lack-basta .param~ WlIhln whlci't.lo plClOUce cljnlcal'skUlli and mEllj!t patient needs.
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·1. Ge.neral Commenfs.

Atlmlnlstraliveiy, the D~tentioli ~urea~ health ~~~ are und~·ihe Counly Ml:1n~g'er's Cd~1. .

PreYlcllsly, the count.y publlg health department liehtrespcnslbillty'forlnmate hellllh services.
Cun-ent structure Is based oJ! a bt.isfness model with a CHa Director reporting to the-Deputy
County Manager, Correctional H~llh, SBrV!cfi\S (CHro.. ~ C9Lln{y's•.~edlcat~ Jan naalth staff, Is
supportad.by it corraclloniilJ nealtlJ 'consultlnp C!'1J1P8T1Y tl'!a~ it Is reportetl~ recommends
'
decisions and actions to· sQSl.ire that Inmqles hailS access to care 10 meet their' ser!Ql,ls'tnedlca),
.dental, and mental health needs.' C~s l~ the ~espQn's1ble Healtli Authol'lty as detiriiid by
NCCHO. ana the CHS DIl'ei;tor perfoflTlslrtja ~ricl!on.of the H~llh ~tho!lly's on-sI.t.e t!el1lgRee.
The CHS Medical Dlrectoris the responslble'Physi~ran •. •
·lIie DetentlDll EiureaI:l has.!i ctf.-pay progr.am. IntnatEit ara given a copy of thE! "inmate Rules .
anti Re!Julatlotrs.· whIch Irn:ludes B description of tile ,c0-P2Y system. The InformallOl'lls
provfded at Intake during the p~opk!ng h!*'lth.scraen!ng pl'Clcess. A $1.0.00 eo:-pay ts
. assessed for lnmaJe Inlllated medical ~rvlCes.
.'
.

The CHS polley manual Was sIgnet! by the Medical DI~rand CHS DrrectOr between
. November 1 and December 6. Z005. .
.

Varloua meetings addressIng aspects of managing the system aceurfrequently, AdmInIstration
hDlds 'I top laval 8lCec.Ul~e meetIng every TUesdqy at 9:30 am with !he Delanlloll Bureau's
Correcllo/1$ Chfef. MInutes of these meelIngs ~re rsWewed and found to be comprehensive.
In.sddltlon, ttlera is a monthly'maetrng of !he .component nursa manager, tiealth care
admlnlstratar, and Jan ccmmander 2005. At each lndMduaI fa~ unit, health $lff (nurses)
meat monthlY. In addition, them Is a systelTJ-wlde prOvIder rneeUng and a nurse leadership
.meeting. All baVe
documented
mInutes. Sla~cal reports
..
.
... are eomprananslve,
McconfidenlJal (April 06)

0008

DEFOOO008

I·

I

'.

.
Aa:retjltalion'SUIVey Report #112
.
Maricopa Counly Sherlifs Office - Detention Buteau
"

.
Psgs7
Febl\lalY 24, 2006

QU~l\ity lmprov~ent actMtlas rel1act a comPrehensive inltla\lVa There Is a syslem-wide
mullldlsclp1m.ary quality Improvement cammlttee that meets monthlY. Dental servtces, preylously
represenl2d on an ad hoc basls,ls' new a regular part of COl actlvllies~ Phannacy does not
partlclpa!e. Process studies On wound care, Inmate movement, and failure moda analysis
(Estrella) ~re conducted. 041come studies on dIabetes care was conducted. MiI1utE:s are
thorough and reflept results and Implementation of correl$e aellen. The CQI committee
ravlews deaths; envltonmenl'alfosPecUo"n reports, 'and infectkm contllllissues•.The medical .
directOr c;onducls chart reviews,. pilfllctpates In;{he COl committee, 'and completes an annual'
review of the ,~veness of the CQI P1'Q9ta11)..
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Disaster drills were. held. These Incluiled I but

were

not limited to, thefollaWlng:rn the'summar of
2005 th!'ll'B was lfwater shortage problem in the clI:y arid a Detention Bureau ma;;a illsasler .
-response liwolved,all1he units•. When Inmates at the 4ilr Avenue and lBJ coin~nal1lswere
transfen'ed from the old jails to newer, on~ in 2005. the eventS were analyzed 'as it response to
a mass·d\!!aster event-and crUlquea acroi'dlngly;"The 41i1 AvenlJe outpatIent clinic had amass
casually situation Involving 7 Inmates. The ~l=ltwas a hazardo~'g~s ~p'osura.tmrt occurred
Oe~bsr 1, 2OO!i. ~ Durango, !here were mUltiple m<\n devm diills on'vatlcl;JS shifts (july 1,
JUlY a; NoV 29, and Nov SO, 2005),
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Taken as a whale, the Deler!tfon.B~au,~~·tienCail adeatl'i~ ,,!po~ m2OQ4: Sf:( oJ the ~
, deaths were on-slta, and Z occurred In the Iio$pltat. The deaths were atlncllted to: sU{olc!es (2),
.. natllmlOSUlJss (5). and accidents (1). In ?005, 16 ~eathS were reported by thefaclllt)': F~!!r" '
WElIl:I Orl-s1tB and the remaindatwere.In kical hosplfuls. The deaths were attribubad fo eulCliles
(5), nBturaI causes (10), and accldentills
The Detention Bureau's Morbidity ahd Mortallty
\;}ornmll1ee reviewed each death A quality review Is performed on Ihe mediCal record ahd a,.
report Is written by.the metfical dIrector an<:l cal ChaIr. A p,sycfiological'autopsy ~ perforined by
the DIrector ofMelJla1 Hearth on deaths by-sulclde. The DliectorofNunilng pravldesfileclballk '
to.lJUrslnE1.staff. The lJ}edlcal dIrector provides feedba~k!o cpnlcal p!,Ovlders. .
..

t1J.'

Cfi~~1 Uais~nlRlsk Manager ami the blrector of' ~~1Ity Manage~ent review al/ external
appro)clmare.Jy 5% Df Itle populatlon submits grlsvSnpas relevant lei health carl'. In· moos,

The

gr/~s:es and a9Sregate·d~.ofinlUa( antllnstit4t!onal grfevan.ce!F.·!t Was reported u,at ._

4,101 medICal grfeYane:es were pJ:QCeSsed. 11JEl nurse superVlsoT, MHP slJpeJV!scr or dentist

responds ~p lnslltuUomil g~vances. ~here,are' ~~ respon'ss tl~,' startl'ng with the lecal unit
nurse mapager en,d golna up the chalri of cO!Tlrnand to central office review.

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In an the Detent/en Buraau sItes, the preponderance of EWfdence from rnt¢rvIews ,WIth heallh

. •staff and offioers indicated that prIVacy 'of care is maIntained. Approxlmately 65% of the
Inmata!llntervlewed stl;ded l1JaHhey'were salfsl!ed WItb tile prlvacy·provJr.Ied during clinical
vlslts. Ne probhims with 'prlvapy were Identified durIng lhl(i! lours ofthe vsrfous units.

Custcdy staff des~ed the facllily as compliant ~IMhe ZOOS Prlson Rape EJlmlnaUon Act
2. Standatd Specific Finding's . '
J-A-01 Access to Care (E). ,
X I compliance [ ) partial CO{TIp!lam:a I )non-eompllance.

r

Me Conffdential (April 08) • .

0009

.

DEFOOOO09

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"

ACCreditatIOn Survey Reptllt #112
• MarIcopa County Sherifl's Offial- ~ei1t1on Bureau

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PageS
February 24,'2006

comments: This standard requires that Inmqles have accesS to care to meet their selious ,
madlceil, dental, and mental health needs and that unreasonable barriers to Inmates' access to
health s~ are to be avol$d. Compnance WIth this standard Is determined by mEWtlng
standarda that bnpact on quanty and timeliness of care a~ determined by the Accreditation

Committee.

.

Mp~llflmates have i1CCl3SS to ca~. Hp~Br, 'In Es1ralla J~II, an Inmates do not have acc= to
health care all a-daily basIS'. The syslem ~oes not satisfy the l~ntf9r alllnmates to have dany
access to health eara. This compliance Issue Is addressed under slalJdarO J-~-01
Ncnemergency Health Care Req~s and SelVicea. Correptlva acllons for J·E-07 regarding

avaRablllty ~f sick call a~ ;;stre{la.Ja1l Villi S?tlsfy concerns regan.llng this ~ndard as WE;Jn;
separate, additional correctlve aoful~' ragardlfl9 J-A..Q1 Is not ~~d. •
"

.

.

"

"J-A...(J~ RespolJSible'Hi:la'ltn Authorjty ,(El.

l X 1aompRa.nce r, 1par:tJal compliance [

]non-compfiance.

J-A..()3 Me!flcal"-!\utonorni~).
,
[ ~ ] coll1Pl1an~ r J ~arllal compliance t ]non-cilmpnanca.
0' "

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, J~A..Q4 .AdmInistrative ,Meetings and &eports {51:
"
[X J'compllarice i J partfid compllancl:! {' lnon~mpliai1[:e,
n

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-!.-A·05 p.otrci~ and' ~~c~"Qres (E).: '. , , ' .
[X 1compll~nce 1partlal complla~ [ lnan-eompllance.

."

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J-A-OEt Continuous ciu~ity ImlJ.rOve~nt?rogram {El.
1 partlal,complta~cei( ]no~-compliatlce.

!xl c:ompllance [

J-A..IJ7 Emergency Response'Plan (fl. .'
[X ] o~mP,llanpa [ P!3rtial comp'~an~ [ "Jnon-compliance.

r

Comment Dunng the surv~, IrrtarvlBVIli ~imrmed that man-dqwo drDls have fIClt occurred

at -

1he 4th Avenue Jail'Also. documentation was not available that at least ona man-<loWll drlll (or

critiqued event) par shift per year has oCCUlred at LBJ, Towers,"Estrei!a Support, EstraUa Tents
and Durango•. Itis probable, given ,the size of the population, that at least one emergency
involving one-Inmate has or will occur a1 each of tAe sites on l3.ach of the shifts on whIch health
• alaff are regUlarly assigned. rhe Intent of: tf)erslandard Is !hat'all health staffara capable of
resPonding appl'ljlp,rialely to, emergency h~alth llitu¢lons !hrough practice of their lrtage skills.

Supsequent in the survei the faclllty ~ubmi!\ed a log doc~ml'mting completed "man down" drlU5
or ememency events on ,each shiftln the varfous componenls that occurred before the 5U!Vey.
(February 2008)

Recommandalfon: ApproXimately 90% of the officers interviewed (officer lenglh of ller{ice
ranaed between 2 months and 22 YSSIll) Indicated that !hey had notparticIpated In a mass
dlsastar driD nor. particIpated a critiqUe. Althpugh \he standard specifically re:qUlres
partk:lpatlan of health staff, [rivolvament pf cprrectlonal staff and community emergency
agencles Is recommended. "
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.

In

Me Confidential (ApfU'08.)

.
0010

,

DEFOO0010

-'r-:.

"

Accredltatfon Survey Report ttf12

P.aga9 '
February 24, 2Q06

Merlcopa County Sherilfs Office - Detention Bureau

"man

SUbsequent to !he
ihe faclfily submitted a log docum'eI)ling completed
d~wn· drllls
Dr emergency evenls cn each shift in the various components that ocqurred before the survey. It
is reported .that com;c:tional slaffwere Invol~. (February 2006) .
'

stirvev.

J·A-l>a Communication all Special Needs Patients (E).
[X 1 ~mp'Ua~ [ '] parijal,compJlanca [ In(in-co~pfiance.
J-A 09 Privacy Df Care (i).

,

[ Xl compllance ( -] partfal CQlDpli~nca:[ ]non-compllance.
J-A-10 PrOcedure in the 'event of an Inmate Death {Il.
[X j OOmplf?ncB [ Jpartial compliance [ Jri0n-conjpRance.

Bacommendatlon: If the faaIDly Is not already doing SOl lhe sp~c eomponents and sJ~s In .
whIch' deaths occur SIlbUlt! b~ tracked:a'nd monitored ~r the el]iergenC!3 pf patterns that would
Indicate need for fullher smdy. 'for eXample, if suicIdes are oct:uiTlng prlmar1]y 1n one facility or
settlng,
propterns ~~i'a r~ ihat COJ1!rlbute to:.tho~ deaths, aCuen ?Dole!' be fr:I1tlate9.

andJ-;G:-Q5 ~1,I1c1q? P.rEixe~lI011 Plan.).

(~efil,IilJ:i!~
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:1.A~11' Grievance Mechanism fQr ,liealth Comprain~ (I),

.

[X J
compliance [ ]..par!fal co":IP.nan~
[' Inon-etlp1plfan~.
:
....
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not

Recommend?lIon; If lh~ facility Is
al~d{d~lri'g so; ~tles In neel:l'o!' corrective acHon
be ldentftiBd by logging pnd monitoring grlevances by types, sites, slaff,limes of day, etc,
Monltcrlnglnma.ts grleVances'~rt bEfan etreellve plece.gfthe COl program;

'may

"'SUixlequent to the February 2005 AgcredItaUon Commltteemeellngr tlia facllit}' prOvided .
addllJonallnfDm.eiion. J::xternal grievanceS are'revi~d and trended by !:lie ·Cllnlcal .
UafsonlRlsk Manager arid'the Dlrectot Of Qua!lty Mailagemant.
"

J~A-12 Fede~ai Se~tial ~a~l~~e;l?rti~~ 'Re~lafiotJ~ (I).

..

[X 1compliance [ ) p~lSl. compnanc~:[ 'lnatl-cOmpli.a~" .
, 8. MANAGING A SAFE AND HEAl.THY eNVIRONMENT
ihBse standards address those aspecls af the physical plant anti fal:lllty oparellons the~ are related to
mailtalnlng ahealthy envfronmentfilrstaffand Inmates allke. Although dJl'lllltresporn;Jbfl/tY forseverallssues
considered hBte belongs to lile torTilCllonal aUlhor!lIBs, health staff a5sJstrn monllorfng and advising when
Issues arise affeclln9 health and safety.
.'

'I. General.Comments

lnfed.l..on control subcommittee meetings ars hele quarterly to address sysfuin-wide concems.
Mfnutas indicate a comprehensIve and axt:ellent program. The county health department
inspects faCIlItles monthlyfor cleanliness. Overall, heallh staff ~ppe.ar to WQrk undersafe snd
sanitary condltfons. Only Inficted fn~tes are treated for ectoparaslles.
:
Me Confidential (~ril OS),

0011

DEFOOOOll

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AcClidi\a'don survey Repofl; #112 .
~arfcop'a Oounty Sheriffs Office - Deten6c:n .f:lureau

Page 10
February 2.4, 2.006

Inmates ~ communic;abl~ dlseas~sari place~ In the lBJ lnfumary, Thera are 19 nagatl\Je'air
flow (NAF) Isolation roOms avallable on site, There are also 2. NAF Isolation rooms at 411\.
Avenue.

.

.

Meals are prepa(ed In a m~1ve modem kitchen uamplex at LBJ.· The kltd1en has s{ate-of..theart equipment and the facility reports It·~ efIlclent end effecllVe. i=acJil[y staff and Inmateworken> are employed In the fQad servlc:es operjltloos. dn'ce prepared, fCad Is p1aced'on
Individual. sealed food trays that are Icaded lnlo speelallnsulated carts. The carts.are ioad~
onto mfrf9ei'a~ trailers fcrtransportto~!! cOmponents ofth~ Oe~ntion.8ureau. At eat!h
facUlty, carts are Icaded Into dooklng stations which refflgarate th~ trays until an aUlornallc cycle
begil1s before meal lime • DUring.this cycle, bayS are both heated anc! chfiled, keeping hot
foelds hot on one side, and GOld things Cold on the other, The.survey team rioted a YelY·efficlenl
food seryJce fn place.
•: ' .
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M~ls:art:! 5~ed tWfCl!·a.·da¥i·th~ f~tetVal

~1n9'

mOrTJl~g.m~al d~

between Jlie
meal and
np.t exce~ 14 ho~. Th~ ~omlng dlStrlbution -ls:~~9.~~n 7 am antlS am. }nlJ1ates who
are'working also.£J:!!;:etve'a "sack lunch~ at this time,. The.eveu(ng meal (s servEKI betweE!iJ 5 pm
and 8 pm. piabetles, those ~~ ~ p~n?!'lt ~n~ !hQs\'l.•wti~~ he.2(1h requires mora frequertt '
or addltlonal ma'als or foOd are provided for. SUlVeyors noUced ltIal there were no oomp!aints
regarding
food sE\lVIceS, from tile Inmates.
•
.
.the.
.
The. only olher klfuhen Is at Durai,lgo, This kitchen Is 'old, yet staff aJ'ct Inmates are atb;Inttva to
dally cleaning and mah:jtena~ce,. yhere are pl"!\']s to stop .using ilie ,Durango k!l.t:hE!n•

.i.

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,Standard Spliclf!c Findings

.

J~a-u1 lnfeetion Col1tr'a( Program (E).
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compl!anca [ ] pl}.rtla! conipllan~ Jl1'on-oo.mllnan~•.

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Comment The standard reqUI~ s'urveillance to il~ecllnm_
senaus Infec,tlous and
communlcable'dlsease. MRSA can become a slgl)lfI\:ant'Pl'Oblam wltliln correcUonal settings,
'SubseqUefI\ the sUMlY, si'aff reporlsd. ttiat CHS ~fs i1iei mora .complex MRsA p1J6ents
through the coun[y's medll;al centel:. As' part'ofthat treatmen~ milTlY of ths'ctil!uJes that lml
obl;alnecl for ~tlenls wlth compllcat@ wounds are obtalhed at ihe hospital. CHS shares ihat
clinIcal data and \lSB$,the information ttl, ma~e lhese complex cases. CHS reports ~ cllnlcal
guldellnes wltn respect to lnfecUons haVe b'een develcp.atl vtlth \he assIstance of fellowshlptrained Infectious disease coul1!Y physlclans,
•

willi

ro

CHS reP9M that countY pubic ~ltI1 gUideUnas clJrreh!ly do not recommend eullurlng of skln
abscesses at lnltlal presentalion. If the wounds do not respond to Inltlal imgatlOl'l. debrldemsfll
Bnd fJppropriate woun'd care, then culturing Is deemed appropriate and Is performed.withln the
county's !'I!edjcal facUlty. 1'I1e county's Infectlous d1Sel!llle nurse m!lnrtors the cultUra results of
patients WIlh WDu{lds and maintaIns an ongoing su,vsill'!nce of this. dlsease.entlly, IncludlrigJall.tBlatad cases. It Is reported that MR¥ has been 1I1e focus of signmcant locBI ettenlfon.

It is reporleQ ·that the county frequently uses the disease surveillance data'and cilnlcal
observatfons to'monltor any sianijioant deviellons in 1I)e prevalence of these InfecUons wlthln
the IaD population. CHS staled that because the survelHance system occurs In' conjunction with
the local hospItal, tha axtenh of lhe facility's monltortng of MRSA may not be reflected In jail
Me GonlldentiaJ (April OB)

0012

])][FOOO012

. Aceredltatlon survey Report #:112

.

. Page 11

Feb~lY 24, 2006

Marfcopa County Sheriff's Office - Detention Bureau
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the

doetJmentalion; It Is recornmendiid that In the futtlre
J~irs documentation Include this
information as well. Minutes of the facility's Infection Control Gommittee were forwarded that
retIscIed a very acijve program.
' . '. .
.
·Subsequent to the february 2006 Accredltatlon Ooim.n1tlee.meeting,.the facility proVIded
additional infon:naUon.ll rep.orts that th.e coUilly s,ea.rehas fur ?osltive N\RSA oullures in all
laboratory results from Sonora Ques~ tIia Maricopa 90unly pubrlC Health LaboratolY, and all
hospItal rspo$ coII~~ bl'0HS Ulllkatlon Management. For the calender year.2.005,
Maricopa COunty laenlfli~ a total t1f 40 inmates with MRSA. ApproxImately 15 t1f those In!J1ates
acqUIred the infecilon In the community ralh~ than tn the jail. (Ju,ne 2006)
,

CQmrnent SEie J-E.-04 Health Assessment for concerns regarding the lack of.univers<ll TB

teSting. .

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J·B-Il2 Environmenfiil Health and Safety (E).
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[ ] compllfl/1ce [X ]-partlal, compliance [ ]nt1J;Kcwpllanee.
'.'
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lh
Overall/the envlronm!3nt at the_olderfaollit1e5 were acceptable. Although lhe 4 Avenue and
J.:e..J' ~ql\llil$arl'l n~w; 1here'ware.~mEl'!Ssu~I~\illiid. '.
.'

tiay

M. 411 AVenue ariel DUlangci; there wa.~

accun,u(atecl dust on
room and hallway floors. .'
Showers li1 mast of the LBJ hoUSlng'uniW Weie:uniil~ii with noIfcellble mildew In shovier .
ocimBrS and CBUlrigS, Jo!ouslng units'had trash on the ff90rs and were 'Ve1J' du&ly. Showers In aU
the Towe~ l10usmg units were unclean wlth nDllcaab\~ m~d5W on "\he wans and floors. Many
Inmates commented that the shoiAlars were not Worklng, T~rs hoUSIng units were dusty wfth
trash on the floors. At Es!iella. shOwers lri:the hous[nli'Unlts were unc(ean and, In one. paint
.was peellng·cffthe walls. Housing units were du~wIlh /rash" on the floors.. .

~01

~,1s retiui~ db~pnance

Correll\lva acUen t' ] Is
retJ!Jired.
tor
Inolcator{s): #5.'
Docun'ientaUon'of correctlva actions. Is reqUIred forihe noted condlflons.ln the speclfled
components ofthe fa~lli\y. , .
.
*In SUb~uent dDcumenfatlcln, the facll!Ly rep~rted doubBng the cleaning schedules Tn Ilia -.
esb'ena snower areas and ordenng renovallons. The fa!'ilily re~orts seeking additional funding
. to address shower areas within Towers.· Dusly floors notecl"have !:lee!) addressed and'
subsequent inspeclfons by facn!ly health staff Indlcate these Issues were corrsoted. The faolRty
fs In compllance·wlt!1lhe siendard•.(F~ru~ty 2006)
.
J·B-03 Ki1chen Sanitation and food Handlers (1)•.

{X i complIance [ 1partial t:ompllance! lnon-compllance.
J·B-04· Ectoparasita Control (I)•

.tX] compnance t ]partlal ~Q1Pllance [

lncn-compllence,

Me Conlidential.(April 08)
0013

. DEF000013

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AWl WilBtlon Survey Report #112

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psg-e 12.

M~llicopa County Sheiifl's Office - Detention Bureau

February 24-, 2006

C. PERSONNEL AND TRAINING

.

'.

The lbcus of!hls sec1kin Is an staff - health slaffand corre(;Uonal staff- and the prnfess!ol}aR~ Wllh wMcll
they meet.lhelr responslbHilles. The goat Is to have iljlpllJprlately c:redentlaled and skilled healll1 sIa1f of .
5Ufficlent oumbers ami types able ~ meell!te hE:81tlt needs.of the Inmate populallan. COJn!cllonal5laffare
provided the necassal'{ tralrdng to be able to support health semces and InlalV8lls III an emergenG)' In the
. absence of health slaff; Health staff areorlented to the Issues of co.ncem r~tated to provkllng heallli care .
wflhln aoo.m:cllanal environment. .
•
1. General Comments .

111e folloWing staffing'numbers were provided by the facility; s.laff numbers repr.esent fulillme .
equlVIiIents (FTEs). According to ctlS, SDme '?f the staff Irs~d under oha component may also
provlde serY/cas at another In a schedule desenbed by the ~t1JIty as ~COmpIBx.·
INTAKE CAMPUS

. 41b Avenue Cantrallnlake:
1.0 PA
.'
. '1.0 RN Manager'
16.4 RN

12.2 I;PN

.

1.0 Physlclan . . ,
1.0 pA," ,
1.0 RN Manager

. 6.1'

RN
6.1 I,.P.N

2,.6 ¥e!1tal.~ltfJ P.rofass,lcmals CMHP)
1.Q ~alt;al ~rda Tecqnl~,(MRT}

.

:

'Melital H~altt, i:!'l~tonal!! .'
0.5 PsychIatrist (T-W-F). : ..

'31

.,'

1.0 " Oenllst'
. .
2.0' DSf1tlill ~ntS .
1.0 \'t'Iec!!~! Records.TecllOlelan

1.0

10.2. CHT

.....,

a.5 Cijr (qQrre~natK~lth T~nI9lan)
6.3 HUC (Health Unit Clem) . .. .. .

4th Avenue Outpatient CIiGlo:

...

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RadtologyTet;hnlcl~.

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3.9 Hue
MAIN CAMPUS
Durango Oytpatlent Cnnie:
1..0 HCC
.

1.0 Physlclan .
2.1 PA
0.2 psychiatrist (1/wk)
1.5 MHP

.

.

7.4 RNa
3.0 LPNs.
7.4 CHTs
4.0 HUCs
1.0 Medical Rerorgs Technlclan

1.0 Nuise Manager
Estrella Olltaatlent Clinic:

1.0 HCC
1.0 PhysIcian

6.6 LPNs
7.4 ClfTs

2.0 NP orPA

4.0 HUes

1.0 Nurse Manager

1.2 PsychIatrist (Monday through Thursday)
2,1 'MHi' or MHA
.

.7.4 RNs
Tent CIlv.OutpaHent Clinic:
0.9 NP (T-F)

1.0 'Medical Recoros Jechnlclan

0.5 MHA
Me Confidential (April'08) .

0014

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DEF000014

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AcCreqftalion survey Report· #112 '
.• Ma~copa cOunty Sheriffs Office - Qe1en6on Bureau .

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" Page 13
February'24, 2006

Consuillng Physician (The.E;streUa OU~lleht CUnrc MD Is avaUable for consult)
"

LBJ Ipflnnary: ,
1.0 Physician (M·F)
1.0 RN Nurse Manger,
7.0' RNa .
.

4.2. LPNs
4.2 'CHT-s
2.0 HUGs

Mentai ~ealfhcOn~lts a~ reques~ bY'outpa~ent staff

LBJ Inpatient Psycfiiatric Un!\;
2.1 PSYChiatrist
:,
1.6 Pl?yCholaglsl
4.1.MHP "
1.6 MHA '
6.Q CHT;S

LBJ OU!tJelient ellolc:
, 1.0 . !'ICC'
2.0 Physlcfans '
'2Jj . PAs
.'

'1.0 Nurse Menager
9.4 RNs:
10.2' LPNs
9.6 CHTs

0.2 -MHA or MHP for Saturdays only
to' Nurse Manager
.

19.7 Rr-J"S : '

,A.4 LPNs'

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1.5 HUe

4.7 'f-!UC

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. 'O.~ .. P.!fign~'!VisHM--:P~~fJ '.. ."
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3:4 "MHP aR~·MHP.. (1 MHP'lsasslgned to.Juvenlles):
. 0.9 ·lJerit!~·~Th). . . ,; .. '
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1.B D'~ntalA$slslahls (M·Th):
- 1,0 'RaQioloyy"Teclinlcllin
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2.,0 Mec:jical R!'!cortls Tecl:lnlcl~n

LBJ P-4 Unll: .• +. '
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'(12 hours'a ~ay, 7 days a week stafffng to c.omplele Inillal h!3a.lth assessme:nts)
2.1 RN-PNE
. 2..1. CHT •
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2:1 LPN
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Towers OLi!:pa!lent Clinic: '
1.D HOC,
.
4k'.RNs· ,.,
4.4 .1.?Ns
1. 0 Physician
5.~ eHTs
o.~ .Psychiatrist (1lwk)
1.0 MHP
'.
.
1.5 HUe
0.4 MHA (Mon. & Wed.)
,to Medical Records Techryiclan
1.0 Nurse Manager

a

The C~lanllon Bureau reports that It has 2- fa 30year staffing malrlx plan. Thera we~ 33 RN
and"13LPN vacancies (a 54-% vacancy.lflte) mUte li)ne of the on-site survey. The facility
reports that these posItions are befng ffned with ov:eitlhis, agency',·.ariO liaveler (locum, tenens)
nurses" The nursing direotor end chief of operations described to-sfJrveyors an aggressive
nUrsa recruitment plan to illll!la vacancIes. This Includes a long~vlty bonu6 prqgram,,5!3!ary
adjustments, slgn-on bonuses, mentorlng' program,.and a recruIlment and referrallii:!hua.
program. Certified health rechniclans (CHT)', a position speclllc ttl this fcfcBIl1~ assist nurses.
,ihe faciRty reports 1hE4 CHTs are quafified as eIlher medical assistants, cerIIfled nursa
assfslarrls, EMT$, or paramSi::lk:s; they are assigned duties withIn their defined scope of

prac:lIce.

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Me Confidanllal (April 08)

0015

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DEFOOOO15

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ACC(edltafion Survey RepQrt 1t:11Z
,
Maricop~ County Sheriff's Office - Detention Bureau

::;)

~gEl14

, FebruaJY 24J 2006,

The faclllly reports lhat several i;linl!:lans were hired just prlor ltIthe on-site ~rvey:, 3
psychlalrisls{iiI0712005; 11/1412005. 1211212005), 1 p~yslcian {11/2.BI2.005}snQ 1 PA
(10J2005); Thefaetlily elsd reports tba~ severa! nUrses were recently hired, There was
cl?i1firmaUon that new health staff had received the necessary orlentatloll, '

'"

s.urvey

Heaith professlonills had current !Jcel1SBS and llthar ~p'p'iiJ.prtate oredentlals on file. Toe
team was able to conflrrn that health s.talf had th~,mqt!!~ number of cnnlfnulng eduPaljOl1 '
credits; all were current In CPR wining, There ls'rermblirs~ment for c.OUl5eS that the 'emplpyee
comple~,
' . ' ,
There l& an acUve cUnlcal perfomiancB enhancem~nt program In place. R~IEl'/lS,were
'
conducted October 13, 2005 and shared with pra91dei's'oh Decem6er e, 2.005. At me ttme of
, the lllllVey, reviews had been e'ompleted on slXphyslaans. eight mid-level proVIders. and two
dentlsts.
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Cfll1;elllloosl officers receive regular In-servtce, trainlng that Includes: OSHA llnnual ~liing;,
penronal protectlon kit usei Heart Saver F1rst'Ald wftlT C,f.~ andAED u:;Ie (1'e houro); q[Spo~i:dof
'contaminated body flUids; d~alfng wllb p.nm.MllloEiIv.EtlomCllesi acUons to take in .emergencjes,
InclUding m~,tnt~nce 'cit an, ;;jlrWay and e!J'e,gW1l!i,'fSf ll~,bre.athlngi k1entflicitUon Qf-a!gns
and symproms a heart attaCk; first aid a~ot;l~'ff)~J~Jllood sugar, stroke, a'F)d,self;u~i"
otlenta~on to mental health; liite~htlon ~e.IJ ,a~.If1lJmle 15 dangerous to self or othfJ!f~i and. stress and anger management
'.
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or

M~lca~!nventory ~nd S~ek~,echnlc1anS p~o,*-,~~the k~e~n-person Q<OP) tm:icil~~I1S to·

Inmatea.ass1gn¢ to the self~mBdit:al!tJn program. [Medioal ~nvantory and stock: Teal\nk:1af1!l;
provide medrcaUpns to ,~lJi:ates as.sIgnad,to,~~ keep~.person-self-meP!t;?tlOllPr.?grC!in.F ~ :
NUIBal1 admrnlste~ slr19.~e dose-medlcall~ns.
,.'
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Inmate workers perfonn only ncusekeepln~ chores within 'heaftl1 care areas and a~ ~upe~ed
aoccr.d'~lY,
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z.

Standard Specfflc'Fimlings

J-eoo01 Credentlaling (E),
"
•
~ X1compliance [ 1partial c:ompUancB [ lncn-c:ompHance,

J-C-G2 Clinical Performance Enhancement (II.
'f X.1 c0ll1l21Janee [ 1partlal coflipllenca [ ]non-compnance.

. J-C.os .Contlnulng I:dtica.t1o~ for Qualffilld Health'Care Profes~ionils (E).
[X] compllanca [

I partlai'oompRant:e [ ]nan-compllanee-.

.

.

J-eoo04 Training fur Coi'reotlon~1 Officers (E):
•[X 1ccmpilance ( ] partial compliance [ ]Ilon-comp/[ance.

.

,

Gommani: Compliance indicator #5 reqUires that,at least75%'.ofofllcers present on each shift
are current In Ilielr health training. Documentallon provided during !he surve.y by the facllil1s
training department indicated that 71 %. of the corret:tlonal officers are Cl.IlTBl1t In lirst aid a~
CPR tra!nfng. S~~equent to the SUt'I{ey. the facllily forwartled addlUonal statistlcs! by shift. that
Me Confidential (AprIl 08)
0016

DEF000016

....
Aecnidltation Su/Vey Report #112
Maricopa County Sheriff's Office - DatenlioR Bureau

Page 15
February 24, 2006

showed slgnfllcantly tnore than 75%. at officers on eaell shllt are current In CPR tralnlng. The

manne"iin ~ch the data .was pres~nted !aclUlated determlnallon of compliance.

!-

-

J-G.Q5 Medication Administration Training (E).
l i compUance [ 1partial comp([ance l lno/!-compllance•.

x

J·C-oS "Inmate Workers (El.
'
[ X 1-compliance [ _1 parliiii.complianCe
[ lnon-cQmpliance.
.:
J-C-07 Staffing Plan ( I ) . '
,
,'
[ 'J compliance [X Jpartial compliance [ lnon-j,1ompllance.
The fac;llity reports that due to the high vacancY rata; 50l1)a components that are to be staffed
24 hours per tlay. have had clInic closures during the nlght shifts. SUN!oy Iindlngs indlcare \hat
the effects of ilia staffing' shortaQa fn~l:lda problems'ln making siCk call appolntrhenls, triaglng
requests; PToV.l~g care \0 the' chronically II~ and assuting that consUltant ~te 16 accOmplished.
The lack of Sufficient staffing haS hemp-ered the system's abillty. to assure coritlnuify of care.
Ow

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coITec1lve ai:tlon Is tagylred; DoclJlTllintatlon of. C0h'E1cllve' atJUon ml.l5i: be siJbintttOO that shows .
howfhejall's staflinsiileeja'the neelJs of.the paueiitpopul~IIGn,
:..,.,.
.

~ 5u~~~~t:~~'i~~ 5~~~: ~~s:~~~~',~~i the, co~iltY' has !niUated ~'c~~~"hl~9 effort,

, Sl/pported 'by an Improved salary '$Jchlre. Accorqrng 10. the faclnty. 'In~reased .Staffing to dat~

(Femuary 2006) sInce the Deeemoer-survey Include 6 RN's. 4 l.PNs,4 m?fj(ear ~rds clerks.
10 CorrefCUcBlll health·aare technlcfans, 2'PllYchiatrlsls, aiid 2 mental health profeSslonjils. 'In"
addition, CHS'reported that 6 B4dll!orial med1Cf.1I pl"f:lViders have been requested. A summary of
CHS~ staflloS and recrulttnem: plan was t'6lY/aTtiad;
•
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4

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. This St,andard wlll be'met wilen .th~ otlie~ stari~~~, cited In thtS report a's' deflc;ll'!rrt dU~'tc staff
, shonages affecIlng·the delivery ofeaTe, are m'el The faQ1lJty remaIns partlally compliant .
{l:'eblUary 200~)'

•

•

"The atJier"~"dards'~leill;ed by C\'lrreetlve aelion s~l:i&equent to the 5UJVey indICates that the
facnlty Is now I':J compnance WIth the Intent of th!s standard, (June ZOOs)
•
J~~08

Health Care Liaison ( I ) . '
,
r Jpartial compnanc~ [ Jrion-ccri1p"a~ce,['X}nct appUcable.

[ ]'compUance

'J-C.QS Orientation 1'9r Health Staff (I). '

[X I complIance [ 1parlfat compRance I

Inon~plfance.

D. HEALTH CARl! SERVICES AND SUPPORT
These standards ad~ss requlremBt!ls:,Df space, materlals and ~urcas for llie deRveJ)' of healU1 care,
'Nhelher\hey are proylded wilflfn !he facility orclkfte In !he community. These are ll1e "Ioars' wlth whIch II1e
health slelrprovlde assessment antIlr\!alment seN!ce6.
1. General Comments
MC ConfidelTliaf (April 08)

0017

DEFOO0017

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,

ACcredlfutlon survey f{epQrt #112
.
Ma~copa qaurrt.y Sheriffs Offiee - Qetention Bureau

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'·Page 16 :
. february 24, 2006

Pharmace\tlk:al services fer !he Detenllon Bureau are provided thrpugh a national pharmacy'
vendor. PreserfpUons are faXed to the vend~r who then fill!; the o~ and expresses the
shIpment to a'central warehOUSE! on ihe facUlty's main Oilmpus. Merllcallnvenltlly' and stock
Technfclans courier the medlcalions to the respective-components. who !hen.ln tum 'parse out
the medications to apPl'Q?rlate me<llt:alton ca~ms. The M~lca[ Il\yentory. ant!. S~ "te<;lmfclans
also delIverpre-packaged medication to IndMdua\ cUnlcs Bod medroatlon carts. GlInlolans WJiIe
prescrlpfions that are InItially fill¢"frpm stock medicaHons by LPN!i' The sy~m .Inal4dlaS a.
keep-on-person (KOP) program and It!e MedIcal Invantory ang Stock Tecnnlclans delIver the

KpP medlcatfonS-dfrectlY to the Inmates w~o !5S9p 'Ih~m In tlielr po~sslon.

QUarterly medlrialfon ioo m1nsp,ectlons'bY vendlll' pliarinaclsts are ·documented. .

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~In(O spacEl ViJrles a!llon~ the components. At the 4!h AYenUB, CHS has clln~, on-1he 2nd, aw,
. a'n~ 4~ llgors, with the 4th floor clInIc beIng slightly. sma;\lat than \he oth.er~. Each. clinlt;; area
"C011slsts of t!Jl'ee' ~mlnation rooms and 2 9fflces. ,~~oilc'dNgs are not kept 1n tbese clinIcs.
Tjle cen~l cllnlc I~ IOCl'Il"ed 1~ the b;ls~ht veJY. near.llie cantralln\al<E!.a~: The central clinIc
has. a m~lcalion'l"Opm wIlh narooll~, 3 examlnatlon.rooms; 4 afflces, an x--ray area, laboratory,.
and medIcal recoo:ls roam. AD. cllnlCS have.."man-down 'emergency bags.~ Thera:[s a dental'
·offiCe In t!1e m!dn dIln/G In tria basement: ThEi.dE!!1lai clinIc has a 2 chf:lrr 9P!$tprY~ •.Ylfth' a de~
on-slte on Monday and Wednesday, The initial health assessments are acmpleted at the .
oUlpalient.cllillc. .The clinic pi'ovldes medications' admlnlstratJon, sIck oal[,'.chranl~ care clinics',
outpatient psyCh!atrlc care, denllal ~, an!;t~~ ~~rvICes to the 1,990 innia~ who are
•permanentlY al!Si9r1ed there. J11e canlra£ l.ntakl[l1.l]1lt tlas 3.heallh >lSsaS.sment stations end 13 '
responsible for rsceMmrscreenlng on an male arrestees.
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A~ towers, there Is a smafll1eaJth service area ~ ve'ry Ifmlted W9rl:t SPEl~ for staff. The' ,.
fac!1lty Tepo,rts 1hera are plans for·fUture expanSion: .There Is e\t1 ofli'Ce,.medloaiion room, i;lnd
Iabpratoiy itre~ Th,~ are 2 m~cal exap1lnatloll ro,on:ts and a Fllf1n~1 ha,a.llf:i,lntarvfBW.ro0i:!1.
There'ls 1'10 walling room. Ofllces and,cammon'areas are clean sud Cfder{y. ,The~ Is no dental
operatary Qnma1is. are sent to L B J ) . '
".

LBJ has a 60 ,bed lfrlirmai¥•. .1~ere Is alS!' an outpatl~nt clinIc vttllch is neW ~nd spaclous,
Thera are 7 oftlces, 4 examInation rooms, a medical records room', '2 medicsllon rooms,
laboratory room, and a 2 chalroperatory.

'

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'Estrella Supportliealth semcss'araa has an office, dental operatory, medic:atlol'l ream,
iaboratoly area, medIcal rec::aJtls room and 4 examlnatlon rooms.

Ai the Estrella Tent City, all rnetlicElI care is pr.ovlded·ln the Qutpa1Ienl clinic, includIng
emergency treatment (unless moVing the Inmate presents a greater rlsk). There is a manager's
office Blld menial heaJlh IntervIew room. There are S examination rooms, a medication roOm.
medical'records room. ani:! SlTIsillabo'ratory area. Medl(;!Jlions are provided at medIcation
dispensing Windows In the clInic. Mf-jPs sea Inmates forfolJow-up"caum;eling 11"1 the clinic; The
clinic. fa open 12. hours a day, with emergency sEliVlces provided hy the E$trella Support Clln[c
staff after nalHS.
Durango has a'Stnali cIln!c.

Me Confidential (Aprll 08)
0018

DEFO00018

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, Page 17 ' ,,' ',~:;'il

Accreditation Survey Report #112

,
Maritropa County Shertfr.s Office - Detention Bu~au

F.ebrualY 24, 2.006

Thera Is documentaijon that describa the arrarigemel'lls and agreements with local hospitals for
Inpallent and oufpallent spect~\ity'cara. The contracts are elated APi'll 27 and July 20, 2.004.
2. Standard Specific FIndings

J-D-G1"Poarmaceut!cal Operations'{E.}.
.'
{ JcomplIance (~j'pcntlal.compltance [, }tIOlT-compilance,
There are probleins with the lImenness pf delivery of medlc9tions and, at lImes, orders are
m1s:red altOliether.-The facniJ,y l'l!P.Orls 0lJgolTlg oorreti~ action jn thls regard. The pharmacy
vendor reports workli:!9 tei Imprev.e .!he fax transli1IssJ6n p'roceas; and nurses B're 'SaId to be
verifying If thQ fax
B9tu,aDy
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. trarisml~s1on
,
. 'want
. lhi'otig!l."
:

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InlT)2w Ir:lterviews'anci IE!vJew of the flledlcallldmln~l:ion records (MARs) confirm that the
'medication renewal pr0ce5S Is n(;lt working,. In ona faclll1i the Sunday night nurse checks all '
MARs fOr explratlon dStes for the comins' weeK, pulls the charts,' rilliRes a"note and places the
InfoJTnatlon In the proyk.Ier'a box to renew the ·medication. .In:anather fadlllty, ~ nurse wrj{es on a
pri~ 3lc5lnch Q;lrd wharlT~plt:aUt?ns are- ~ b~ re~~ antl.flla~ lhe l'!t#e In th!'l' provjd~r's
cubIcle. In elther ease, UmeJy renewal of the medlcatkms by lh~ proVIder does not occur ana '
,nursilig 'Staff dlscontinue.the m~Qrcatrons.' ' .
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, PhYsiafan surveyorS.JJotBo that'the medIcal !~rds somejlmas Indicate that prescribed
'
• 'll1adlc?llPns are Issu9d Wlthillit the provider seeir)g. the Patient or, possIbly, lhat.lhe provfders
ijre not Qocull)Elf!ting the enci~~nters: ,. '.
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coirectlve amlO"!s !'2QulreCf foi-:comOU!iQca Indleatotls1: #7. Do!:lUmentatlan'af coireclfite "
aallons Is neeqed to confirm that.prescrUilng pto'vl~ers are'!iollfled'l?fthe impenoh;g 6xptratfon
of drug orderS so the praclltfoner can determine If ilia drug-Is to De continued llr, altered.
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*Subsequel1t to the~, the facl!1ly ~rte<! o~ co~ ~l'! takeMIf)ce,lha aud~
were on-slte. CHS reportS It has re6Blllghed ltle;[liBdlCiltron process. 'They·[epPTt d1sconllnUlng

\he use ofgual med~oh admln!Stratf15n'rBoonhi-'(MAR!i). ~ reeqi'ds have bien unffied Inta· _
,one MAR, which II' how malnlalnecl exclusIvely by nulOes. thIs lricludes a uniform method'used
to alartihe provider of the up.comfng explral!on;ariMolltiw up 'to see ttiatlha ortIers are

completed In a 6nie!y fclshlon. Th'~ reVhJton began on February'1. 200'6, and the facllliY reports
Improvements In the process fllJ:eSdyevldent CM.S will' perfonn a quaDJ,y llssuranee Stuay' on

the medication renewal process after the naw.prPcedures have run f.or several weeKs,'

.

Confirmation that Iile c.orreqtlve "aC:t!on has 9!l1ved the problems is requrred fuj-full cpmpllance.
The faclllly· remains In partlal cOll1pllanc~l'with-tf1a standarCl'. (February 2.qoe)
, '
"Subsequent to the February 2006 Accradltatioo Committee mealing, tl1e faclfity sUb~lttad the
results of COl studIes that C9nf1rmed their correctfye action has ImproVed tl1e rriedleatrcn'
renewal process. The facllil¥ reports that lImely renewals fur J\prll,2006 ware at 92%
compllancej and for May 2006'. at 97%. The facility is In complfance wlth the standard, (June
:1.006)
,
;
J..I)-DZ Medl~tfon Services (E).
{Xl compliance [ ) partlal compliance [ )non-compllanpe

Me Conlidennar (Apn1 08)

0019.

DEFOOO019

...
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ACCl'ii6ffilnoCl Survey RepOrt #1;2
Maiicopa Counly Sheriffs Of!!ce - Detenllon Bl]Tea1,l

Page 18 "
FebrtJ!'Iry 24. 2006

+0-03. Cltnlc Space, ~q~lpme~; and Suppll~.(1}~ .
( 1compnance 1partial compliance L!non-compliance,
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At 4!' Avenue, !hare IS' no syringe count befng conducled,' Proper accountabilily Is not possible ,
WiUlout this process'beIng conducted at leasl weekly.
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eMma action is ragulred for Compliance Indlcator(s) Documentation of.cllrJ;6!:tlve action
Is needed, including Veri!i~Utlt1 of at least a month's worlh of syimge coOnls at-the. 41& Avenue.

.~

~In documeniatlon of correction ~~tlon ~ff aft.er,uie. ~~IYl&. ~ sUNey repo~ !h~ sh~S

counts were hlipl~e'l1\ed atll1e ~111 Avenue JaIL Su~!¥quent aUdl!5lndl~!e thatlll Febru~ry,

March and Aprll20D6. complJal'l!:e wllh wee.kly'~~afPs bl?llht,was 100% at 4~ Avenue Intake,
~md 100% at 4111 Av.elJue Oulpa!lenl CUn!c In May, The 'fat:llity Is In compliance with the .
~ndard.

June 2006)·,

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J.D..o4"Diagnostic'StlllVices.lij. ..,'.

r.X J comFlnarlce
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] plldial. compllanoe L .]l'Jon-cClTlpIlElnce.

J-O.05· !10spi,ta1 ~~d'5~epiqJty Q~~ til, '
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[ 1compliance [ X] partla!,compltance-{"·lnoi1-Compl!emce, . "
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Pregnant Inmates aqmitte9 witt! a hlstory of opJatj:! lise are maintained on methadone ·Cfubl!'JIs}.
The slan~ ~[/lres that these tetvlces beap'propl1$lY..!f~nsed ana cerll!fed. The Jallis not
'federally ~. to, operate su~h a P,J:09rapj•. as rjlq!l!J;etl. ~Y .l9W, by.1he Sv,b$(tCl'e ~u.sa and.
Menial HeaJlh SerJIc:as AQ!l'Ilnlstratlcn (SI\MHSA). eHs malrrta)ns that ee.~qn h~ not '
n~S'!I}'. ai1ci In do~entatJon sUPJ1Itttad subseijue"! to the SurVey. ·eiP.lalnEcl.that It does riot
adminIster malhad0Ji~ to ~.~nant lllm~~, ~~$B~ .l!b\1&e dl~rqers, out to pf?VIde .
medleal trea!m\mtto pr.~~nt h.!!ftI})b. tile .d.~lo'P.fng fi:!J'~¢ (nCliJOlng sp.o.ti~Ol:JS abOrtion.

CHS' poslll'o!.t Is that the admlnJ~on.af. mel!li1dcm~. to:p~vent sponlaneous abortIon Is

by their r-tliyslclan's DE:A number. not SAMf{S~,
·,regulated
...
.
..

.

.'

a ~ 1& liI~d . :~o
~ ce. ndlcalo S' # 4. :F~r full bmnpllance, !he faclilty
n~$ certlffc;;tlqn frl}fI1. S HSA, or"must ol$Jn an exelTlPUon or waiver.
.
'-

·~cc~c has b~ co~ 00 ~sp'cl:!dence b~n':u"e' eiAMHS~ reprasBnla!l~ an9.:the

faclllly regardIng the need for OTP cnnic aecredltatlon leadlng.to federal certlllcatlon, There.
'remains dijferences In '.nt&irprelaUcn by the factm.y.and lli~ SAMHSA rt;Jprasentatlve Cftlie .
federallejll:sJaUDn whicli exemptS "hospitals qr c:Ilnlcs or Insti\1Jllonal ~ngs'ln which
· rn!l-~ado~ Is l:l5ed only fer the protaglion iif the health at a devetiplng fetUs and w!lelher a jaU
• setting quSlilles as.such an exempted setting. However, the era/ague ccntlnues and !he facif\tY
remains In'compUance with this standard lit every'other a$fJect. The Intent ofUje'standard Is
mat. .(June 2006)
•

,

.

Eo INMA1E CARE AND TREATMENT

These sland!lrds fotm !he ~ of a heallh program and Include requlremenls for those heallh servlcss to be
provided to aU Inmates at the Instltutlon. ~ ale outlined lha ~tend IleBtment PfllCe$Ses, and
procedures fer oblaWng heallh IlalVlc~ N.';cBs! 10 lllbvant ~rallon hs;llth h/sIxltles, .calli th?t is
prcVlded dU1fng Incan::eratfon. and arrangement for ~nll"u!ng care upon dtscharne or transfer ere aa
~dre~
:
.

.......

-Me Conf!OOntiai (April OS)
0020

DEF000020

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Accredila~on SuJVeY Report #112'
"
Marlc:tipa Counly ~herifl's Olliee - Detention 8u~

" Page19
February 24, 2006

1. General COmlTlli!\1ts

AHhe I!' Avenue, heallh pmonne{ check fOr ,8 hlslDlY ~f substan~ abuse or inloxi~l:Ion,
'
dlal:ietic care, seizure medications, sulcldewatcb', psychlabic evaluaUon, and' Wound care. ThIs
Is conducted prlpr to acce~~ 1$ the jan: Once proqassad, the ari'estee is turned over to
!he custody staff who lhflCl officially cu;cept the Inmate Inlo the Jail. 'PJ any given lime there may
be a5 many as 160 lnrri~es lri the holdJng'3l'$as. :the ~t:ttral ird~e:generaUy processes 300,
booklngs in a 2:4 hourperlod.
'
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';'

-

.

.

.

: The 4th Avenue Jall'sertJes as the Intake f1iclllly' for all,males limnIng Into !l'ls Detention Bureau.
Upon admlsslDn Inmates receive handbpo\(s that are available-In EngUsh end'Spanlsh. the
inmate handbook .conf:;jrns,lnfcrina~oit on t!ie'sVcijlablJl1Y'Qfhealtn care.senilces, fee for l?Brvl~".
and1he fa<:IIlty.'s health grievance procedures: ReceIVing, ~cr~ei1trig is completedoy '4111 t\Yen1:J9
nursing staff. The In~k'e proi:~ss for.females mirrors Ihlir pro~BSs but Is co'nJPleted .at the "
Emlla fcicntty.
~
.' ,•
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,.',
.~

.'.;-:'

..

.

Health as~ments era, gener:ally completed by ~edlcated: trained ~ursS1> and n~rss
'
prac1nla~~r:s.at.the"lr1ta~ ~te~. ,~e,iTi~ilb:!1 heal!i1'eY!a!!!l1ijon ~'eon,pre$~ by-rijaniat health.
pioresslllnal~: ··Oentai·sCrBen/rtgs'afe'·ddrie'by nLlnllng s~.liilrin9'the.hSlllth assessment ' .
When an Inmata Is trimsferred fi'om one comp-onent to anoffier, nurses'cheekthe iJEl~ 'record· ,
to a~'th8 rnmi~1l medIcal, menial, 8J1d; dental heal1h needs. Any'assessrrienls tbatYiere .
~ot cqmp.IeUld du'li!llJ ~ke, tHe In~Kei'CaJ1te~
~tlB d,one'at the ~lvIrig oor'npqnent

at

are
Tl1roug~ut the co~~~nen~ Of Ihe D~tentliin'8uraau: rn~~tell ~~mp~ : 'Slet call i'Bqu~.foim
and submIt It In a request fOrfrJ boX. TIie~ maY-also apprdaqh heallh stEill @enerally t:lrciJl'allng
medication nurSes) and request to be seen. SIC<k can slips are plCked up bY nurses. PolICY
re.qulres trlaglng to-. take place at
o~. fiNerY 2.4. hours, 7 daYs ;;j week.
. least
.....
. '. ' '

cUm!~, th~'a~ ~o

~

-a~~ment P~otaCQts'l~

~.

h~rr ih~ oi~~r Nu~in9

nursing
itsar
of
.and CHS blregtor hay~Jndlcalad ffieyare c!eve!\QRinri Ijufslng as~~~t protocols for Ih~ ,
medIcal d1ractci~s review..
'....
"

TAete.a~ 2 dentrsis who proVIde care at 3 coriip'o~l$ (LBJ, 4!b AVli!itue and Estrella). From
JanuarY to November.2005, there were 6,9SB.ret!uesls ~ be saan. 8,248 appolnlrmmls, Bl'\d

restorallons.
. B33
. no shows (a 15%.rate). .ThBl<!
. . .were 4.20B.proeetlures performed, Including
' . .
~

Emergency seNI~s -and response'lo emergen;;ies 'ara hanct!ed weJI tlvoughout the o'etenllon
Bureau. Sorne staff are ACLS certified. There a~ AEDs In each health unIt.

NecHC standard J-E'..Q9 calegortzes segregation by the conditionS under wI'Ilch inmates are
confIned, and each c:ategary has different hSaIfh ro~nci requirements. Centllllons of seg~atlon
at this l'ac1l1ty Include.tIle '~me rsolation' category (referred to by !he fac!fily as ,\t1~ 'Super
Max" section) at 411I Avenue's 288 cklse custody sup~an celfs, alid bolh 'Uinlted
.
segregation" and "segregatlon' c4tegories at the other 411 Avenue segregalB9 areas. Dlher
oetenUon Bureau components haying segreg~n are conslderEd to be 'Umited $egregalion,"
2. Stapdl!lrd Sp~lflc
. Flndtngs
..

.

Me Confidential (April 08)

0021

DEFOOOO21

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ACCi'SilltilUon~UfVey Repo~ #11Z

Page 20'.
Februal)' 24,.2Q06

. Marlcop~ county Sheriffs Office - Detention Bureau

':~

J-E.Q1Itlformatlon on Health Services (El.
.]norH:arnpnance.

I X I compliance { J partial cpmpllance [

~

J:E.02 Receiving ScreenIng (E}.
[X 1compliance [ ] .p~rtJal compliance [ ]norH:ornpllsnce.

JwE-lJ3 'Transfer ScreenIng :(1:).

.
[ X 1. compliance [ ] partJ.arcomp.llance [ J~c'n'ccmpUance,

·J-c-04 Health Ass.~l1Jent'(E). .

.• •

< •

, [ J compliance [X] par\lal compliance [.In:qn~mpllance...

:

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.

..

Medlc¢ records reVieW found !hat h$alth.asslJ!SSmerrl;! am not completed ~In 14 c;!ays as
reqUired by the ~ndar;l- ..Health assessmen\$ are s!'i~n to thlJ~.Wltl1 ~ported chronIc or Bcute
RfObleil)s, or:fur:ISq!l~ fof'wOl;k ~nlll3': Thl~ sta!,dar~.(equ!rElJ'l,inltla!lon .of 111!IT!unlzat!on&.
whiln aPPT!JPlfale. Th~ is .no evldElnce In the rnedlCJ3l reeems'fhat dlabetlcs.and aslhmallcs
are getllng -pneumonvax and annuafflu vacolnes.

~Qrte~ aclio~ is're9~~ fprCom~naqge Indl~h:ldsl'jt·2

o~

and'ig', Docpnis'mauqn
.
··eorreottVe action Is fet:lUI~shQWjng:tba.t l~itIal hefolfl:1,a~J;1Elnls are llOmpleled Wll!JIA..14
di:!ys, an~ t,habeceSsa& lll)mUn~~gn6 '''!fa provld~.. . ."
. '.

"'In d~eiitation'

SJ.l!?,~entto~ sl.(rvey, !he:fciqnily.s~bmllted l:! p-I,!n for·~dd~lng the
UmaJrnaSS of he<\lth ass6Ssmanf!; and provlslDn Of ImmunlzErtlons. Confimiation that lhe plan
.hi¥> been lmplem~.ls \1~e?ed fqr,fuR complJanC!3- Document2llon n~ds. tl? ln~ud~ at least
~·mordhs.of.tlmely·healt{l.assessmal]ls. The fugll(ty remaInS in p,@r.ti"al comp,!ii:lnce. (F.ebruary
2(06)'
.
.
. ~rnetlt:.ThB sfanoard ~lso'req~ trnd:~ 1ntti~ health'asSesllment-Iridud~ labc~torY or
9ls9rlOsUC tests fOr comml.lnl~,ble d~S6S; b!Q1udfng:~.~l[yiral"lsmftt~ dlseaSEl$, and a·test
·for tiJberculDSlS. In dooumel'\tati9n forwa~ed s~seiJul:!nt to the. survey, CHs ~d.th!l
c:ollaboratlOl1It h'as had with the county arid slats health deparlments regarding sm' and TB·
tesUng. CHS reports 1he5e agencll'S are fUlly aware of the jaB's screening acllvllies and
symptomatio testing. Theae public-health departments assIsted In ldenllfylnQ the highest rtsk
populallons end protocols used by c~. Joint monitoring' by i/:te county and CHS InfectIous
d1lH!~se staff fs ongoing. (February 2.006)
,
..
* In subseqttertt doeumenta'tlon, the facllfly sugmlttad rasplls ~ lhelr.cor.reclhLa a6tieJi ¢nce the
FebrUary 2006 AccredIlatlon yommlttee meelfng. A CClhi:erted effortis reported at OUrango to
brlng compretlon ofthe health history, vital signs., and lalildiagnostlc tests within lhe 14 day time
frame. yampDance in February was reported as 65% and In ~ay at 82%, Overall completion Of
the entire healUJ assessment Wfthln the requItEd }4 day time fi'illne Is reporte<l as 76% In

January, a~ 77% In March. ..'

..'"'

'

•while lhis re;~ <;;lgnlllc:ant progress, forfu~ compllance, a ~pllance mte of at feast 90%
fs requirad,lilrovldeti the 10% non-ct;Jmpnant:e Is due to ransfom events and not a speclllc
pa.ltem. The faolllty remaIns In partial compliance.. (June .2006)

.

.

"'Subsaql.lentdoeumentatlon IndIcates that while significant prograss·conlinues to·be made, the
overall Cl9mpl!anCe with 1he 14 day time frame for haallh assessments (as of September 2006)
Me eonfldentiar'(Apnl 08)

0022

DEFOOOO22

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February 24, Z00E!

Accredltallon Survey Report #112
Maricopa County Sherill's Office - Delantlon Bureau

)'#as approximately 50%, For fun compliance, a compUi,ll1ce rate of alleast 90% fur at least two
mori\hs'ls required, provic!ed !he 10% ncn-complian99Is due to random events and not a
specific pattern. The fac:llity rem~llJs in I:artlaJ gompnanca. (November ioo6)

.

.

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.

..sUbsequent documentatlon Included CQl monltcrlng results. The faclll!¥ reports an overall
complJtince rate of
than 90% for ihs fasl,s!x montbs. ' ~upporllng dceumentallOn Was
forwarde:d. The facilItY Is now In c~lJ!~nance wIlh the ;sfanaard ~June 2007).

more

J..E..D5 Menta! Health Scree,"!i~g an!1 EV~ltlatton (I), .
[ I compliance rXl p!'lfllal ~mpll~n!2 r ]n0n-ct?mpDance.
.'
Mental health evaluaUons,l1ke healih assessmerrts, are net.being performed wlthln 14 days of
arrival as requlred'by Ilia 'standard: .
.'
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, Corteclive acUon Is mqu!red for Compllanca IndlcalorCs}:# 2, Documentafum of colteetlve
'actlon Is requ~ sh9WIr1s If:iat iJ]ltIafl1ealtn asSel!~ments are completed wIlhln 14 daro; at least
two months of data shew1l1lfcO!,"pliance Is needed, .

".

*In d~l11ent¢lC!n

~rd?d. SUbseq~ntio Iiw sllrvey. the fa.~lily fl'!dloated t~a!' cc~ptive
aetlons taken fer J-E-Q4'Haalth Assessment InclUde plans to bring 1Il\i$ stendartl'fnto
'com~llance, The facinly rem~lns f~ paffis.' c?mpllalicEI: tFebiu,!rY 2(06)'
,; ,
: "In '5Ub~eq~ntdo~umentadon,the facilltY siJlimlttad.leliu."a bf.theiraarreetlve acUon'slnce th~
F~bruary 2906 Ac~!~~~ Pom"!l~' rrieell~g .. Jf
results of the. cal study pf mental
health evaluations completed at all JoCalions In M~ 200610 be a~ 100%. WhUe lh]s represents
slgnlflcent pregress,'cOnfirmation Mat lea.st oRe mota
ofcompllanc:e is needed•.The ' ,
f!!cIllly remains-in partlal',~omplf~n<i~' ~June ~006)' . . '
'.
. .

¥rts
month

~~ sUbsE\ClUa~ doeum'antstldn (~ove~bef 200~:tor s~ndard
, psrtfal i:ompR!lnce,
; . ' " .: : '
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J-t=-04.; faciJfly remaIns in
. .

Joe-OS O'ral Care (1:)..
-' ,
.
[X] oomP.'ial1ce'[ ] parti~1 compliance [ ']non-eom~nance.

NanemaJ'gency Health care Requests and Services' (e).
[ ] cofTlpftance X] partlal comp!iana;: { ]non-compliance.
.
At Estrella JaIl, ~lck can raq~ ("Tahk" Q~ers) are not trlsged within 24 hours as required by
the staritlard. Sick call rSsponslveness is not timely. There appeal'S to balosufflcle!lt nurses
and clinical pTt1Vlders to meet 1he demand of sick

J·E-D7

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t · ·

can.

.

As referenced In J-A-01 Access to .Care, Inmates'illEslralla Jail do not have access to heqfth'
care on a'dal\y b~ls as reqUIred by the standai'd. SiCk caRis herd daRy but notIn ell units ~ery
.day. FcrexarilpJe, on Mondays sICk call Is held fgrunlfl; 8, CiGO, and M200: while on
Tuesdays sick callis for units C4QO, J, L. and I. ThIs syst,em does not meat the requlrem~nts Of
the stEindard.
.
.

CorrectIVe as;tlQn Is required tor Comollaoce lnd1catorts) #: 2·5, DocumetltatlOll of corrective
acitlon or eVide'nce ihat there Is e 'procedure In place at Estre1liil Jail that when tilagelndlcales'8

need for sick can for an Inmate withIn 24 houlS, ~t Inmate Is.glven access'to sIcIt call
regardleSs qr 1he unlt In whICh ha she resides.'
.

or

.

Me Confidential (April 6S)
0023

DEF000023

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Accr~d1taQon survey'Report #11~
Ma~

Page 22 .
Fehruary 2.4. 2006

Ccunly sheriffs Office- Detention Bureatl

"In c!ocumenlallon fcrwa.rda~ sUbsequent 10 the.survey, lhe.faclUly reports it IS revising the
process fer rota\lng c1lnics. The plan Is to centralize the L8J o~lpallent clinlo so tha~ aU who
need to·be seenwlll be seen.regarolass of housing locallon. Tha'faclllty antlolpates the change
to OCllUrWithln twO to four weeks of m1d-Febt'Ualj' 2096. QoeumentaUon Is needed of .
Implementalfon cl'the cIlanges wIth subsequent monitoring that confirms resoluffon of the
Issues noted.- The facUlty remal~ In partfal compUance. (February 2006) . "

s?

°In sUbsequent docume~ta\ion,:tjle fucl\1tY reports it has changed LBJ rounds ·!hat when !he
sick cal[ slip Is p!eK'ed up from the if1!1l2te by .th~ nur.re t;ln the daily \'Cunds, a "fac~to-face. .
triage" of the l'!lqUest Is Jinmedlately' dOIlB. ~rrangem6nts are made for clInic evaluaoon or
· mldJevelIphyslcfan follow-up as clinl~JJy indr~. At Estrella, If an lnm;';lte's ~}ck !laU request Is' .
,'ralged wtth ihe determln~llon thell1male needs l!!c~ call avaluatlol1lhat day oi'tha next, l!le
Inmate15 taken tci be ~ regerot~ of v11et!ler.tha inmata'!l unitis ardlliarlly sclledufed 1hat
gay. C~f1jcal needs, overrides.the s~ule for an indiv.iP,ual as needed. CQI .!'ludl!'li .flt' Estrella
confirm !hat 9Q.%-I: pftliE! si~k ell requeSts ln~~rll and May'were. triaged'WIlhln 24 hours;'1PO%
scj'lel:lule~ for sfck call withIn 24 hours; and 9~ ~een- wlthm 24 hours ~ n8eKied. The facility
Is:!n compiiaRCa with the slaljdard. (July 20(8) .
,
.
.
· J:E-08. Eme..r!Jl!ncy ~~rvlc~s

(E)': ,•.:'.

',' ~

,'.

f X 1compliance [ JparUa1.coryJpnal!~ [ . ]non~ompl!ance..
~-E-oB ·56n.~ga~tllnma~·(I)...

_. . ' .

_

· [ 1coinpltance [X 1ptlftIal OQlIlP.llan?E' r Inci~mpllan~.. . '
.
, "Health rounds to, c~ on seglllg~ In.ma~ In some ~f. file units ap~~r to occur as
.
·lntendOO; however some probleJ!1ll weia noled !'ItA!h Avenue. In this unIt there are a (arge

number of i~niates kept under variOllS 11l~ls of segreg?pon, ?nd monitoring !S not peffprined
aCCordIng lD the standaiP. This facillty reports tltey teeerilly began ~wlthln the pa~ cQuple of .
months) perrodlcally monitoring I~ jn.·se9Te9.allcn: .I:;/o}yaver, spme nu~s do not go cel!
hl cell fa evaluate each In~te all required by the standaJtl•. According to faclllly polley, checks
are conducted 3 times 9 week; however, Interviews and documentallon indicate !:hat checks do
not IX:CUI' If stafflng Is Insufficient. Adilltlonally, the standard requires tha,l ll1ase helti fn
_.
condlllons of extreme Isolation are to be s~en .dally, ~uf ~V qf!'! nol
'.

Based' OIl the standard's definitions as wall as inrortnalion and obsoervatlons durlng the survey,
·the Inmates haused in the 4Ut A~nue'5 268 close custody (S.uper Max}.supeTVISlon c;ells' ara
confined Ul;1cler l::!'JndlUans ofaxlreme ISolation. The inmates are hous~'ln IndMdual cells willi
·seiHhrougb 'dQefli and'a lilot for feedIng and verbatlnteraclion•. There Bf13 barriers 'I1ong the '
· corrldoithat prevent inma\es Qn one side from silelng Inm~.OI1lhe other sIde. Ofii~
conlrol movement remotely and there Is no slgnlllcant regular contact between officars Bnq
inmates. Sick caR triage -wKes place,by convessaUon'through the slot In tile cell door..Inmates
recl9ale and eat alone. They are out of ther~ i:ellsfor one hQur a day. Food trays are .dell\lared
through the ~lots In the doors.'
.. . .
.
Correc!lYe Bellon Is requIred for Ogmpnsnue 1000ica\orJli) # 3 and 4. Doeumeillallon Is requlrE!d

tIlat seg~on heallh rounds occur and arE! doaumented as reqUired,
,

'

In daournentaiion forwarded subsequent to the. survey, the facllity described changes in
procedures and provlded conIIrmatlon that health rbtJr]ds in'segreg!1t!on areas oCGUr'three llmes
per week.' ThIs satlslles the
of !:he standard for areas except'SuparMax, whIch
. .Me Conlldenll~1 (April 08)

II

requ!remeros
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DEFO00024

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Maricopa County:S!)erifl's Office - Detention Bureau

"

Page 23,
February 24..2006

requires that inmates are to monitored dally by medical staff ang as least om:e a week by
mental health staff. The facility remains In partial compliance. (February 2006)
*In subsequent documentation, the facility reports cleveloping a plan to provIde the dally health
checks (n the maximum security seQregatlon \,Super Mat) cells. Confirmation th,at the plan
has Deen implemented
,
.
. . is required for full comp-Iiance.. (June
. 2006)

.

';Co~firm~tion th~tJhe health'rounds by de~ignated

health s~rvlc~ staff n the in the maximum'
SBGUrity ~Bgregatlon ("Super Max") cells is taking place daily. required for full compliance.
(November 200?)
, '
, ' ,
'
'

JwE-10 ·Patient Escort

m:,

[ X I aomplia~'cie [ ] p~rt(af compliaAce [ Inon-compl!ance.

, Comment and' Recommenocitlon: Patient' BSGort~ throughout the system generally operate 1n
compllance'wlth 'the standard, However-, delays were obserJed anq reported'in some unitS that
, hamp,sF patient car~'.
'
. .'.
".
." :
".
For' exartlpla, 4111 Avenue, nut.ss was~delayed:accs:ss to.dlabetl~ PCltlents beGause a,n esoort
was"not available. The delay continued through the morning m'eal d'fstribuuon, The nUrSe, did '
hot have the .means, policy' or dlrecijon to
uP. th~ .cha~n ,of command to e!lsure that blood ,
glucose and insulIn,was completed In a timely and cllnlcally !3Pproprlate inanner: A COl study
should'be 'perfonnea to t1etermlrie IT ihls is a systemwide probiem so that' corrective aaUon can
bata~en.
", '

at

a

gq,

.

J-E-11 Nursing'Assessment Protocols (I).
l X] compliance [.' '] pattlal compliance
Jribn~compllance.
••...
:
':'1
..••
. ' •• "

'r

J-E-12 continuity of Care ptiring:lri~arceratlon (E). '
,
[,] compliance [X] partIal compllanl?e [ ,lnol1-compllance., '
,
:rhe Inte[Jt ofthls stanp'?r4 is en~ufe'fhat patlents''n~!"eive care as ord,Bred by c!lnlq{ans,,-" ,
Th~re Is evi'dence In
records that )aq~ of ~ocumeritatlon by 'provlde~ ~rid .nurslng· staff' '
hampers the system's ability to assure' continuity of care, Care that has been orderei;f' by
clinicians may not "e given, and ordEii's WIillen may no't be "taken off" and Implemented by the
riurses. Record review confirmed slgnlficalit concerns regarding follow through,
.
".......
. .

tne

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Corrective action Is reqUired for CombHance Indlcatorfs) : #2 and,3. Documentation of corrective
action Is needed to ensure that patlent? receiVe care as ordered by ollnicians,

''The facilIty reports corrective ~ctlon after the A~ct~dlta~lori Cdmmittee meeting.. The process
for transcription, implem.entatiC!n and 9m:umenta~on ofprovider o'~ders wastevlewe9 and raeducalJon given tO,lnVolved health staff dUrlng February 2006. 'In Apiil, a COl audIt confirmed
sIgnificant progress an'd confirmat!on that,actions taken had 'adilressed the issues, The review
InclUded all clinical sites, 'The facll1tY reports that 97% of the orders were transcribed In a timely
manner and 90% were Initiated irra tImely manner,' The audit was repeated,ln May with 97%
and 96% results respectively. The Intent of the standerd is now mel. (June 2006)

J-E-13 Discharge Planning (I).

"
[ ] c::ompliance [X] partial compliance [ Jnon-compllance.
MC Confidential (Apri! 08)
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. February 24, 2008

Accredlfa(lon Survey Repoct #112
Marlcqpa County Sheriff's Office - Detentio.n Bureau
Disch1:jrge pfanning OCCU(S at t~e .facinees for most patients.

In documentation for.wardEid sUbsequent to the survey, cHS listed examples of the vario.us
ty~es of discharge planning In effed throughout the system.
The infectious disease stafffollows all patients with communicable dIseases and coordinates
hand-off care with the COUTJty p!Jbllc health department. . .
.

as.

CHS Internally tracks' patients who are identi~8d
seriously mentallyllI'through the community .
mental health' ve~dor (Value Options), Care is coordInated' through tlie on-site visits from the
.
case workers prior to inmate release: Health services reports this degree of discharge planning
for the mentally III exceeds.common Jail practice,
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CHS '[;oordlnates discharge planning for HIV .patlents with the cQunty publlc,health department.
·HIVcase workers come .ta:the Jail, visit wIth the.P?Uents, anp mal\t:. 'plans for discharge .'
medications, food;
.liouslng
.
,.
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. . ah,d .health care ,benefits.
The'cC!unty ti~5 twa full-lime cflse workers 'who provide dIscharge planning for any ho;';pltallzed
.pptlent. Patients are.traD?ltlof}!3d. t~ asj;l~ted Iiv.i~g .env{ronm8nt~, s.kllled nursfng environments, .
.rehablflt~~loli .units qr the jaill~~rmary..
.
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•

•

·Th~. c~untY. supplemerts re~our~~s:!q,r th~ s£?J.im,.lsly men\rlUy [II via JJ:1.e 8estoratlori to

.
competency Progri:;lin... Thls..pro'gram ~oo.rdlnates and kaC?ks c.ara qF mef1t~lIy i{1co.mpstent
p~t!ents. Planning is. critioal as patlenfs move from t~e state hospital back to the Jal! ,
environment.

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Corrective action Is r-egulred for Compliance IndIcator #. 2a, For.fu,1l complIance .for this st?ndard,
. confitrhatlon ls'-needed that Inmates who flave serious. he,alth needs are given' a supply of
.
nec~~sary medications sufficIent to last until the .[nl)1~t~.ls 5~!3n. by. comruunlty. proVIders, .
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0

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*The facility reports corr-ecUve -actlo~. after the .A~cr~}:litatioQ C~mniltlee meetlng, Pr~vlders._
received an in-service regarding the processes and the facl/lty' prOVided addlflpn<!l· detaIls on
their practices. ,Tlie.Keep-on-Person program atthe facility Is extehsiv,e, Thol'!e inmates being
released.who are on' this program, ta~e with them 'all remaining medications issued to them. .
Inmates who receiVe dIrect observatIon medlcatlons rec~ive prescriptions.. CHS works with the
Value Options Case Managers df released inmates with seri0us mental health conditions so
that Value Options Is able to contlnue the necessary medIcations, The facilitY is meeting the
intent of tllis standard. (June 2006),
:
'.
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Comment It may be neoessary to revIew the discharge protocols to address two possible
problems. If ~n Inmate on.the Keep-on~Persan medlc,atlan program Is dis[;harged at the point
tile medications were about to be refilled, the "remaining me9Ic~t1ons· may 110t be enough to
last until the community prsvlder can be 5~eri, It 15 also possible that inmates receiving the
prescrIptions do not have .the finances to be able to get the me:dlcatlon immediately upon
discharge. The facility may wish to
. explore these issues. .
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Me Corifipential (April 08)

0026

DEF000026

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Aecr~ditatlon Survey Report #112
.
'Maricopa County Sherilf~ Office - Detention Bureau

"'Page75
February 24, 2006

F.' HEALTH PROMOTION AND'DISEASE PREVENTION
This section focuses on a twofold approach to heallh e'ducat!on: opportunities for all Inmates 10 learn about'
and engage In a healthy life style, and, specific health teaching for patients regarding their partiCUlar health
Dondl.llons.

. !

1; General Comments

..

All compon.ents of the Detention Bureciu' ~~oYlde indivlc':loal health edubatl~n t~. 'patients' during
he~lth encoul)ters. :S~fVeyofs .note the a~ailability ~f health related iFlformatronal pamphlets In
the facility,.
.' .
.
At the Estrella Unlt there'are several programs provided to Inmates. These in~lud~:
.
a fulth-bas~d SIJpport progra'm', ACTS, whIch occurs Mon'day and'Thursday at 7PM;
(this 1'2-week pr<:!gram Is E!.v~i1abie. to 9j3neral population inmates); . . . '
~ Hepatitis AWlil-reness P.rogram··availa~le to 'general popUlation Inmatt;!~ and held on
';3 monthly. basis; (l~ts' 3.:c1ay'progr.ain 1.s av.a,ilable In English arid S'panlsh);
.
.
,Rickers l-:leallh Advocacy Progr,sif! (RHAPl6fferE!d 6n'Wednesclay..ang f.ridaY at'S
'.PM,and· aV,ellable to g!?n,erarpopi.i!~ti~n inmates'b"etWeelfiJie ages' pf-1.B!'!nd 24··(this
2-week prqgniirO Is available hi 'Engl)sh and SpaniS"ti);::a'rlct, . :." ,...
'.:
, •.. GED elasses avallElble to general'population Inmates on tuesday ahd Frio13yat
. 11:30 AM. . ..... "
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Medical diets are currently'· being ~rE!pared' for:patl'ents-wlth :specific health-relateo dIetary
neeas:The Assistant Food Service Manag!"r has a reglster~d dietitIan on staff who Is
responsible for overse!3lng the nut~ltl9nal ~qAtEmt of meals.servei:L
•

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to'

2. Standard.'sp~Pifirl'Firi~lngs.

•• "

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J-F-01 Health'Educa'tilm <i.n!=! proiTi~tiordl).
. .
[X J com'pllance' [, .] paftlal'co'inpllaric,:e [. ]nan-compllance.
.'
.
. ' "."'
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Recomm~ndation{s):Both 41h Avenue and tBJ are new facilitres and at the.Hme of tbe survey
were stili settling on som~ educalfonal routines, It Is recommended that morel opportunities be
given for the general popUlation, to receive health education and participate In activities to
,encourage healttw (ffe-so/les.,.
..
J-F-02 Nutrition and Medical Diets (I).
[X] cOlT\Pllance [ ] partial compliance [ Jnon-complfance.
J-F-03 ExercIse (I).
,
(X] compliance [ Jpartial compliance ( lnon~compUance .
. J-F-04 Personal Hygiene (f).
.
[X JcomP.llance [ ] partial compl1ance [ )oon-compl1ance,

.
Comment Facillty potlcy Is to provide outer clothing orice week. im:!udlng ~o parfS of
underwear: Inmate Interviews indicate they may mIss a wel;'kl)' distlibution due to court or
.
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MC Confidelitial (April 08)

0027

DEF000027

P.age 26
2.006

Accreditation Survey Report #112. Maricopa Cpunty Sheriff's Office - Detention 8ur~au

Fe~ruary 24,

programming. The facility should have'? process to. meet the requirement for dally underwear
changes, .especially when the health needs 9f patients and women require It

J-P·P5 Use ofTobacco (I). .
£.X] ~omplian.ce: [ ] partial complian,?e [ ]non-cDm~(jance,
G. SPECIAL NEEDS AND SERVlCES

The standards InclUded in thIs secUon address specific health needs of those with chronic illness or health
conditions requiring mul~-dlsclpnnaTY' Interventions', Age, ·gender, and Illness-related. considerations are
hIghlighted, and guldal1"ce provided. to the health staff In org'solzlng necessary treatmen\. A.speclal concern
wit!! care provldeCl to these paHents Is that It be in ~eeplng with current community standards. .
1.
'Generfll
Comments
\
. .
.
-

.

The Detention ~ur~a~ ~lInlclans report llsl'ng modified N~GHC ~1I~lc,al gUidelif1\:!5 to gUIde the
provislorj ?"f~qhr611{p" 9~re ~e.r,J.IGes:·.W~lI':l theire .~re .so~~ .g~ps i(1 mah:MJnlng nat!o:nal . ,
guldelhie~, t~~r§ .i~. ~'{rdenc~··tbCjt;~S'.o,~·,cllnl~1 c~r~.l~:.belng.prp~ld~d. };=C?r-. s>.c8tnple,,·,.Qlaqetlc
,p.~tlent~ ara:~e~r)§I. a9quc"'~S*s .. ~hd}:!g~A.1 ~ l1}onlt~~Dg 08 a freq~e.l).t,and rellat?!e;basis.,
Almost all diabetIcs arl?, g~~ng aD, ACE Ill.hlbltor. P~ak flow measure[1!ents are.. gettmg done on
·as~hrn~~i~. ThE!rl?l..l~·!3 fgl11).(a[ sp'~c.lat.n~~c!;3. Ir.eatmen! plans tha~.if used,.Wt?l,lld provide ,
.
. .
. comprehensive and consIstent docUmenfatlon.
."

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Specialty c1inlq; for orthopedic~l..\nfectiou5 di~eEjs.e, and suyglcal needs are conducted at the'
,LBJ unIt'
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Ment.al health care and. services are extensive. In FY2006, In the entlr!'l Detention Bureau; there
were 11,973 psychiatric and 49,940 psych~loglciaJ ?ounseling apP?i.ptm.ents. The mental health'
service had'8 caseload of 1,413 persl:Jn!3 .wlth'bf-polar, 1,ag!') schizophrenia, 862 major
.depresslons, and 3~ demenfta·dla'gnoses. A r8n~om sel.ectlcm \l.f ~~. ctl~r\~,of ~ho.se Who were
on the mental health <?!3se load found ;tl'11~ly identification of need. and p'rovision of apprqprlate
clue. Initial mental health assessments were complete as required by the standard. In FY2005
th~re were 22,034·lnmates on Rsychotropic medicatlo.ns.
.
.
Sheltered ment~[ health tiouslfJ9 Is p~ovlded for in~ates who need a higher lev~1 of psychiatric
care than can be provided in general popUlation housing or segrega~on units, ThIs, special .
hOUsing Is used for inmates having sIgnIficant mental health'disorders once they have been
evaluated by the psychiatric staff. .
.'

a

"Inmates in mental.health housing are under continuous care by psychiatric team, Adjustments
In medh::;atlon, therapy', .and ap~ropri.ate houl:;lng are made qy the psychiatrist, as the Inmate's
condition warrants. Day room, selVlces, and program ac.~e56 for Inmates Is detemllned .on an
Individual basis by psychlatrfc personnel. Detention staff may implement additional security
measures, or place the Inmate In morer secure housing or additional"restrainfs..If
Inmate
poses a safety or security risk.

the

In the !'last two'years, psychiatric servlGe~ have conducted patient satisfaction surveys on
inpatient psychlatJic unIts. Psychiatric services flre Inyolved In data collection and. analysis for
Inmate grievances. ~sychiatrlc services conducted 8 chart audit pr<;Jcess ant;l established a
.
MC Confidential (Aprif08)
0028

DEF000028

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Accreditation ~urvey Report #112
,
Maricopa County Sheriff's Office ~ DetenHon Bureau

Page 2.7
FebruaiY 24, 2006

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psychiatrIc peer review process. Psychiatric ,services also trained RN' nursing staff 1n AIMS'
assessment and'-competency.- Provider,assessment forms wen~ revlsed to provlde consistency
In documenfation. finally, p~ychlatric services conducted 'an outcome study to streamline the
Madison Street JaIrs Qall slpoe closed) 6 am t~ 3 pm medical slck·call process by reduclng'the
sick call. length of time by 50% (2 hours), which In turn Increased the available time for ,_
, psychiatr.ic Interveritions.
'
The facility ha,s a suicide prevention program that add~s~es each of the twelve aspects of
planning as descrioed by 1he standard. There <Ire 2. dry cells used' for suicide observation of
, Juveniles In the Infirmary. Ihese cells hav,e window views from two sides, no ma'ttresses, and _
no .'hitching posts. In-patient'
charts'were
complete- with special .neegs treatment,plans,
. "
.

~~ 60-bed' lnfirniary.ls· located ~t~he!LBJ ~nlt Me9Ic~I'pro~~ers ~SS~S5 pa~ents ad~itt~d to
the Inflrmary'and give an aculty'score to each: An:acuily of 1 (the hIghest score) meEms'that
,nursing assessment and vital signs'are due evefyshfft, eveiY day, 'An acuity score of 4 (the

lowest s90re) ,mean,s ho.8s!Rg oiiiy; no assessments·, ,Level 1 Is, used for ~lsabled Indiyld,uals
who are unanle to ,taRe care of ~hek ~ctl~ltles. of dally living (Aq~l?) (e.g., 'a, guadrjplegic)' ~nd ,
need sheltered housing.. Level 4 sheltere~f hou'sing 'patients request medl.cal'i:lare by fllHng out a
.'.sick call slip ("tank order") and are charged' a Cq-p~y for theise' requests" "
"
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. Tne It'lfirmary Is stflffed'with a p.!1Ysician from'B:OO am fo 4:'30 pm and a [l,iJ~se,tnanag~.r 6:00
", ain·to 5:Olfpm; . Mond'aythru Friday. Thete are RNs and LPNs on duty 24 hOUfS, 7-d<lYs a
wee~. Even If t\.1e ,facility experiences a shortage: of hec:lIth s~ff on a' given da~ ~r ~b!ft,_ the
facUity repons the InDnilari!s never unden?tafTed. ryJe'ntal he~lth servlG~s are provld~d to
inmates in lIie IIJ,fimia'ry as needed. AII'medlcation admlnistr'ation in the inflrmaiY Is by dh'ect
observalIon ,tIierElPY.
'.'
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The'IFlfirma!1's scope qf health s,ervii::e Includes 'lfteroare for trar:1sfers back fr~m ,area hospitals
followJng surglcal'prQcedures, as well as acute "or In.tensive Inpa~lent oare for iIInas,s or In]u'ry.'
Inmates ihfected wit~ commCJnlm;tble dl~eas8'a're hous'ed in the infirm·oIlY. Jljverilles'requlring
sl.ilcrd.~ watch also are housed here.
.- . .
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"
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Substance abuse servlce.s are provl~ed at varying degrees wltlJlnfhe 'componf,lnts of the
Detention BUreaL!, At the Estrella Unit there are several substance abuse programs proVided to
inmates. These Incluqe:
.
Alcohol!e;s Anonymous ~Engllsh) at 4 PM on Monday: a 12 Step based AA program .
,'
,
for general populatlqn Inmates; .
• Narcotics Anonymous (English) at 8PM oriWednesday. a 12 Step based NA
-program for genera! P9pula'tion Inmates;
, - .'
Cocaine Anonymous (English)' at-iOAM ori Satu'rday, a 1'2 Step'based CA program
'for general populaHon lnmate~;
.• drystal Meth Anonymous (English) at 3PM on Saturday, a 12 Step.based CMA
".program for general populath;m Inmates; and,
"
.
Alcoholics An'o'nymous (Spanlsh),at 8:30PM on Saturdc;ly, a 12' step based AA
program for Spanish speaking ge~eral popUlation InmE!tes.
'
The medical director reported" that thare Is no detoxlficatfon being performed at '\he jail.
Pregnan~ Inmates adrnltb:id wltl:J a history of opiate use are maintained on methadons'(tablets).
(See also standard J-D~05 Hospital and Specialty Services.)
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Me Confidential (April 08)
0029

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DEF000029

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.Ac;cr!3dltation SurVey Report #112
'Maricopa County Sheriffs Office - Detention Bureal,! ,

Page 28"
February 24, 2006

Policy and procedur?s illdlcate what acllr;ms are to be ,taken in lne care of terminally ill inmates.
The jail has housed IndIvIduals with terminal Illnesses such as acute myelogenous leUkemia,
metastatic malignant me!anom~, and Ilver cirrhosis..
Services ar's 8vallabt.!3 to car~,fpr the heeds of pregnant inmates at Estrella. The,r\? were.917
pregnant inmates treated in ff2005. There Were 7 a-sectIon and 3B vaginal births p'erfqrme~ FIt
the local hospital. .
"
.
2. Stand~rd

s.peeiftc .Find;F1gs ."

J-G-01 Special Need~ T'reatment Pia·l)s·(E}.
.
[ i compliance 1partial ccimplianc~'( lnan-compllan<::e. '.
,
,
The facility has exc;;ellent torrtis to qqcument \he treatment pl!3.ns for llIeqical problems. They
are rarely us~d, h9weiter, and whelJ .pr~sen~.are' only part!aIlY·.fine~ a.tilt. iElev~n putpatlent .,
oharts.that l1el;lded the plans la.cKecj tl:Jem....Mantal hea.!th plans were also. pn:lplematlc. WhHe It
was possible In all put 4 chart~ to Identify What caused.entry into .menlql health c:are O.e., sIck
call request" val\lt;l..oPllcin~·.~nroIJJl1,ent, p~sitJYa.recelvl~g'5cr.~~nl·or !:Jeterition 9fffcer
"
n6.tlficat1oii)I·If-ldlvldu~1 pl,ans. ~o O,utllris arieL guide the tre~tment "!Jers generally missing•

ex

.

c~n:e~t1v~'

f~r ~o~PllarlCe :il'ldicat~~f~)~'

Docu~entatlOri i~

action 15 reqUired
2 ,:ind 3.
needed
that Indlvi~ual treqJrrient plans are develGJpe.d to ~ddr~ss all elements as reqUired by Ihe .
.. ,
.
stardard.·

*in do~ument~tlon 'f~r:W~~ded afte.r the .sJrvey,· the fucllfly.reports pl~~ril~9'to Iqentify chr.qnl,c
.care' patJsl1is a'nd.'sqliei~!Jle'them In dedI6ated:~rro!1lg c~~e 611fJlcs duFing ~hlch the treatment
plans'yvlll be developea and "followed. time is needed. to finalize pla'nning, Irnplem.8flfand,
8valuat~ corrective actions. Tlia facility r~tnalns In partial compJiahce. (FeqruarY 20GB)

*In·sUb~eqUet:'td~cum~nt~t1?ri',.th~·fa~lIiiYi:~~qrt~ ~at treatm~~t pl~IJ'for~s 'lYere re.~'

.

Implemeflted and ~he l?fCivlders reeducate~ regat;dlng·thelr Use. The'mental health -S\'lTP format
was reVised, provld,ers re-educated, and its, use It:nplel1lented "n Aprll'ZOOB, 'An April. ~Ql aydlt _.
of the Inpatient psy,<.hiatrlc unit fouj1d B9% co~plianca that th~ SNTJ?·lncluded necessary
elements, and a 100"/0 result when the results of the tr!'l~tmel'\t plan were reviewed;. I.e.• whether .
.the needs,ofthe inmate were met consIstent wl,th their SNTP. The intent of the standan:l' Is met.
(Juno: 2006)
.
"
~;G·02 Management qf Chro.nlc pisease (I).

[ Jcompliance [ X ) p~rtfal compliance [

"

.

)non-compllanc\?
There Is no effective system of tracklng chronic disease. There ar~ no regUlarly scheduled
clinics for patients with· chronic dlsease~ such as d[abet~l>; hypertension, or asthma. Rather.
~hronlcally ill Inmates ari;! given appointment!:) as .requE*?~~Q by the inmates for complaints.•
More physician Involvement tn chronic care 15 neede~. The chronic cond[tion flow sheet Is nat
optimally used~ and blood pressures are notbeing moni.to~d frequently enough. Diabetics are
riot getllng routine foot Of eye examinations. R.ecord~ do not reflect care that·ls lo'keeping with
current natlonal guidelines.
.
CorrectIve action is required for Compliance Indicator's):# 4. Documentation Is needed of
ac.tions taken to bring
the .
clinicians' practice Into compliance
with nc:jUonal. gUidelines.
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.MC' Confidential (April OB)

0030

DEF000030

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Accre~itation Surv~y Report #112

,

Pi3ge 29 ':
Febrt.}ary 24,"2006

, Maricopa C.ounty Sheriff's Offit::e - Detention Burea'u

*See J-G-O"1 Special,Needs Treatment Plans nJr information 00 plE\ns for corrective action as
reported by the facility subsequent to the survey, As of February 23, 2.006, the facility remains
In PEl~ial compliance.

""In sUbs~"quent documentation, the facili~ rep~rts eflat the !nfluenza vaccine for the up.coming

flu season Was ordered,ln May 2006: The facility replllrts t~at an effeotive system of tracking
chronic disease patients has b~en qeveloped by using a consultaljt firm, The data bas~:C!lIpW5
monitoring frequenoY'of. appolntR1~nts so that tHey ar~ schedule,a' as re'qulred. The chronic care
forms lias been re-=implemei"nteo and providers re~trained In their consistent Use. See"
further.lnformation uoper J-G-Oi." Th~ Int~rit of th~ ~a.ndarci is lDet., (June 20P~)

alse '

J-G-03 Infirmary Care (E).
."
t. J c6mplranc~ [ X J P!3rtiaJ ,corUplIance [ln~n:-~ompliaric~.
. ., .
.
The lnnrmary in-patient chart 15:oot wen-organized, ,Among the oharts rsviewed'durlng'ths .
surv~y ," admttting 'notes mls5ed'qiign'(i~I~, medIcation, ellef, activjty 're'strIctIons,' diagna5U~ le~ts
reqU!l'ea,',and"frequ"ei'1oy of vital' 'sIgn monitori~g. ':The In7patient,recbr~ .i:loes not alw~y~ l~dlcate
a disoharge plan or pls~harge notes..."
" ,"
','

COrT~cti\le aaUan is (eEJEllred'fbr ,comPli~nce'lhdlcat6ds)'# i:Hhrcitibh 9. :Docurttehtatlon Is'
"needed of the aC:tlo"ris·taken·tiS: address the{citaUons:' , '. "'"" '""
" "
"

i'~u~sequ'en~'to'~h~~S"tlrv~~)tl~~fa:~lI'I~"SUO~~e"C1~'~I:~~ f~"~~~r~~~=t~e i~~ues ,cited. ,

Confinuatlon that the acfion:,? "taken have solv!'ld the Gohcems Is'heeded for full compliance.
" .. ," . : ,"" : • .":
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,(February 2006)
,

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ccin:ments: CHS polley requ1~es that'a physli::la~ che;k daily all patients In'the Infi!T(lary.
,However, surveyors noted In" actual pracUce that the physician on-call wlll check In-patlents
Mqnday tt)rough Friday and not on weekends. Nel!her a ph,Y~lclarJ" or..ll!id level practitioner is In
the infirmary on yveekends, although a p~y~iclan Is on-call..-". . '""

".

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.

During tlie survey, ,~h~rB 'was no "manual of nursIng c<!~e avail~ble. Th~ Dlf~tar of Nursing"and
,CHs Director Indicated that the manual Is currently beyng'-wntten. In documentation submitted
after the survey, the facility clarified that it useS ,the ReirY" and Patter Nurnlng textbook as.!ts
manual ?f nursing care. The facllltY remains iO p~~IElI compllanoe, "

,

. "In s,ubsequent documentation, "th.e ,facility sUbmltt~d res:ults of CQI audi~ that cOnfinned "
actions taken nave' resolved the Issues related to Il]firmary care. The !.\pri!"!:md May 2006 audits
looked at the cOntent of admission oroers (diagnosis, freqoency of· vital signs, activity allowed,
dlet-prescrlbed, labs or olher dlE)gnos'Uc testing); wheUier medications'were ordered and.
documented on,the MARs; prese!1ce of documented discharge plans; anc! whether the
physiclan'end nursIng rounds occurred as required. Compliance'"ranged from 94% to 100%.
The facility Is in compllanc,e with·the standard, (Jun~"2006)
,
J-G:04 Mental Health Services (E).
[X] compliance [ ] partIal compllance [ Joon-compliance.
J·G-05 Suicide Prevention Program (E).
,
[ Jconwllance [X] partial oompllance [ ]non-complfance.
MC C.onfidential' (April 08) ..

0031

DEF000031

.1

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I:"::
#'

AccredItation SUf\ley Report #112
Maricopa ,County Sheriff's Office - Detenti?'1) Burea!J

.
Page 30
.. February' 24,2006 '

There were a total 9f. 5 ?uccessfu!.sulcides in .calendar year 200.5. ~ptably. the facility reports
Ihat morti'llity reviews found no major lapse .of oonscienUous mental nealth care. Mental health
5i~ff closely monitor Inmates on suicl~e .watch. HOWeVl'lf, The 4~ Avenue Jail inia~8 unit
contlnues to pose a risk for suicide attempts. For example, an Inmate successfully hung himself
ali telephone cord in hi~ intake Is~latlon cell•. Suc~ tel':lp~ones continue to po'se a.risk for
suicidal inmates in the unit
.
, '
.
.

a
.

·Corrective.action· is required. 'Further d~tails on the flndlngs of the suicide
reviews for
2005, is required 59 ~rat complia"n,Gs with the intent Qf the standard can .be assessed,
.',
..
. .
'Thls st~ndard Is irlt~nded to ensure that suloides are prevented If at all possible.. When suicides
do occur, appropriate G6rrecti~e act.l~n Is !.dentified'and implemented to prevent.resurrt;lnces. In
addition, aggregate f!!,viaw of sulcjde related, .data Is.tt:) be m~l1lt~r~d ~o as to'be ~l5le to aadress
any discem$ble pat\ems~ T.tJe Acoredltatiol) Comml~~s r.eguel:lt~ thi;1t CHS'Ti3rward a summarY
of tlie faclflty's nn.dl,ri9l! f6gEiigin~ theIr 200~, mortalitY ~~~I~'!Vs' q9[flpl~ted ~n .the.5 ,~eaths by,"
suicIde, ~llot1g with c1mfirmatii?n that E!ny correctiv~' actions recommended as'a result of .the
fif1dlrigs were'lmplementea .
,"
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morta'lIty

~Of tl:le eigh,t. de;atJ:1s aHli~ D~,te:ntlori ,~u[ec;l:l.J:,J.:.~QO~i ~o \fIIlj!r~ ?ttrlbu~lf.~ ~9 ,;>,41.9Ide:.ln:~005,
16 deaths were reported, l'lno five were"aftrjbt4eCl to' !jl.t.11c;:ldes. Tlie, De~eritloJi Bureal,l's Morb.ldlty

and Mortality"Committ~s revlewed,:each death, a' quality 'review"is' perfomll':!d' on thl? medical"
. record, a report Is written by; th~ rned,lca! dlreclor.and,C'?81:chalr, ~nd·~·psychologlcal autopsy'ls
performed ,by'the Di~ector. of Me,ntFll, Health. 'The: Dlr~~to(of..Nurslng,pr-ovld8s f!?eP.bac~ to
nursing staff. Thei medIcal director provides fee[jba'cK to clinIcal provIders. In sUbsequent '
dpcumentatlon, the'facllity reports? that documentation Is avallo;lble on site to confirm that all ..
corrective actlons,were complFlted'and fmp.lemsried. The Intent of the stlilnq8td is me! (June
2006),'
..
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, ' '
. . . . . ' :',:'
. . . . . . , . '. '.

J.G.os' Intoxication a~d ·Withdrawal· (E).

. : . '. ' ,

[X 1compliance [ ] partial compliance [ ]non-compllance.'
J-G-07 C"re of the Pregnant Inmate (E). :
..
1partial compliaAc~ t.·]npn-compllance. .

[ X 1compliance [

J·G-DB Inmates With Alcohol or Other

[ ~ J. compliance
[
.

1partial compliance, [

Drug Problems (I).
lnon-compliance.
. .

Comment While Estrella has stron~ prol;{rammriig~ ..the other sites,· especially the neWer 4111
.Avenue'af)d .LBJ; are In need of enha~ced ~rogrammlng regarding substance abuse. ,
J-G-09 Procedure In The ~ventOf Sexual ~ssault (I):

[X I cqmpUance [ J partial compflance ( , lnon-compliance.
Comment The facility reports there were no allegations of sexual assaults report!=d by inmates
throughout·the units'of the Detention Bureau.
.
J-G-10 Pregna,ncy Counsellng (I).

[ X] oompHance [

Jpartial compliance {

Jnon-compliance..

Me Confidential (April 08)
0032

DEF000032

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".:;'

Accreditation Survey Report #1i2
'
Maricopa County Sheriff's Office - Detention Bureau

P~ge31

February 24, 2006

J-G-11 Orthoses, Prostheses, and Qther Aids to ImpaIrment (I).
[X 1compllal'lce J 1partial compll,;ln [lnon-compliam:e:
'
.

ce

J-G-12 Care For The Terminally 111"(1). ,
(X 1compliance [ 1partial compliance [-' lnon-compll~nce..
H. HEALTH REGORDS

The complexities ofgo~d documentallon ofhealth, services In the medical recortl are addressed In this section.
The legal requirements for health 'reco~ con!epts Is Included In this, sedion, as well as the special
conslderath;ms necessary due· to the'stal~s qf tlJe patients within a cO'~r?ctlonal settIng:' There musl be
adequpte m~ans for sharing crltlcalhealth InformatIon on'an ongoing pasls qmo'ng the vanous providers Where
medical and menlal health records Bl}!,kept separatelX.
'

" 1. 'General Comments
Inmate h.eajth'recordsare In,haft! ~opy, The facility' rei ports that a proposal for an e:{eclronlc
medical r~cords system,is (1;1 th.e. planning stages. Curreotly, a computerize'd information !System
15 5hare~ wltll cU5~ady to determine·inmate location.
. . . , ' .. '
.
"

'

2" _Standa~d Spe'cific FI.oding.s

J~H~01 Health Recorct'Form'at and'Contents (E). ,

[X.).complla'nce ~. ]"partlal compliance [ ]non~compliance.,
Comments and Recommendation:

,

A system of thi~ sIze and comp!el<lty wo.uld'lIkely !Je'1e;!it"fr.9111 afl.el~~tronlc me!il,cal information'
system:, ..

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Demtal recprds are 's~parate frqm the. ine~lcal record~ a~d ds,'ntal siaff ~omm~nlcate with' health
sta'ff vernally' for jnstfU,c~ons. ~iven the 'l;lUlTl_b~r,s ·qf p~tlents and dlv'srsltY 9f pomptin~nts, ari~
, lack of an'electronlo medical record, a written meUioi:! of communlcathig instructions for health
staff should be d e v e l o p e d . '
.
J·H-02 Conficientiallty of He~l,th Records and Inf9J:111atiorr (E).'
[ X ] o0!T'pllance [ ] partial compll~nce [ ]no~-compJlance,

J.H-03 Access,To Custody Information (I).
,
[X] compliance [ ] partJ~1 GO,mpllanc8 [ Inon-compllance.
J-H-04 'Availability and Use of Health Records (I).
[ ] compliance [X 1partial complIance [ jnon-compllance
Health staff report that the health record Is not always available at the time of the medical or
mental health encounter. Staffing deficiencIes have been clted'by tAe facilitY as the main
reason why charts are not ready or available at the time ofthe encounter.

Correc:tive actl~n Is required for C~mpnance Indicator #2; Documentation of corrective aqtion Is
needed.
'
MC Confidential (April
0033

~8)

DEF000033

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,

Accreditatiof.1 SurVey Report #112
f.1aricopa COtll1ty Sheriff's Office .. Detention Bureaa

Page 32
F,ebru~ry 24,

2006

*In documentaUon sUbsequent,to t~e survi3Y, U:le faclllty rep?rt:; that while CH~ conUnues t~
pu~ue'an EMR, in the m~antlme. thl;lY have hfrJKI4 adpjtlonal MR Technicians :?ince 01/06,
leaving the facility with one vacancy. CHS implemented a process thatlransfers medical.
records too on-site speciality clinics on the day of clinic so that" medical 'records C!re available to .
the provider p.rtor to the appoIntment. .In May 2P06, aU sItes particip'ated in CQI stt)dy. which
confirmed that the medical record was' available to the p'toVider at the time of the encounter. .
The facilitY Gontrnu~s to monitor this. The facility Is on:c;:ompilance ~ith,the Inteht oftha

a

standa'rd; (july 2006).,
:

"

"

j-H~05' Tra~sf~r of Health Recq'r'ds (I):
t X] comp.liance [ Jpartiai complia~ce ( Joan-compliance.
J-H-06, Re:tention of Health Recoi,ds (D.
[X J compliah~e [ 1partial compll~nce (, .lnon-compllanc~.

I. MEDICAL-LEGAL ISSUES
'.'

.,

-.,

Th~se are among the'm05t"complex Issues faolng correction~1 health-cara pr9yldefs. 'Whlle the rights of the

Inmate' as a pa~ent are generally the sa'me as rights of'a 'patlent lI:i-lhe'freeworld, the correctlonalseltln'g often
adds addltlol1al con~lderaUon5, to be Inaluded IIJ the decisIon-making proce?s about patient dare. Rights of
the patlent aod the duty to protect the patlent and othen; may prepentaonnlctlr19 priorities; however, ethlqal
gyfdellnes, professfonal practice stands'ros, and NeCHe's-tandards are the determining factors regardIng
these Interventions and Issues.' ,

'i. General CommentS

'~ysteril~wJde'ci~tafor."zo:65 ~hdr~at~:tH~ft~ere

medlC~ilY

~~straints tl,~

Were 280'
ordered
in
. psychIatric In-pallent uf1lt ,at the LB~ facility. Leather restrflints were Llsed In 84.4% of 1he
Incid!:!nts, and the res~~lnt dhalfwas used In 11.2.ro of the tlm!':l.,~eGlusion.Wal:! u~ep 4,5°~ of
-the. time., Appr~xlrhately 70"/0 of restraints, were for less tha(1 6 h~U~. ~hel1 rei?ualn\s are, '. ,
/, applied by c!-,stody 5ta11 In otner components of t~e system, [nrn?t~ are, uSl,Jally transferred to
LBJ and monItored by health staff there.'
"
. ,
'" .
'

.'

Interviews with custody ~nd health staff at 41h Aven~e and Durango,lndlcate that medical staff Is
notlf.ied whim restraints are used (in a !Jse of force restraint). Medical staff checks health
,records for contraindications, checks injuries, and monitors breathing and circulation of Inmates
so restrained.
.

as

Interviews wIth mental health professionals and nurses, as well
record revIews, co"nfirm that
,psychotropic medIcation is ordered by a psych!a,trist and administered consIstent with these

standards.
The faclllty reports that health staff are not involved In the collection of blood specimens for
DNA or alcohol testing for forensic purposes. Intervjewed health st~ff indic:ated 1hat they have
never been Involved In a body cavlly search.
2. ',Standard' Speciflc'"Findings
MC Confidential (AJ?rit 08)
0034

DEF000034

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Accreditation Survey Report #112
Maricspa County Sheriffs Office.- Detention "Bure?u

Page.33
February 2.4, 2.006

J-I-01 Use of R!,!sfraint. and Se~lusion in Correcti:onal Facilities (E).
[X ~ complial)ce [ j·pa·rt!al compliance [ ]non-compllance.

.,..
-,

J-I-02 Emergency Psychotropic lYledication (E)•
[X] complIance ( ] partial compliance [ jnon-compllance,

j+03 Forensic ilifonnation (I).
[ X ] complIance [ 1partIal compliance [ Inon-c~mp·Hance.

J-I~04 ~nd-Of·Life Decision Making (I). .
[ X ] compliance [ l p~rtial compUance [ jnon-comp[\ance.
. J-J':05 Inf.ormed con~.ent (I).
. [X] pompllance ( l,p'artlal compllance [ lnon-compliance. .

J-I-06 Right to Refuse T~eatment-(n.
, I X ] compliance [ ]partial oomplia'nce [ In?n-complIan 9el,

.J-I-07 Medical !ind Other Re;se?rch (I).

l X1, conipliance [

] partial,oompllance [ ]non-c0':1PUance;.

!.

MC Confidential (April 08)
0035

DEF000035

MC Confidential (April 08)
0036

DEF000036

NATI'O~'~AL CO/VW1ISSION

01\1
CORRECTIO~AL H-tALTH CARE
Hereby

Grants ThIs
~

To

Maricopa County Sheriff's Office..Detention Bureau
Phoenix, Arizona
for its achievement in providing quality health care that meets
the 'Standards for Health Services established by the National
Commission on Correctional Health Care and as determined by
the NeCHe Accreditation Committee on this date.
June 28, 2000

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NCCHCClPilr

P,OOIdonl

Me (April 08)

0001

DEF000037

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Phoenil.<, Arizona

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The above ~ed'fa()i1ity is hereby :recognized'by·the National Commission on Correctional Hc3~th Care
upon recommenda:tion of its Accreditation C~ to have met aU the :requirexnenm ofaccreditatio:n
under NeCHe's StaniloFds for Health Services.: Feb~ 2004.

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Maricopa County Sh~8 Office - Detention 'Bureau
Phoenix, AriZona

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The'above named facili-g. is 'hereby recogn.ized by the National Commission on Correctional Health Care
upon recolIll1lendlrtion of:its Accreditation Committee:to .have met all the requirements ofaccreditation
under NeCHC"s Standards for Health Senrices.
Februaty 2006.
C:":'h.r:Z .c. /f3'~ A'/..~
01liir, NeCHe Accreditation Committee
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MARICOPA.COUNTY SHERIFF'S OFFICE
JOSEPH M. ARPAIO
•SHERIFF

MllI'Ch 1. 2001

~

Joe Tansill, Interim Director
Correctional Health Services
111 West Monroe. Suite 900
Phoenix. A:z. 85003

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..

.

Dear Mr. Tansill:
CongratulatioJJS to all of you at CHSI I reoeived Judith Stanley's letter lIUnouncing your
continuation of accreditation by the NEltional Commission on Correctional Health Cllte. I always
assure both ooXious family members and.'carping critics that the medical care provided inmates
is attentivE: imd caring-and I believe it. 80 do MeSO employees who worle most closelywith
CHS employees in our j ails. Ob~ously, so dOE:S the· accrediting agency. Well done!

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J~AIpaiO

Maricopa County' Sher.ift. .

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Wells Fargo Plaza _100 West Washington - Sulfa 1900 • PhoenIx, Arizona 85003
·160~l256·1000. 5Ia~wlde"olrFreB 1-800-352.·4553. WWW.Mcsp.ORG
Me (April 08)
0004

DEF000040

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. \145 W lil'lm:t 1'l<Yii

TIfftl

C~rrectional"Healtn

113-880-\4lill pbune

Care

June 28, 2007

Undy Funkhouser
Maricopa County Sh'erlft',6 Office: - Detention Bureau
234 N: Central Avenue SuIte 500
PhoenIx, AZ 86003
Dear Mr. Funkhouser. .

.

.' :

.. Congratulatlonsl The.l\ccredltatlon Committee of the National Commission on Correctlonal
. Health Care (NeCHO), upon receipt of further documentatlon,' voted to cOIJUnue to accredit the
Maricopa County Sherlff'e Office - Detention Bureau for Its com p/lance with NecHe' Standards
for Health SSNices in Jails. Enclosed is the Accredltatlon'Report of your fElcility which
.'
... ~.. .. ...d.~c.u.~~.~.sns :cicllTlP!lc:~~e. ~I~h t.~e. ~a.n~~rd~. .__.. ...... ..... ... ... .. ........ ..... ... . .
The Commission ctlngr~ltulates you on your achlevemeI1t and wishes you continued success In
the future•. Your framed Ce'rtlflcata of Accredltatlon wUl' be sent under separate cover.. It Is
.. '. - 'emtlplpated ·that t)1e next scheduled on-slte sUNey'of the faclllly will occur sometime prior to
February 2009. If we can be of any assistance to you, please feel free ~o call us at any time.

Ff~

Judith A. Stanley, MS, GCHP-A
DIrector of f,ccredltatlon
Enclosure
cc; Edward A. Harrison, NecHe PresIdent
Sheriff Joseph Arpalo

MC.(ApriI08)

0006

DEF000042

Jumi 251, 20D'} .
Susan Svllak

Dr Current Hearth Admlnislrator
Maricopa Coullly Shetiff's Office-Detention a.ureBu-rviadlson
111 W. Monroe, Suite 900
Phoernx.AZ 85008

.
.

Dear Ms. SVitak:

Congralulallonsl The Natlona\ Comrolsslon on OorrecUonal Health Care Is pleased to
conflrm your continuing aCGl'edltatlon In good slandlng. In accordance wIth our
accredltatton policy, an gnnual malntenam.l6 report has been submItted to our office to
malnlaln your accreditation. HaVing submll.lad the Annual MaIntenance Report for
reView, It has been determined that the Maricopa County ~herlfl'5 Offlce-:Deterrllon
.....Elllr~1:'!u~M.?d'!l.q.t:J.I~.111.. cRmp!lapC.e.wJth. NeCHO's .standards
HealI~ Sarv/aes In. Jails.

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Sincerely•

.'

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JudIth A. Stanley. MS, CCHP
DIrector of AccreditatIon

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Me (April 08)
0005

DEF000041

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713-UlH4a4 fGli
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June 28, 2007

Undy Funkhouser
Ma'r\copa County SherlfF.s Office. ~ Detention Bureau
234 N: Central Avenue Suite 500
•
Phoenix, AZ 86003

Dear Mr, Funkhouser. '
"

.

" Congratulatlonsl The·Accreditation CommIttee of the National Commlsston on Correctional
, Health Care (NCCHe}, upon receipt Qffurthar-tlocumentatlon,'voled to co~tlnue to acoredltthe
MarfcopaCounty Sheriff's Offioe- Detention Bureau far Its compliance with NecHc' standaTds
for Health SSlVicea ;n JaffB. Enclosed 15 the Accredltatlon'Report- of your facility which
, .'

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'

The Commission congratulates you on your achievement and wishes you cDrrtlnued success In
the future•. Your framed Certificate of Accretlltmlon wlU'be5ent under separate cover.. It Is
-, ". -'-antlplpated 'that the next scheduled oTr:slta survey·of the faclll!;y wllf ocour sometime prior to
,
February 2009, If· we can be of any assistance to yau, please feel free ~o call us at any tlme. ,

stn~relY,

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Judith A. Stanley, MS, CCHP-A

Director of Aacredltatlon
Enclosure
co; Edward A. Hamson, NcCHe President
Shertff Joseph Arpalo

Me,(April 08)

0006

DEF000042