Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 1 of 24
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Marc F. Stern, MD, MPH
REDACTED

REDACTED

February 2, 2012

I. Introduction

This report contains my medical opinions regarding the health-related care provided to
inmates at the Idaho State Correctional Institution (ISCI), Boise, Idaho, in compliance
with Order 806 (July 20, 2011) by Judge Windmill, U.S. District Court for the District of
Idaho, in the case Walter Balla, et al. v. Idaho State Board of Correction (IDOC), et al.
(Balla).
My report is based on information from a variety of sources. I reviewed numerous court,
IDOC, ISCI and patient-generated documents (including video) provided by both parties.
I conducted an informal status conference with current and previous counsel for the
parties on September 9, 2011 at which time both parties presented summaries of Balla
and the issues at hand from their vantage points. On July 7, 8, and 9, 2011 and January 2,
3, and 4, 2012 I visited ISCI. On the latter three days, I was accompanied by Dr.
Amanda Ruiz, a forensic and correctional psychiatrist. At my request, the Court
appointed Dr. Ruiz as Deputy Special Master; Dr. Ruiz concentrated her review on Balla
issues related to mental health care. During those visits I (or Dr. Ruiz) met with over 60
patients (including the three Class Representatives) and reviewed over 45 patient medical
records. We visited all key areas of the facility including the Health Services Unit in
Unit 20 (HSU) which houses most outpatient and inpatient medical and dental activities,
the dining hall (Pendyne), Unit 16 which houses the Behavior Health Unit (BHU), Unit
15 which houses the Receiving Unit (RDU), Unit 8 which houses the Segregated Housing
Unit (SHU), Unit 20a which houses the Medical Annex for inmates who have health care
needs requiring some level of sheltered housing, and living units 9, 10, 11, 13. Dr. Ruiz
and/or I met with a variety of IDOC, ISCI, and Corizon (the contractor providing
medical, dental, and psychiatric care) employees, including but not limited to:
IDOC
IDOC Health Services Director; IDOC Dietary Services Manager
ISCI
Warden; Deputy Warden of Programs; Deputy Warden of Security; internal
investigator; numerous custody lieutenants, sergeants, corporals and front line
officers; Acting Food Service Manager and food service staff; Grievance
Coordinator; Clinical Supervisor of Mental Health Care; inmates who function as
Companions in the Suicide Observation Program

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 2 of 24

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Corizon
Regional Medical Director; Regional Vice President; Regional Director of
Nursing; Facility Medical Director; former Facility Medical Director (by phone);
facility Director of Psychiatry; facility Director of Dental Care; facility Health
Services Administrator (former and current); facility Director of Nurses;
Correctional Medical Specialists (CMS) 1 , nurses, dental assistant, and support
staff in all areas of the health care operation, including inpatient and outpatient
(for medical, mental health, and dental), dialysis, medical records, pharmacy;
Grievance Coordinator; off-site appointment scheduler.
With the permission of both parties, I conducted an exit briefing on January 4, 2011
attended by counsel for both parties, and representatives of IDOC, ISCI, Corizon, and the
Class. At the briefing Dr. Ruiz and I presented our preliminary factual findings. I asked
both parties to provide information to correct any factual errors they heard during the
briefing and informed them I would take such information under advisement prior to
issuing this report.
I felt Dr. Ruiz and I were afforded unfettered access to people, places, and documents
during our review and note the full cooperation received from Defendants in order to
obtain the information we required. At the conclusion of our review, Dr. Ruiz presented
her findings to me. I have incorporated them into my report; however, I accept full
responsibility for the contents and conclusions herein.
In its Memorandum of October 30, 1984 in Balla I, the Court identified several areas
requiring remediation. Four orders pertained to health care specifically:
-Order 1 (Balla I): This order addressed the need for an adequate dietary program
to serve the needs of the medically infirm.
-Order 3 (Balla I): This order addressed the need for (a) 24-hour emergency
medical care and (b) unimpeded access to medical care (including, at the time, the
addition of at least one full-time physician).
-Order 4 (Balla I): This order addressed the need for a properly staffed and
organized health care system to allow for effective utilization of the HSU.
-Order 5 (Balla I): This order addressed the need for an effective psychiatric care
program.
These four orders form the backbone of the health care issues in Balla. For simplicity, in
the remainder of this report, I will refer to issues contained in Order 1 (Balla I) as
“Special Diets,” the issues contained jointly in Orders 3 and 4 (Balla I) as “Medical
Care.” and the issued contained in Order 5 (Balla I) as “Mental Health Care.”
The Court asked me to address two items: 1. the status of conditions at ISCI relative to
Compliance Plans (or “Plans”) created as part of this case in or around 1984 (Order #5
within Order Appointing Special Master, Docket 806), and 2. the constitutionality of
1

CMSs are staff who have received limited training (and state certification) in how to administer
medications.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 3 of 24

health care currently (Order #6 within the same docket). I found it difficult to fully parse
my findings into these two items as there is tremendous overlap between the two.
Moreover, for reasons explained in Section III of my report, the Compliance Plans bear
little relevance to the ISCI and the science of correctional health care delivery of today.
As such, I believed it would be more useful to the Court and the parties to couch the bulk
of my findings and conclusions within the second item. Nonetheless, Section IV of this
report contains a brief analysis specifically responsive to the first item, i.e. the Court’s
Order #5.

II. Executive Summary

In my capacity as Special Master in the case Balla, et al. v. Idaho State Board of
Correction, and with the assistance of Deputy Special Master, Dr. Amanda Ruiz, I
reviewed the state of health care at ISCI in three domains (medical diets; medical/dental
care; mental health care) using the benchmark of three (presumptive, see below)
Compliance Plans from Balla I and the U.S. Constitution’s Eighth Amendment
prohibition against cruel and unusual punishment.
I found the state of health care with respect to medical diets to be fraught with some
problems, but, (a) to be compliant with the spirit of the Balla I Compliance Plan, and (b)
to not result in violations of inmates’ constitutional rights.
I found serious problems with the delivery of medical and mental health care. Many of
these problems either have resulted or risk resulting in serious harm to inmates at ISCI.
In multiple ways, these conditions violate the right of inmates at ISCI to be protected
from cruel and unusual punishment. Since many of these problems are frequent,
pervasive, long standing, and authorities are or should have been aware of them, it is my
opinion that authorities are deliberately indifferent to the serious health care needs of
their charges.
That there are problems with the delivery of health services should not come as an
unexpected conclusion. IDOC staff monitor care delivered by Corizon under IDOC’s
contract with Corizon via annual and follow up audits. During the annual audit of 2010,
Corizon failed 23 of the 33 categories of the audit. Despite feedback and follow up (and
assessment of liquidated damages), Corizon failed 26 of the 33 audit categories in the
2011 annual audit.
In response to my invitation to both parties to provide corrections to any errors in the
factual findings Dr. Ruiz and I shared at our exit briefing, I only received a response from
the Defendants. Their response did not lead to any factual corrections in my findings.
According to their response, IDOC had made some changes to their ISCI operation prior
to my first site visit, made some further changes after my first site visit, and are in the
process of, or are planning other changes. None of the changes IDOC made prior to my
first visit affect my conclusions, but I did note any changes that were significant in the
relevant sections of my report. As to any changes IDOC reported making after my first
visit, I did not audit to those changes, so I cannot comment on their effectiveness.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 4 of 24

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Despite these comments, the willingness of IDOC to entertain change is very positive and
commendable, and I include a copy of IDOC’s response (without attachments) so the
Court can appreciate their efforts (Appendix A).
In a similar vein, I think it is very important to note some of the uplifting bright lights at
ISCI which bodes well for change and improvement. The Warden recognizes the critical
importance of health care delivery, is progressive, and is willing to entertain change. The
ISCI Mental Health Program Director is energetic and actively involved in the health care
delivery system. Corizon has hired a new Health Services Administrator and a new
Director of Nursing, both of whom come with a lot of experience, devotion to their work,
and ideas for improvement. The chief psychiatrist is well trained, hard working,
dedicated, and trying to do his best. The dental program is without problems. With few
exceptions, the most important members of the health care team – the front line health
care and custody professionals – are hard working, dedicated people who clearly want to
do a good job. Finally, while this report describes examples of problematic health care,
many instances of health care delivery at ISCI are good or excellent. But many is not
enough.

III. Analysis of Order #5 (Docket 806): Compliance Plans
In Order #5 (Docket 806), the Court instructed:

Dr. Stern shall investigate and attempt to reconstruct the injunctive relief issued
by the Court in Balla I, 595 F.Supp. 1558 (D. Idaho 1984), pertaining to the
delivery of medical care – including special medical diets – and mental health
care at the Idaho State Correctional Institution (ISCI). To that end, Dr. Stern
should determine, to the extent that he is able:
(a) the terms of the compliance plans that were adopted by the Court to remedy
the constitutional violations in these areas,
(b) whether changes in circumstances have rendered these plans ineffective or
unworkable as a practical matter, and, if still applicable,
(c) whether Defendants are presently in compliance.
With regard to the terms of the Compliance Plans (part (a) above), as the Court is aware,
neither the Court, nor the Plaintiffs, nor the Defendants have retained copies of the
original Compliance Plans. Plaintiffs provided me with three documents from historical
court filings in this case. Both parties believe that these likely represent the Compliance
Plans for Special Diets, Medical Care, and Mental Health Care (Appendices B, C, D,
respectively). My analysis is based on these documents, however, it is important to note
that no one is certain that these documents are indeed the original Compliance Plans.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 5 of 24

Below I address parts (b) and (c) of the Order for each of the three disciplines.
1. Special Diets
The presumptive Compliance Plan for Special Diets is a Field Memorandum (similar to a
Policy/Procedure). The Memorandum is largely still relevant.
Conclusion 1. Special Diets
In my opinion, ISCI is largely compliant with the provisions of the Plan dealing
with Special Diets. I did not evaluate those portions of the Plan that were not
relevant to Special Diets.
2. Medical Care
Unfortunately, this presumptive Compliance Plan is largely stated in terms of the
expected structure of the health care delivery system (e.g. actual number of employees
needed) rather than expected processes or outcomes (e.g. there will be a sufficient
number of employees to conduct certain business within a specified period of time). In
my opinion, the circumstances at ISCI have changed sufficiently in the past three decades
to render much of this Plan irrelevant. The nature of these changes include such things
as: increased number of inmates; changes in physical plant; changes in operations and
mission of ISCI; increased complexity of medical science and health care delivery (such
as the existence of MRI scanners); increased severity of illness among inmates (such as
HIV/AIDS, Hepatitis C, and an aging population).
A few items within the Compliance Plan have or may have some relevance in 2012.
Defendants are in compliance with the requirement for 24-hour physician phone
availability for emergencies. Medical Request Form boxes were envisioned in the Plan to
eliminate barriers to access to care. The boxes are no longer relevant because the system
for accessing care has changed, but access to care remains a problem. The Plan described
the organization of a typical patient medical record. The current medical record is
compliant with the Plan. However, as noted later in the report, this state of compliance is
relatively recent. The Plan prescribed the number and hours of a number of employee
positions. As noted above, it is difficult to extrapolate the relevance of most of these
prescriptions to 2012. Two positions, however, deserve separate mention: dietician and
pharmacist. The Plan called for one full-time therapeutic dietician and one full-time
pharmacist (adjusting for the change in population size since 1984, these would now be
approximately two full-time positions each). ISCI is not in compliance with either
position at either staffing level. In my opinion these positions are not absolutely
necessary. On the other hand, ISCI continues to face challenges in delivery of special
diets and pharmaceuticals in 2012, and lack of these positions may be a contributing
factor. Both issues are discussed in more detail elsewhere. Finally, the Plan called for
some measures with which ISCI is not – in my opinion, appropriately – compliant. For
example, ISCI was to have purchased and operated blood testing equipment. In 2012,
blood tests are more accurately and reliably tested at nationally certified commercial
laboratories than on prison-owned and operated machines.

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Conclusion 2. Medical Care
Most of the elements of the Medical Care Compliance Plan are no longer relevant.
Of two elements which are or may be relevant, ISCI is compliant with one
(medical records) and not compliant with the other (staffing for pharmacy and
therapeutic diets).
3. Mental Health Care
The presumptive Compliance Plan is a two-page memorandum authored by the then
Deputy Warden. It is largely a description of operations. Further analysis per the Court’s
instruction was impossible.
Conclusion 3. Mental Health Care
I was not able to analyze adherence with this compliance plan.
*

*

*

In Order #6 (Docket 806), the Court instructed:
Dr. Stern shall also assess the overall medical and mental health care delivery
system ISCI at the present time and offer his opinion as to whether members of
the inmate class are experiencing current and ongoing violations of their Eighth
Amendment rights against cruel and unusual punishment in these areas…
The following three sections (IV, V, VI) address this order with regard to Special Diets,
Medical Care, and Mental Health, respectively.

IV. Analysis of Order #6 (Docket 806): Constitutionality, Special Diets

Special diets are those diets which differ from the usual prison diet (“main line diet”) and
are administered pursuant to a practitioner’s2 order for medical reasons. There are two
components to successful delivery of special diets to patients: planning and execution.
IDOC and ISCI have developed an effective system for planning. There is a full-time
Dietary Services Manager in headquarters who has been there for several years. There
are several standard special diets which cover the most common medical dietary needs.
There is a system in place to ensure that the contents for each of these special diets is
established centrally and that local staff have the materials and skill to produce them.
The nutritional content of the special diets appears appropriate to me. There are regular
audits (which I reviewed) of the menu by a Registered Dietician to assure that the
nutritional plan is translated into meals which actually contain what they should. There
are also quarterly audits of the preparation and delivery of special diets (which I
reviewed) by the Food Service Manager. These audits suggest a reasonable degree of
compliance.
2

I use the term practitioner or prescriber to connote an individual licensed to write medical orders.
Generally this is a physician, but can also be a physician assistant or nurse practitioner.

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Execution entails getting the right diet to the right patient. It appears that in some
aspects, this has improved over the past few years. In the past, the system for ordering
special diets was very complex and it is possible that practitioners did not have complete
autonomy over the orders. Based on my evaluation, those flaws no longer exist. The
order for special diets at ISCI is currently the sole province of a health care practitioner,
as it should be. The form for such orders is quite simple and is only subject to review by
a supervising physician, which is also reasonable.
It is difficult to audit the effectiveness of the execution phase. One tool is assessment of
complaints. There have certainly been some patient complaints and I have reviewed
those brought to my attention by Class members. Complaints can also come to light
through the Grievance process. The Grievance process at ISCI has a gap in it which
makes it easy for patterns of complaints to go unnoticed. The gap is that diet-related
grievances may be channeled through any one of three different chains of command
(Dietary Services Manager, Food Service Manager, Medical Service), each with a
different final appeal authority. It appears, however, that most special diet-related
grievances go through the Food Service Manager, and based on my review of grievances,
there appear to be few. Another assessment tool is customer surveys. IDOC conducts
annual satisfaction surveys (which is actually quite progressive for corrections). I
reviewed a number of these. ISCI generally scores in the middle to just below the middle
of all IDOC prisons. ISCI scores for individual scales are rarely at the very bottom. In
2008 ISCI scores were considerably lower than in other years; however, scores for all
facilities appear to fluctuate significantly from year to year.
Based on audit results, interviews with patients, and interviews with staff, I found that at
least two significant problems still exist with the execution phase of special diets. First, it
is not uncommon to have a delay (days to weeks) in the ordering or communicating to the
kitchen of special diets upon arrival of new patients to ISCI. On the other hand, though,
(a) kitchen staff seem very sensitive to this and make an effort to accommodate the
special need, even in the absence of an order, and (b) in the short-term, it is unlikely that
getting the wrong diet would cause serious medical harm, especially for diabetes, which
is the most common special diet. 3 Second, communication and coordination between the
HSU and kitchen with regard to unusual special diets is severely lacking. For example,
food service recognizes two mechanically altered diets: a “fractured jaw” diet, consisting
of liquids drinkable through a straw, and a “modified consistency” diet, consisting of
main line foods that are either soft or processed in a blender. A practitioner recently
ordered a “fractured jaw/modified consistency” diet for a patient. Kitchen staff have
been understandably confused about the composition of such a diet and have been unable
to receive clear direction from HSU staff. On the other hand, though, these types of
problems seem to have arisen, not from deliberate indifference, but rather from just the
opposite – a well-intentioned effort to fine tune or tailor dietary needs to specific patients
when there is no appropriate “off-the-shelf” solution. Similar confusion has occurred
with other patients requiring special diets such as diets with high or low residue (fiber).
3

Of course, this would not be true for food allergies. However, I saw no evidence that this has happened.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 8 of 24

Conclusion IV. Constitutionality, Special Diets
It is my opinion that problems exist with the successful delivery of special diets at
ISCI. There is no question that these issues need to be addressed. However, I do
not believe the problem is pervasive enough nor the consequences generally
serious enough that these problems rise to the level of a violation of patients’
constitutionally protected rights as defined by the Court; where there are
problems, the conduct of ISCI is better characterized by “well-intentioned
confusion” than “deliberate indifference.”

V. Analysis of Order #6 (Docket 806): Constitutionality, Medical Care
1. Sick call (SC)
Sick call at ISCI is the process by which patients are evaluated for non-urgent health
problems. The vast majority of care delivered at ISCI is through the SC process.
Generally patients communicate their need in writing on a Health Service Request (HSR)
form and are seen at a scheduled time. The initial evaluation is conducted by a nurse. In
Units 8 and 15 the HSRs are collected by HSU staff. Patients in all other units personally
deliver their HSRs to the SC nurse stationed at the SC window in Unit 20 at a scheduled
time each day.
Based on my review of health care at ISCI I believe there are three serious problems with
the SC system: (a) delays or no response to HSRs; (b) poor quality of nursing care when
it is delivered; (c) lack of confidentiality during care.
a. Delays or no response to HSRs
Delays or lack of response to HSRs was identified as a problem at ISCI as far back as
Balla I (HSRs were referred to as “kites”). The problem persists. I found delays as long
as five weeks between the time a patient submitted an HSR and when he was seen for the
problem. One patient stated on an HSR that he thought his blood sugar might be too low
and that he might have diabetes; he was not seen for 11 days. A patient who requested to
be seen 15 days earlier had not yet been seen on the day of my chart review; there is no
way of knowing if his care will occur late or not at all.
Timely response to HSRs is an essential component of adequate access to care.
Generally, patients should be seen within two to three days (slightly longer on weekends
or holidays) of submitting non-urgent requests for health care. This time frame is subject
to some variation depending on other factors such as the ease with which patients can be
seen during off-tour hours, the presence and quality of triaging of the HSR, etc. In any
case, delays of the order of magnitude occurring at ISCI are too long. They pose a
significant risk of serious medical harm. For example, if the patient above who thought
he might have low blood sugar did indeed have that condition, he was at risk of becoming
unconscious and either falling and injuring himself, or simply dying. In the RDU (Unit
15), where SC is conducted in the living unit, the delays in access to care seem to arise, in
part, from insufficient staff and/or space. I did not determine the underlying reason(s) for
delays elsewhere. Corizon has implemented a relatively novel approach to submission of
HSRs in units other than 8 and 15: patients deliver their HSRs personally to a nurse in the

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HSU. It is likely that this innovation has reduced lost HSRs and delays to responses.
However, as noted above, this innovation is insufficient.
b. Poor quality of nursing care when it is delivered
Once a patient is seen, the quality of care in SC is, at times, of poor quality. The first
(and usually only) patient evaluation in SC is usually conducted by a Licensed Practice
Nurse (LPN). These nurses often operate independently, i.e. taking the patient’s history,
conducting examinations, making conclusions about the patient’s condition, and
providing treatment, all without input from a Licensed Professional Nurse (RN) 4 or
practitioner. Most states’ nurse practice acts, including that of Idaho, draw a clear
distinction between the scopes of practice of LPNs and RNs. Generally LPNs collect
data which they provide to RNs or practitioners and execute care plans as developed by
RNs and practitioners. Making independent assessments (the nursing equivalent of a
diagnosis) and prescribing nursing interventions is the sole domain of the RN and is
beyond the scope of an LPN. 5

4

Licensed Professional Nurse and Licensed Practical Nurse are two different licensures. The former
receives significantly more training and can supervise the latter. Unfortunately, in Idaho, the acronym for
both nurses is the same. To avoid confusion in this report, I abbreviate the Licensed Professional Nurse
with “RN,” which is the more common designation used outside Idaho.
5
Nurse Practice Act, Idaho Statues TITLE 54, CHAPTER 14, 54-1402. (Emphasis added)
“(3) "Licensed practical nurse" [LPN] means a person who practices nursing by:
(a) Functioning at the direction of a licensed professional nurse, licensed physician, or licensed dentist;
(b) Contributing to the assessment of the health status of individuals and groups of individuals;
(c) Participating in the development and modification of the strategy of care;
(d) Implementing the appropriate aspects of the strategy of care as defined by the board, including
administering medications and treatments as prescribed by those health care providers authorized to
prescribe medication;
(e) Maintaining safe and effective nursing care rendered directly or indirectly;
(f) Participating in the evaluation of responses to interventions; and
(g) Delegating nursing interventions that may be performed by others and that do not conflict with this
act.
(4) "Licensed professional nurse" [RN] means a person who practices nursing by:
(a) Assessing the health status of individuals and groups of individuals;
(b) Identifying health care problems that are amenable to nursing intervention;
(c) Establishing goals to meet identified health care needs;
(d) Planning a strategy of care;
(e) Prescribing nursing interventions to implement the strategy of care;
(f) Implementing the strategy of care, including administering medications and treatments as prescribed
by those health care providers authorized to prescribe medication;
(g) Authorizing nursing interventions that may be performed by others and that do not conflict with this
act;
(h) Maintaining safe and effective nursing care rendered directly or indirectly;
(i) Evaluating responses to interventions;
(j) Teaching the theory and practice of nursing;
(k) Managing the practice of nursing; and
(l) Collaborating with other health professionals in the management of health care.”

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It is the expectation of Corizon administrators that LPNs at ISCI use condition-specific
nursing protocols 6 when evaluating patients; they believe that these protocols represent
the input of an RN or practitioner and that, as such, LPNs are not operating
independently. This reasoning is flawed for two reasons. First, LPNs do not always use
the protocols. Second, protocols cannot substitute for clinical judgment. Nursing and
medicine are professions which cannot be practiced by recipe, which essentially is what a
protocol is in the hands of an LPN. At the outset of the patient encounter, the mere
selection of the correct protocol to use for that encounter requires the LPN to have made
a diagnosis. For example, if a patient complains of pain in the area of the chest wall,
should the LPN select the “chest pain” protocol, which is heavily geared towards
managing a patient with life-threatening heart problems, or the “strains, sprains, pains”
protocol, which does not? Selecting the correct protocol at the beginning of an encounter
is tremendously challenging, even for a physician, and once the incorrect protocol is
selected, the likelihood of arriving at a correct diagnosis and treatment is markedly
decreased. Another challenge in choosing the correct protocol is when a patient has two
symptoms. For example, if a patient complains of vomiting and diarrhea, should the LPN
select the “nausea and vomiting” protocol or the “diarrhea” protocol? In this case it
would not be correct to select either or both – a very different approach is needed. In
summary, making a correct nursing assessment or diagnosis (leading to a correct
treatment plan) is a very complex task requiring training and skills beyond the level of an
LPN, even one aided by a single page set of instructions. Thus the use of protocols by
LPNs without the assistance of an RN or practitioner poses an ongoing threat to the
safety of patients at ISCI.
Protocol use or not, care delivered at SC is poor at times. This is most true when patients
are triaged or treated and then released by the first nurse they encounter (as opposed to
being shunted immediately to a higher level professional as does happen in certain cases).
I found instances when those evaluations were cursory, leading to great risk of patient
harm. It is not uncommon for the nurse to omit any examination of the patient (including
measurement of vital signs) prior to arriving at a conclusion. I personally observed this,
such as a patient presenting with foot pain prescribed a corn pad and a patient presenting
with a tooth ache prescribed no pain medication and told his request would be forwarded
to the dental clinic. Neither patient was afforded further history taking or examination.
While patients with symptoms like these usually turn out to have benign problems which
resolve on their own, these same symptoms can occasionally accompany much more
serious conditions; only a more thorough evaluation can tell the difference. Even more
serious presenting symptoms, such as bleeding from the rectum (which can be a sign of
life-threatening disease such as intestinal hemorrhage or colon cancer), resulted in release
from SC by the LPN without further diagnosis, treatment, or plan for follow up. When
nurses do appreciate that significant disease is present, care is not necessarily better or
provided at all. Patients with dental infections may be treated with regimens that are not
aggressive enough, with the patients later developing more serious infections. One such
patient presented to an LPN. The LPN’s only documentation was two words: “abscess
6

The nursing protocol is a sheet of paper that guides the nurse through specific steps to take during a
clinical encounter. The same sheet of paper also provides blank spaces for the nurse to document the
results of each step.

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[sic] tooth” followed by a verbal order from a practitioner for oral antibiotics. The
following day the patient’s abscess had gotten much worse, requiring admission to the
infirmary for intravenous antibiotics. 7
c. Lack of confidentiality during care
Upon submission of an HSR, for most patients in the facility, first contact with a nurse
occurs at the SC window in the lobby of the HSU (indicated by the arrow in photograph,
Appendix E). During SC, the lobby can be extremely crowded. Patients waiting to be
seen in SC line up in front of the window through which the nurse conducts his/her
evaluation. Due to the proximity of patients in the lobby and the need to speak loudly
due to the din, it is impossible for other patients not to overhear the nurse-patient
encounter. These conditions constitute a blatant violation of a patient’s right to privacy
during a medical encounter. Not only does our society consider confidentiality of health
care encounters a basic social right (which does not evaporate behind bars), but when
patients cannot share health care information freely without fear of breach of their
privacy, they tend to withhold information. And when clinicians do not get the whole
story from a patient, patient safety is at risk. 8
Conclusion 1. Sick call
Patient requests for routine care through the sick call process result in no care,
delayed care, or care which is dangerous, all of which deprive patients of their
constitutional right to access to care and the opinion of a qualified health care
professional.
2. Urgencies/emergencies
An urgency or emergency is when a patient has a health care need which cannot – or the
patient believes cannot – wait until the next regularly scheduled SC. There are medical
staff present on site and a physician 9 on-call 24/7 to respond to these needs. There is
always an RN on duty. However, the first responder (Emergency Responder) to
urgencies and emergencies is not always an RN; the Emergency Responder currently can
be an RN or an LPN. Further, according to information I received, this is a recent
change; previously a less highly trained person than even an LPN could fulfill the
Emergency Responder role. It is the expectation of Corizon administrators that nurses
use nursing protocols for every encounter and that each encounter conducted by an LPN
is immediately reviewed with an RN.
Based on my observations, the system in place for response to urgencies and emergencies
at ISCI is seriously flawed, both in planning or design as well as execution of the plan. In
parallel to my assessment of care for Sick Call above, two flaws are: (a) delays or no
response to urgencies or emergencies; and (b) poor quality of medical care when it is
7

There was no documentation of any examination of the patient on the day of infirmary admission either;
the first time the patient appears to have been adequately examined was on the third day of his illness.
8
I have been informed that following my first visit, the HSU lobby window is no longer used for sick call
evaluations. I did not personally verify this during my second visit.
9
The first level practitioner may be a nurse practitioner or physician assistant, but a physician is still
available. Such an arrangement is acceptable.

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delivered. In addition, urgent/emergent care suffers from: (c) poor continuity of care
upon return from the hospital emergency room (ER); and (d) emergency response
equipment which is either not kept in order or not carefully tracked.
a. Delays or no response to urgencies or emergencies
Patients report, and many correctional officers confirmed, that when correctional officers
contact HSU for an urgency, it is not uncommon for the nurse to either take a long time
to respond, sometimes requiring repeat calls to the HSU, or for the nurse to obtain some
second hand clinical information from the officer, and based on this, to instruct the
officer to have the patient submit an HSR on the next regular business day. 10 This state
of operation places patients at an unacceptable risk of harm. While many urgencies
which sound benign over the phone are benign, some are not. The only way to determine
the difference is through basic – and timely – nursing triage which usually requires taking
a patient history and conducting an examination.
b. Poor quality of nursing care when it is delivered
Nursing care given during urgent and emergent situations suffers from all the same
defects described above for care during Sick Call (see Section 1.b.); by reference that
section is included here. The following example illustrates many of these defects as they
apply specifically to an emergency response. An LPN responded to a living unit for a
patient suffering from an extremely low blood sugar (too low to register on a meter). The
patient had an altered mental status. This is a life threatening situation. The LPN
prescribed and administered an injection of a medication, without use of a protocol or an
order from a physician. Without further determination of the cause of the episode (which
is important for predicting and preventing a recurrence) and without arranging further
follow up, the LPN discharged the patient back to his living unit. The LPN acted
independently without any oversight or input from an RN or practitioner.
In addition to problems which are common to both SC and urgencies/emergencies, I
found a number of troubling cases of poor care demonstrating problems specific to
urgency/emergency care. The following two examples are illustrative. In the first, the
Emergency Responder was emergently summoned by staff for an unconscious person in a
living unit. This nurse found the patient to have agonal respirations (respirations which
are very weak, very intermittent, and are insufficient to sustain life). The nurse failed to
measure any other vital signs such as blood pressure, pulse, or amount of oxygen in the
blood. Such evaluation was critically important at this point because it was highly likely
the patient was not getting enough blood to his brain and required resuscitation. Instead,
the nurse moved the patient to the HSU. During the move, the patient’s vital signs were
not monitored and he received no supplemental oxygen. Upon arrival at the HSU (a few
minutes later) the nurse finally assessed the patient (including application of an automatic
external defibrillator [AED] for the first time), found him to be in cardiac arrest, and
began CPR. The patient died. It is impossible to know if immediate application of life
saving measures in the living unit would have saved this patient. However, failure to
provide these measures greatly reduced any chance for survival.
10

It should be noted that I was told of, but could not confirm any cases of, a delayed or deferred HSU
response when the situation was clearly life threatening.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 13 of 24

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In the second example, an Emergency Responder was emergently summoned by staff for
another unconscious patient. This nurse only brought part of the emergency equipment
with her to the scene (she failed to bring oxygen, a bag-mask resuscitator to provide
rescue breathing, or an AED, all of which are available in the emergency response
vehicle). It is not clear from the video footage I reviewed whether or not she checked the
patient’s pulse, but it is clear that in the 19 seconds she was at the patient’s side she did
not check any other vital signs such as blood pressure, respirations, or blood oxygen
level. The nurse then left the patient unattended (i.e. unattended by any other health care
professionals) for approximately 2.5 minutes 11 after which she had the patient loaded on
a gurney and transported to HSU. The confused and apparently ineffectual behavior of
the nurse so concerned one of the correctional officers that he described it in his incident
report. This case also highlights problems ensuring staff competency, discussed in
Section V. 7.
Finally, an additional problem with urgent/emergent care relates to interpretation of
electrocardiograms (heart tracing or EKG). Interpretation of an EKG requires
considerable training and expertise. Therefore Corizon administrators expect that nurses
will fax urgently obtained EKGs to on-call practitioners to interpret. However, I found
that nurses sometimes interpret EKGs themselves. Since these nurses do not have the
requisite skill, this puts patients at risk because serious heart conditions may be missed.
c. Poor continuity of care upon return from the hospital ER
To ensure that patients are safe when they return from an ER trip, the following should
occur: the patient should be evaluated by a nurse (including condition-specific
evaluations and often including measurement of vital signs); the nurse’s findings as well
as those of the ER (found on the ER medical records) should be communicated
immediately to the on-call practitioner; the practitioner should then issue appropriate
orders (which usually includes implementation of the ER physician’s recommendations
or some explanation why not); on the next business day the practitioner should personally
review the ER medical record provided. During my review, I found examples of
violation of each of these steps.
d. Emergency response equipment which is either not kept in order or not carefully
tracked
I found a number of problems with the condition or use of emergency response medical
equipment or maintenance of logs. There are no oropharyngeal or nasopharyngeal
airways in the Emergency Response kit taken to the scene of emergencies. These are
basic tools used to maintain an open airway in an unconscious patient during rescue
breathing. There is a set 12 of oropharyngeal airways in the HSU emergency room.
11

As the most qualified health care professional at the scene, there is rarely a reason for a nurse to leave the
patient’s side. My review of the documentation of this case failed to indicate any justifiable reason.
Leaving a patient unattended for such a long period of time puts the patient at risk for serious harm such as
their breathing or heart stopping unnoticed, or vomiting and having the vomit enter their lungs.
12
Since the proper sized airway must be used based on the size of the patient, an emergency kit should
contain a set with various size airways.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 14 of 24

However, of the set of five or six, the two sizes most commonly used on adults were
missing. Based on the inoperable condition of the bag-mask ventilator in the Emergency
Response vehicle and the caked dust on its protective container, it is apparent that this
essential piece of equipment is rarely if ever taken to the scene of emergencies and is
never checked for operability.
There is a log book in the HSU emergency room which is supposed to be used by staff to
document periodic checks of essential equipment. The book was in disarray. Pages for
different devices and different (past and current) months were intermingled. Some were
filed in the rings of the binders, others were stuck in the binder’s pockets. Many spaces
corresponding to checks which were supposed to have been completed and initialed were
blank. Where the facility owns multiples of the same piece of equipment (e.g. machines
for checking blood sugars), the titles on the log sheets were very unclear as to which units
were to be checked. Given the condition of the log book, it is impossible to imagine how
staff can effectively assure that all emergency equipment is in working order. The
following observations supports this impression.
During my first visit I found that the main oxygen tank in the HSU emergency room was
significantly depleted. 13 I brought this immediately to the attention of HSU
administrators who were accompanying me. They said they would address it.
Apparently, some time between my first and second trip, there was a need for oxygen,
and the tank opened by staff during the emergency was empty. During my second trip
(and unaware of the second incident), I checked the same oxygen tank I had checked
during my first trip. This time it was completely empty.
Conclusion 2. Urgencies/emergencies
Patient requests for urgent or emergency care result in no care on the day of
request, delayed care on the day of request, or care which is of substandard
quality. Much of this care is delivered by LPNs, practicing well beyond the scope
of their training and abilities, without protocols, and without direct supervision.
Some equipment required for emergency responses is missing or non-functional.
When returning from ER trips, steps important for safe continuity of care fall
through the cracks. These conditions are dangerous and deprive patients of their
constitutional right to access to care and the opinion of a qualified health care
professional.
3. Outpatient medical care by practitioners
Most outpatient medical care provided by practitioners occurs in the following settings:
referrals from nurses conducting SC; Chronic Care Clinics; over the phone for
unexpected events such as urgencies or ER trips. I found instances where the quality of
care delivered was poor. Some examples follow. One patient was found to have a lesion
13

It should be noted that there are several extra full tanks of oxygen in the HSU emergency. Thus ISCI
will not run out of oxygen. However, the tank I checked was the tank which has the regulator and oxygen
tubing already set up on it. It is the tank to which staff turn first in an emergency. If that tank is empty, it
will add time delay (and anxiety) to an emergency situation while staff obtain and prepare another tank for
use.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 15 of 24

on a chest x-ray which was suspicious for cancer. Practitioners were aware of the finding
and followed it with several tests but never discussed the possible cancer with the patient
until a full seven months later. Though the patient may have chosen the route followed
by the practitioners (i.e. periodic repeat x-rays), that route was not the only acceptable
route. Indeed the patient may have opted for more aggressive diagnostic tests at an early
stage, such as bronchoscopy or biopsy, or consultation with a lung or cancer specialist.
Or he may have decided not to undergo the tests that he was given. 14 Recent tests
showed that cancer was highly likely and he is currently receiving treatment. I was
unable to determine his current prognosis or whether or not a more aggressive approach
would have affected it. However, failure to tell the patient what was going on for seven
critically important months denied him of his basic human right to participate in his care
and to provide informed consent for the care delivered.
In a second case, a patient who had an ER evaluation for a possible heart attack felt dizzy
and fell four days after returning from the ER. A nurse responded, measured a blood
pressure of 170/109, obtained an EKG, and informed the on-call practitioner. This blood
pressure was quite high, and given the recent evaluation for a possible heart condition,
was particularly dangerous. The practitioner should have either sent the patient back to
the ER or have done a complete assessment to determine that the patient was stable,
including reviewing the patient’s EKG. The practitioner did none of this. The
practitioner did order some treatment for the blood pressure and requested repeat checks.
However, despite these measures, the blood pressure went higher (183/111; 200/115;
188/110). Even if the patient did not have a heart condition, these blood pressures are so
high as to place him at risk of a heart attack or stroke. The practitioner’s failure to treat
this patient’s high blood pressures swiftly and aggressively – especially in light of the
patient’s recent history of a possible heart condition – put the patient at grave risk of
injury or death. 15
In a third case, a patient with a history of heart disease was inexplicably dropped from the
rolls of the heart disease Chronic Care Clinic. Thus practitioners ceased to conduct
regular check ups focusing on the patient’s heart disease. A couple of years later, during
a routine visit to a practitioner for other problems, the practitioner noted that the patient
was having occasional angina (heart-related chest pain). The practitioner did no further
evaluation and provided no change in treatment. Four days later the patient died
suddenly of a heart attack. Practitioners failed to manage the patient’s heart disease on a
chronic basis, and failed to manage it on an acute basis. This death may have been
preventable.
Conclusion 3. Outpatient medical care by practitioners
14

These tests were not without risk. Without knowing what was going on, it was impossible for the patient
to have given informed consent for the tests to be conducted.
15
Additionally, despite knowing of the extremely high last blood pressure (188/110), shortly after this
blood pressure was measured, the practitioner allowed the patient to return to his living unit. Three hours
later the patient fell and hit his head. I was unable to determine if the fall was due to high blood pressure,
the treatment for high blood pressure, or another process exacerbated by the high blood pressure, such as a
heart problem. In any case, this patient was clearly not stable and should not have been allowed to return to
his living unit.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 16 of 24

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Care delivered by medical practitioners in routine and urgent settings is at times
substandard and as a result, dangerous. A prisoner’s Eighth Amendment
protection includes the right to a qualified medical opinion. The quality of
medical opinions at ISCI is at time so poor as to render them unqualified. In
those situations patients are deprived of their constitutional right.
4. Long term care
Patients bemoan changes to a previous program for dying or physically incapacitated
patients. Part of that program included training and provision of inmate companions. In
and of itself, the existence of a hospice program, Life Transitions Program, or use of
inmate companions are not requisite for constitutionally adequate care. However, in
whatever manner they are provided, certain components of care must be present. Patients
who cannot feed themselves must be fed. Patients who cannot get to the sink must be
provided hydration. Patients who cannot write for themselves must be provided a
mechanism of submitting medical grievances or HSRs. Patients who cannot move
independently must have their bedding cleaned when it is soiled. Patients in significant
pain must be provided comfort.
Based on my evaluation of long term (and terminal) care at ISCI, it is my opinion that
none of these essential elements of health care are provided consistently. For example,
one terminally ill patient was ordered to receive pain medication up to three times a day
as needed. During the several days prior to his death, nurses only assessed the patient
twice a day. Thus it was de facto impossible for nurses to execute the practitioner’s order
for pain relief. Another patient who cannot feed himself has not had food provided for
some meals.
On balance, it should be noted that Corizon has increased the amount of staffing in the
Long Term Care unit to try to address some of these deficiencies. The staffing change is
fairly recent and, unfortunately, helpful but insufficient. The remaining deficiencies
result in inhumane conditions.
Conclusion 4. Long term care
Care delivered to patients who cannot fend for themselves, such as providing food
and water, cleaning soiled linen, and treating pain, is at times inadequate at ISCI,
resulting in conditions which are inhumane and thus violative of patients’
constitutional right to care which is not cruel and unusual.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 17 of 24

5. Pharmacy
The two most serious and pervasive problems with provision of medications at ISCI are a
failure to ensure seamless provision of medication as ordered, and poor documentation of
medication delivery or administration. 16 It is not possible to totally disentangle these
issues from one another. A third problem is use of expired medications.
There are gaps in delivery of medications to patients who will keep the medication on
their person (KOP). When patients see that they are running low on a KOP medication,
they are to notify staff who then order the medication from an off-site pharmacy. At
times (hopefully rarely) these medications arrive late, i.e. after the patient has run out of
medications. When this happens, there are back-up systems in place which are supposed
to provide an interim supply of medication. However, medications arrive late more often
than is expected and the back-up systems are not always successful in providing
medications to cover the hiatus. Thus patients at ISCI may go several days to –
reportedly – weeks without essential medications. Similar things happen with
medications which are directly administered by nurses. An additional complication in the
system is that the decision of whether or not to invoke one of the back up systems is a
subjective one made by the medication nurse based on the nurse’s perception of the
necessity of the medication. Unfortunately, the medication nurse making that decision
may be an LPN (or even a less-trained non-licensed person such as a CMS, a person who
is not licensed or trained to make such decisions. This entire area was a very difficult one
for me to evaluate due to extremely poor record keeping. However, I feel confident of
my findings based on triangulation among patient complaints, officer reports, the few
records I was able to find (and their poor condition), and a Corizon administrator’s
statement.
One particularly troubling area of medication provision is how ISCI deals with patients
who refuse nurse-administered medications. It is presumed that patients are only
prescribed medications they need and if they don’t take them, their health is endangered.
On that basis, a safe health care system takes remedial steps when a patient refuses their
medications. The nature of the remediation is a function, among other things, of the
particular medication and the number of doses missed. For example a long acting
medication for pain can be missed more safely than a single dose of an antiretroviral for
HIV/AIDS. Thus it was troubling to find that not all staff I interviewed who regularly
administer medications were sure what to do in the event of a missed medications. There
were staff who were vaguely aware of a “critical medication list” but didn’t know what
medications were on that list or the exact rules to be followed.
Whether as a result of this confusion of other factors, the outcome is that patients are able
to miss even one of the “critical medications” without staff taking any remedial action. A
16

Delivery of medication means the provision of a package of medication to a patient that he will
administer to himself. Administration of medication is the provision of a single dose of medication to a
patient by a nurse. Anyone can deliver medications (e.g. US Postal Service). Administration is a much
more complex task requiring a more highly trained person – usually a licensed professional such as a nurse
– who makes assurances such as the right patient is getting the right medication at the right dose by the
right route at the right time.

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 18 of 24

staff member was able to provide me the “critical medication list.” It contains three items
(isoniazide, used for treatment of tuberculosis; all HIV/AIDS medications; and a blood
thinner). I was easily able to find instances of patients missing these medications with no
action taken. For example, Appendix F shows the medication administration record for a
patient on the tuberculosis medication. He missed a dose on December 2, 2011 and five
doses in a row starting on December 5, 2011. There was no record of any remedial
action taken.
Medication-related documentation at ISCI is extremely sloppy. The log on which nurses
are supposed to record missing medications was replete with missing or incorrect
information, making it impossible to trace whether some patients actually received bridge
medications during a hiatus of their regular supply. The other record in shambles was the
individual patient medication administration record (MAR). These pages are the
contemporaneous record on which nurses are to document every dose of medication they
administer. If a dose is not administered, the reason must also be documented. In other
words, it is unacceptable and unsafe to have blank spaces on an MAR (except for
medications prescribed “as needed”). During my inspection of MARs (at various
locations throughout ISCI) I found an alarmingly high number of MARs with blank
spaces, often with several blanks on a single MAR.
While it is difficult if not impossible to determine with certainty whether all these doses
were actually missed, the lack of complete and accurate documentation in and of itself
creates a danger for patient care. Indeed, if a patient becomes ill, it might be difficult to
determine whether that illness were due to the medication (or despite the medication) or
due to its absence.
Finally, HSU staff continue to administer medications which have expired. Without
much effort, I found three packages of actively used medications which had expired five
months earlier, and another which had expired a year earlier.
Conclusion 5. Pharmacy
Medication management practices at ISCI are dangerous. Medications are not
seamlessly provided as ordered. Record keeping of medication delivery and
administration is markedly deficient. Expired medications are used. These
contribute to and/or constitute deprivation of patients’ constitutional right to the
care which is ordered.
6. Segregation
I identified two areas of concern related to health care delivery to persons housed in
Segregation (Unit 8): deficient welfare checks and lack of seamless provision of
medications.
Inmates in Segregation are at particularly high risk of physical and mental health
problems, either due to the segregation itself or due to limited access to services or both.
As such, it is imperative that health care staff – independent of custody staff – conduct
regular welfare checks. A welfare check must involve a face to face visualization and

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Case 1:81-cv-01165-BLW Document 822 Filed 03/19/12 Page 19 of 24

interaction with each and every inmate. At ISCI these checks are assigned to a nurse and
are planned for three times a week (which is reasonable). Unfortunately, the checks do
not always occur. In the recent past, it was a common practice for a nurse to fail to make
cell-to-cell rounds, instead standing at the entrance to the unit and yelling that he/she was
present if anyone wanted him/her. There is evidence that just recently this has improved,
though at times, the individual nurse-inmate interaction may too often be limited to
visualization.
As noted elsewhere, there is a problem with seamless provision of medications to patients
throughout ISCI. This problem seems particularly common in the Segregation unit,
especially when inmates are first assigned there. It falls on unit officers to notify – and
re-notify – HSU staff that inmates have not received their previous medications for days,
and sometimes weeks. Such discontinuity of prescribed medications is clearly
dangerous.
Conclusion 6. Segregation
The general welfare of inmates in segregation has not consistently been monitored
by health care staff (although there have been some recent improvements). There
are gaps in the provision of medications. While failure to conduct welfare checks
may not, in and of itself, be unconstitutional, it is a safety mechanism to assure
that problems – such as gaps in provision of medications – do not go unchecked.
Thus, overall, I found that conditions of confinement in Segregation resulted in
deprivation of patients’ right to access to health care. Additional problems
specific to access to mental health care is discussed in Section VI.
7. Ensuring staff competency
A safe health care system has systems in place to prevent or detect and respond to health
care professionals who are not performing in a minimally acceptable way. I learned of
two specific circumstances demonstrating that these safety mechanisms are not
functioning properly at ISCI.
With regard to prevention, in Section V.2.b I described an example of a problem with the
competency of a staff member responding to an emergency. That problem arose from
flaws in the system for selecting and training Emergency Responders. It should be noted
that as a result of this incident (which occurred very recently), Corizon has made
significant positive changes such as improvements to its method for selecting and training
Emergency Responders.
Since staff competency cannot be guaranteed – even with proper systems for selecting
and training qualified staff – a health care organization must also be able to detect and
respond to evidence of lack of competency. The following case reveals that this did not
happen at ISCI. ISCI received troubling allegations regarding a nurse (Corizon
employee) in the dialysis suite in the HSU. Allegations included suspicion that she
overtly did not like inmates, was failing to provide food and water during dialysis,
prematurely aborted dialysis sessions or simply did not provide them at all, and failed to
provide ordered medications resulting in patients becoming anemic (low red blood

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count). Based on my discussion with staff members and review of available
documents, 17 it is more likely than not that authorities were aware of the potential danger
to the safety of patients for several months but unduly delayed taking action to protect
them. Further, IDOC’s internal investigation strongly suggests that the delay was based
on financial rather than patient safety or labor relations considerations. This fact set is
very troubling and indicates a conscious disregard for patient safety.
Conclusion 7. Ensuring staff competency
Systems to prevent, or detect and respond to incompetent staff are deficient,
resulting in dangerous conditions for patients at ISCI. In one very troubling case,
authorities were aware of ongoing employee poor performance and/or misconduct
which presented a significant risk of serious harm to patients, yet deliberately
took no action. Such conditions violate patients’ rights under the Eighth
Amendment.
8. Medical Records
A well organized and complete medical record is a necessary element of a
constitutionally adequate health care delivery system. In my opinion, medical records are
currently well organized and complete, and all loose papers have been filed. However,
this state of affairs is a recent development. According to staff, until May 2011, most
medical records did not have clearly marked sections, were disorganized, and were
missing many essential documents, such as lab and x-ray reports which were in loose
stacks waiting to be filed. If this is true, the medical record at that time would likely not
have been able to support constitutionally adequate care.
It is a basic patient right to be able to review one’s medical record. Aside from other
purposes, a patient’s review of his medical record is one mechanism to help ensure that
information in the record is accurate. Patients at ISCI do not have this right. It is
important to note that this deficiency is not under the control of ISCI; it is dictated by
Idaho Code 9-342, 3, e. Unfortunately, this Code lumps medical records together with all
other state records from which prisoners are barred access.
Conclusion 8. Medical records
Prior to the middle of last year, the medical record was likely insufficient to
support constitutionally adequate care; that is no longer the case. Patients should,
but do not, have the right to access their medical record; this is not under the

17

I requested the employee’s personnel file (a document maintained by Corizon) and any IDOC/ISCI
documents related to any investigations and actions taken. The employee had been dismissed about 18
months prior to my request. I was originally informed that Corizon had already “purged” all of this
employee’s personnel records (with the exception of payroll data). After a repeat request, I was informed
that the records had not been purged but had been sent to an off-site storage facility and would be
forwarded to me prior to issuing my report. They were not received as of the date of this report. IDOC
conducted an investigation about one month after the employee’s dismissal. I was provided IDOC’s 22page investigation report. The report is an accounting of the facts in the case. My subsequent request for
any other IDOC documents containing conclusions and action plans based on the investigation also remains
outstanding as of the date of this report.

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control of ISCI or IDOC. Problems with inadequate entries into the medical
record for mental health care are discussed in Section VI.
9. Systems to support a constitutionally adequate health care delivery system
This subsection addresses three ancillary systems which support health care delivery:
policies and procedures, inmate grievances, and death reviews. Absence or dysfunction
of these systems does not in and of itself mean a system of care is constitutionally
inadequate. However, these systems are so important that when they are absent or
dysfunctional, it is hard for a correctional health care system to provide constitutionally
adequate care. These three ancillary systems are dysfunctional at ISCI. Given the
problems with the health care delivery system at ISCI described in this report, the
dysfunction of these three systems should be considered as one of the contributing
causes. I will discuss them briefly.
I did not review many individual policies or procedures and do not offer an opinion about
their specific content. However, I did find that the overall structure of policies and
procedures at ISCI it very cumbersome. IDOC has policies. IDOC also has Standard
Operating Procedures. For each IDOC policy ISCI may have its own Field Memoranda,
which essentially expand on policy and procedures. Corizon, a national health care
vendor, has corporate level policies. In addition, state or facility operations within
Corizon may have local instructions. Not only does the mere existence of these various
(and overlapping) sets of documents make for confusion, but the platforms on which they
reside (i.e. internet, Corizon intranet, IDOC intranet, paper) are disparate and not
coordinated, making it very difficult for an individual staff member to use them. This
difficulty of use was apparent to me during a number of interactions with staff on issues
about relevant policy and procedure. From floor nurses to secretaries to medical records
staff to HSU supervisors and even Corizon regional supervisors, everyone had difficulty
finding relevant policies and procedures.
In the IDOC Grievance system, inmates may submit Concerns and then Complaints;
under PRLA they must exhaust these remedies prior to seeking judicial relief. Dr. Ruiz
and I reviewed over 100 Concerns and over 75 Complaints. I found a number of
problems with the Grievance system which erode its value. First, when addressing a
Concern or Complaint, with rare exception, staff never talk directly with the inmate to
better understand (and attempt to resolve) the issue. Second, at least half the Concerns I
reviewed are essentially HSRs. Staff allow inmates to use Concerns in that way.
However, policy for handling Concerns does not have the same clinical rigor as policy
for handling HSRs. Thus, Concerns about clinical issues are not necessarily triaged
according to clinical protocol, are not responded to within a short time period, etc. For
example, a patient submitted a Concern stating he was on lithium pills and was
experiencing extreme tremors. This might have been a symptom of a toxic, lifethreatening lithium blood level. Staff responded to the Concern several days later,
indicating simply that the Concern was satisfied because the patient had already been
seen in a clinic six days after submitting the Concern. Instead, the Concern should have
prompted an immediate (i.e. within hours) face-to-face clinical evaluation. The way the
Concern was handled placed the patient’s life at risk during the six days after submitting

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the Concern. Third, appeals of Complaint responses are not always reviewed by
Corizon’s Regional Manager, as required by policy. Additionally, they are often
responded to by an LPN – who is sometimes the same staff member who was the subject
of the Concern leading to the Complaint. Such responses are inconsistent with the
facility’s high level of response to Complaint appeals for non-health care related issues
(which require the Warden’s concurrence), and can present a conflict of interest. Fourth,
and most importantly, facility responses are often non-responsive to the issue, flippant,
and/or fail to address any underlying system problem leading to the Complaint.
According to IDOC Policy 18 and good medical practice, deaths are “sentinel events”
which should be reviewed to evaluate the quality of health care delivered and make
remedial changes based on lessons learned. At ISCI no such review occurs. Corizon
conducts an internal peer review which is protected from review by anyone outside
Corizon, including IDOC. Corizon does not prepare a report for IDOC, it does not
forward any recommendations for improvement to IDOC, and IDOC does not request or
require this from Corizon, despite policy to the contrary. As an example of the
importance of the death review process, in Section V.3. I described a death. My own
review suggested that there were errors which may have contributed to the death.
However, no review was conducted by IDOC nor was any report created by Corizon and
provided to IDOC. Thus if there were indeed preventable errors, to my knowledge ISCI
has not taken any remedial measures to prevent the errors from causing future deaths.
Conclusion 9. Systems to support a constitutionally adequate health care
delivery system
The state of guiding documents, the inmate grievance system, and death reviews
at ISCI is poor. While not in and of themselves unconstitutional, it is important
for the Court to be aware of this and its possible contribution to other
unconstitutional conditions.

VI. Analysis of Order #6 (Docket 806): Constitutionality, Mental
Health Care

In Balla I, the Court described a constitutionally adequate mental health care program as
one which contained six elements 19 :
18

“Within 30 days of the offender’s death, the facility health authority and facility medical director (or
designees), shall jointly conduct a clinical mortality review, and submit a written report to the health
authority. ..[The report shall contain]… Events leading to the terminal event; Diagnosis as established at
the time of the clinical mortality review; The primary cause of death…For the period prior to the terminal
event- the timeliness and appropriateness of diagnoses, treatments, preventive measures taken, and staff
responses; For the period of the terminal event- the timeliness and appropriateness of diagnoses, treatments,
preventive measures taken, and staff responses; The reviewer's opinion of whether the level of housing and
available healthcare was appropriate; and A narrative – prepared and signed by the facility medical director
and other participant in the clinical mortality review process, to include conclusions, findings, and the
reviewer's recommendations for improvement….The [IDOC] health authority (or designee) shall review
the completed and signed Clinical Mortality Review Report (and other relevant documentation) to
determine whether the death may be part of an emerging pattern or indicative of opportunities for
improvement in the overall healthcare delivery system.” IDOC SOP 401.05.03.11
19
The Court’s source was Ruiz v. Estelle, 503 F. Supp. 1265 (S.D.Tex. 1980).

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1. A systematic program for screening and evaluating inmates to identify those in need of
mental health care;
2. A treatment program that involves more than segregation and close supervision
of mentally ill inmates;
3. Employment of a sufficient number of trained mental health professionals;
4. Maintenance of accurate, complete, and confidential mental health treatment records;
5. Administration of psychotropic medication only with appropriate supervision
and periodic evaluation; and
6. A basic program to identify, treat, and supervise inmates at risk for suicide.
These elements remain viable in 2012. 20 Along with an additional element,
7. Systems to support a constitutionally adequate mental health care delivery
system,
they form the framework for my analysis of current conditions at ISCI.
1. A systematic program for screening and evaluating inmates to identify those in
need of mental health care
Screening is the process by which all arriving inmates are tested for mental illness,
whether or not there is any overt indication or history. The screening does not have to be
conducted by a mental health professional. If the screening suggests possible mental
illness, an inmate should be referred to a qualified mental health professional for an
evaluation to determine if mental illness truly exists, and if so, implement (or continue)
therapy. If the screening score crosses a certain threshold, the inmate is considered at
imminent risk of danger to self or others and merits immediate referral to a mental health
professional, prior to a bed assignment.
ISCI recognizes the need to screen newly arriving inmates for serious mental illness (SMI)
and has nurses screen for SMI on a regular basis using preprinted screening forms.
However, when the screening clearly flags an inmate as requiring professional mental
health care, appropriate referrals do not consistently take place. Dr. Ruiz found several
cases in which the inmate scored well more than seven points (the cutoff over which the
screener should immediately contact a mental health professional) but no such referral was
generated, putting the inmate (and/or others with whom he might come in contact) at
significant risk of harm. One such inmate was described as angry, rambling, hostile, and
unable to sit still, yet was assigned a bed in general population without prior mental health
consultation. Another had a documented history of psychiatric illness and a recent episode
of self-injury. Not only did he not receive immediate referral to a mental health
professional as dictated by his screening results, his routine referral did not materialize until
three weeks later, a week beyond the facility’s own 14-day limit dictated by policy. A
more tragic example is a patient whose intake screening revealed five risk factors for
suicidality. Contrary to protocol, he was not immediately referred to a mental health
20

see NCCHC Guidelines for Mental Health Care in Correctional Facilities 2008; Coleman v. Wilson, 912
F. Supp. 1282, 1298 n.10 (E.D. Cal. 1995), appeal dismissed, 101 F.3d 705 (9th Cir. 1996)

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professional. Eleven days later fellow inmates found him hanging and he died shortly
afterwards.
Conclusion 1. A systematic program for screening and evaluating inmates to
identify those in need of mental health care
ISCI does not have an adequate program for screening and evaluating inmates to
identify those in need of mental health care. The program’s design is adequate,
however, it suffers from poor implementation and lack of appropriate referral
after screening. Failure to identify and treat mental disease can lead to patient
harm or death or harm to others, and violates patients’ constitutional right to
access to care for serious health conditions.
2. A treatment program that involves more than segregation and close supervision
of mentally ill inmates
Dr. Ruiz found four fundamental deficiencies in the mental health treatment program at
ISCI: (a) inadequate work up of and treatment plan for patients enrolled in the program; (b)
underuse of group and individual therapy; (c) inadequate care during acute illness; and (d)
misuse of segregation for mental health problems.
a. Inadequate work up of and treatment plan for patients enrolled in the program
ISCI staff informed Dr. Ruiz that of the several hundred inmates enrolled and being treated
in the mental health program, 144 do not have adequate psychological intake assessments
or treatment plans. This poses a fundamental challenge to providing adequate mental
health care.
b. Underuse of group and individual therapy
Group and individual therapy are important tools for treatment of mental illness. They are
markedly underutilized at ISCI both in terms of the number of groups being run and
individual sessions being offered as well as the amount of time an individual patient spends
in group therapy. Because of their non-invasive and effective nature as treatment
modalities, group and individual therapy should be the first line options for many patients
(before use of medications). Thus the number of patients in group therapy at ISCI should
be much higher than the number of patients on medication. Instead, approximately 474
patients are on psychotropic medications and 464 are in group therapy.21 These data
demonstrate the underuse of group therapy as well as suggest the overuse of medications.
The proportion of the ISCI population on psychotropic medication (about 28%) is
unexpectedly high compared to national norms for a non-specialized, male, medium
custody facility. For those patients who are placed in group treatment, they average one to
four hours per week in treatment sessions. This “dosage” is too low.22
Use of group therapy is largely limited to patients in the BHU (Unit 16). However, only a
fraction of patients with SMI – those who are most unstable – are housed in the BHU; the
rest reside in general population. Dr. Ruiz was informed that in general population select
21

These are not mutually exclusive groups, i.e. some patients are on medications and in group therapy.
For example see Coleman v. Schwarzenegger which mandates 10 hours per week of out-of-cell structured
time for mentally ill inmates.
22

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 1 of 23

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group therapy was being offered, but this was the exception, not the rule.23 For example,
she was told that groups were occasionally offered to patients with SMI who were 12-24
months from parole. No group therapy (or one-on-one therapy) is offered to patients with
SMI if they are convicted of life sentences.
c. Inadequate care during acute illness
SMI patients with the most acutely severe illnesses (other than suicidality) are placed in
the infirmary. They require the highest level of mental health care, which includes close
involvement by the psychiatrist. The following case reviewed by Dr. Ruiz illustrates how
that does not invariably occur at ISCI. A patient with Schizoaffective Disorder, bipolar
type, became nearly catatonic. He had previously been receiving a long acting
antipsychotic medication by injection every two weeks. Upon presenting with catatonia,
he was given intramuscular injections of two other medications (Cogentin and Ativan).
He has some improvement with the medications. However, the medications wore off, his
psychotic symptoms returned, and two days after receiving the two medications he was
admitted to the infirmary with a provisional diagnosis of toxic reaction to antipsychotic
medication. During our visit – 14 days after his admission to the infirmary – the patient
was still in the infirmary, had still not been seen by the psychiatrist, and had still not
received any specific treatment. In Dr. Ruiz’s opinion, his presentation was most
consistent with catatonia due to psychosis/mania (not due to a toxic medication reaction)
and would respond rapidly to higher doses of the type of drug which he received two
weeks earlier (i.e. the drug which provided a mild transient improvement until it wore
off). Whether or not this would happen, it is clear that this patient has a serious mental
illness which required the expertise of a psychiatrist. For 14 days (at least, as of the time
of our visit) the patient was not evaluated by a psychiatrist and thus was deprived access
to appropriate mental health care. He may have been suffering in a catatonic state
unnecessarily.
d. Misuse of segregation for mental health problems
There is insufficient treatment for patients in segregation with bona fide mental illness, and
misuse of segregation for behavior which is driven by mental illness. By design, inmates in
segregation with SMI (including those taking anti-psychotic medications and sedatives) or
inmates being closely observed due to suicide risk receive no group therapy and no one-onone therapy. This situation not only constitutes a denial of necessary health care, but also
violates IDOC’s own policy.24 Inmates interviewed by Dr. Ruiz said they are put in a
segregated cell for such reasons as not taking their medications. Dr. Ruiz was unable to
confirm many of these allegations due to the poor state of documentation (discussed
elsewhere). However, at least one medical record indicated a patient was placed in a
segregated cell for 15 days for disruptive behavior during class. The patient had a diagnosis
of Asperger’s Syndrome, a mental illness that is closely related to autism, and was on an
antidepressant medication. Patients with this disease have trouble relating with others, thus
it is very possible that his “misbehavior” was really a manifestation of his disease. If this
23

Dr. Ruiz was unable to confirm the provision of even these limited group therapy offerings because group
therapists do not document any treatment provided in the patient’s medical record.
24
Offenders placed in restrictive housing for greater than 30 days “shall be offered an opportunity to participate
in therapeutic groups” (IDOC Correctional Mental Health Services System, page 68).

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 2 of 23

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was what happened, he was essentially punished for being ill. Unfortunately, his medical
record does not reflect that mental health staff explored this possibility. Further, even if it
had been established that his misbehavior were not the result of his illness, patients with
Asperger’s Syndrome also suffer from anxiety and depression (as this patient did). Thus
placement in the severe environment of a segregated cell for a protracted period of time was
especially risky because it can exacerbate the anxiety and depression.
The preceding paragraph addressed the issue of using segregated housing as de facto
punishment for behaviors related to mental illness. A related, but distinct issue is
attempting to provide mental health care, but doing so via the inappropriate use of
segregated housing. Frequently, when inmates are considered to be at risk of self-harm,
they should be placed in special cells where they can be closely watched. At ISCI,
inmates at risk of self-harm are placed in segregated cells and either placed on “suicide
watch” (for inmates at high risk) or “close observation” (for inmates at medium risk).
ISCI provided Dr. Ruiz with a list of 137 individuals who were identified as having been
placed in segregated cells on “suicide watch” or “close observation” in the last quarter of
calendar year 2011. Based on Dr. Ruiz’s review of these lists, 45 of the 137 individuals
were placed in specialized segregated cells called “dry cells.” A dry cell is a cell that is
not plumbed with a faucet or toilet. At ISCI, the dry cells in the BHU (Unit 16) are
equipped with a hole in the middle of the cell covered by a grate which functions as a
toilet. Aside from that hole, the room has four bare walls, a door, and nothing else.
There are five problems with the way individuals at risk of self-harm are handled during
these acute periods. First, there is a dearth of documentation of events in the patient’s
medical record. The mere fact that the patient was suicidal and placed in a protective cell
was missing from the medical records Dr. Ruiz reviewed, as well as other information
such as the reason the individual was placed there, when the individual was placed there,
when and why the patient “promoted” from suicide watch to close observation, when and
why they were discharged, etc. Some or all of this information is apparently contained in
other prison (custody) records but is not readily available to all mental and medical
treatment staff. Thus key staff who should know about a patient’s history of suicidal
behavior do not have that information. 25 For example, a psychiatrist coming on duty a
few weeks after an individual was fully discharged from one of these events might find
no indication at all in the medical record that his/her patient had recently been acutely
suicidal. Under those circumstances, it would be impossible for the psychiatrist to safely
care for the patient. Second, the dearth of documentation in the medical record also
means that patients are experiencing changes in their clinical treatment in the absence of
medical orders. Indeed, anyone – including an custody officer – should be able to, and is
able to, place an individual in one of these protective environments emergently.
However, after that point, all decisions about protective living conditions should be made
by a licensed mental health clinician (and documented in the medical record). Dr. Ruiz
was unable to determine if this is what happens due to the lack of documentation. Third,
by practice or policy, patients intentionally are not provided group or one-on-one therapy
25

Other than the fact that individuals were on the list of suicide watches or close observations, it was even
difficult for Dr. Ruiz to determine if, in fact, these individuals had been placed in segregated cells due to an
actual suicide risk.

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when they are in segregated cells on suicide watch, a time when such therapy is of
paramount importance. Fourth, the number of individuals at ISCI on suicide watch or
close observation, and especially the number placed in dry cells, is in excess of the
number that would be expected for an institution of the size and composition of ISCI.
Due to the poor documentation we encountered, it was impossible for Dr. Ruiz to
determine if these high numbers are clinically justifiable, if they represent clinically
unnecessary overuse of these specialized cells, or if they are a reflection of gaps
elsewhere in the mental health system resulting in higher incidence of suicidality.
The fifth problem is one of the most distressing: patients with SMI spend far too much
time in dry cells. In a three month period, eight individuals spent five or more days in a
dry cell (six of these stays lasted 10 days or more, the longest of which was 16 days).
According to Dr. Ruiz, the use of these dry cells on a long-term basis can only be
described as degrading and inhumane.
The following capstone case illustrates the problem with the use of dry cells (as well as
other problems with the mental health treatment system described elsewhere). A 20 year
old male was admitted to ISCI. His intake mental health screening revealed seven
positive findings, including prior sex offense and prior history of victimization, which
should have triggered an immediate referral to a mental health professional. Instead the
screener checked the box for ‘no referral’ to mental health. Ten days later the patient was
placed in segregation and was (in this case) seen by a psychiatrist. The patient reported
symptoms of depression and ‘voices.’ The psychiatrist’s diagnosis was polysubstance
abuse. No medications were prescribed and follow-up with a mental health professional
was only recommended as needed. About six weeks later the patient was placed on close
observation in a dry cell, presumably due to some risk to the patient due to his psychotic
and/or depressive condition. His only contact during this depressed and/or psychotic
state was another mentally ill inmate-companion who was marginally trained for the task.
There was no documentation in the medical record of this placement in a dry cell on close
observation (including lack of a medical order placing him in that status). He remained
there on close observation status for 10 days during which time he had no initial mental
health assessment, no follow-up by mental health staff, and no treatment plan. At each of
his three encounters with the mental health system (at screening, in segregation, and in
close observation), the care he received was inadequate. Lapses in care at the first two
encounters likely led to his subsequent two deteriorations. All three encounters,
especially the third, reflect diminished or absent access to mental health care.
Conclusion 2. A treatment program that involves more than segregation and
close supervision of mentally ill inmates
There are significant deficiencies in the treatment program at ISCI such as inadequate
work up of and treatment plans for patients enrolled in the program, underuse of group
and individual therapy, and misuse of segregation. These deficiencies result in denial
of medically necessary care to patients with serious mental illness and are therefore
violative of patients’ constitutional right to health care.

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 4 of 23

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3. Employment of a sufficient number of trained mental health professionals
Professionals from a number of disciplines provide health care to inmates. In mental
health, these disciplines include psychiatry, psychology, mental health counseling, and
nursing, among others. With one exception (psychiatry), it is difficult to establish a
formula for calculating the proper staffing level of different correctional health care
disciplines. The best proxy measure – albeit imperfect – of the adequacy of staffing is
the effectiveness of operations that are staff-dependent. Using this proxy, based on
information I provide elsewhere in Section VI showing deficiencies in staff-dependent
activities (such as sparse provision of group therapy), there may be insufficient staffing of
non-psychiatric mental health personnel. For a variety of reasons, it is easier to directly
assess the adequacy of psychiatric staffing at ISCI. Based on this assessment, it is my
opinion that there is insufficient staffing of psychiatry services. The data supporting this
conclusion come from local and national metrics.
The local metric is the Balla record itself. When Balla I was adjudicated in 1985, the
average daily population was 923. Nine percent of the population, or about 83 inmates,
were on psychotropic medication. As a result of a finding of deliberate indifference,
psychiatric staffing was increased to 0.65 FTE. Currently the institutional count is about
1664; 28% of the population, or about 474 inmates, are on psychotropic medication, and
psychiatric staffing is 1.25 FTE. Thus the number of patients on psychotropic
medications has increased over five-fold (from 83 to 474) while psychiatric staffing has
increased less than two-fold (from 0.65 FTE to 1.25 FTE). 26 To keep pace with the
population increase, ISCI should currently have 3.7 FTE psychiatric staffing.
A useful national metric is provided by the American Psychiatric Association (APA).
APA states that for every 75-150 inmate-patients with SMI who are receiving
psychotropic medication, there should be 1.0 FTE psychiatrist or equivalent. Using this
metric, and assuming there are 474 medicated SMI patients, ISCI should have between
3.2 and 6.3 27 FTE psychiatric staffing.
Another way of looking at the adequacy of psychiatric staffing is at the level of
individual patient encounters with the psychiatrist. The ISCI psychiatrist spends an
average of ten minutes per encounter with enrolled patients and 20 to 30 minutes per
encounter with new patients. There is no time allotted for administrative duties,
comprehensive assessments, or discussions with other staff about difficult cases.
Nationally, the correctional norm for encounters with enrolled patients is about 30
minutes and for new patients is about 60 minutes. Based on these numbers, the
psychiatrist cannot be expected to have enough time to safely evaluate and treat patients.
Based on Dr. Ruiz’s review of medical records, the psychiatrist does not have enough
time to safely evaluate and treat patients.

26

The reason for tying psychiatric staffing time to psychotropic medications is that medications are
prescribed and followed by a psychiatrist, psychiatric physician assistant, or psychiatric nurse practitioner.
Other mental health professionals cannot prescribe medications.
27
The estimate of the number of medicated SMI patients (474) is likely conservative. Thus the resulting
calculation of FTE based on the APA formula (3.2 to 6.3 FTE) is also likely conservative.

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 5 of 23

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In summary, based on Balla I guidelines, ISCI should currently have 3.7 FTE
psychiatrist; based on the APA benchmark, ISCI should currently have (at least) between
3.2 and 6.3 FTE psychiatrist. ISCI currently has 1.25 FTE. Thus whether using Balla I
metrics or APA metrics, psychiatric staffing is clearly inadequate. Empiric review of the
amount of time psychiatric practitioners have to spend with their patients and evaluation
of the actual care delivered during these brief encounters confirms the staffing
inadequacy.
Conclusion 3. Employment of a sufficient number of trained mental health
professionals
There are deficiencies in the delivery of psychiatric and non-psychiatric mental
health services at ISCI. The deficiencies in non-psychiatric mental health services
may be the result of insufficient staffing, however, I cannot state this with
certainty. I can state with greater certainty that there is an insufficient number of
psychiatric practitioners at ISCI to provide the care needed for mentally ill
patients. As such, inmates at ISCI do not have sufficient access to mental health
care to satisfy constitutional requirements.
4. Maintenance of accurate, complete and confidential mental health treatment
records
Dr. Ruiz found significant problems with documentation of care provided to suicidal
patients placed in segregated/protective cells during crises, documentation of mental
health treatment plans, and documentation of care delivered in group therapy. Problems
with documentation of care provided to suicidal patients placed in segregated/protective
cells during crises was described in Section VI.2.
Generally, mental health treatment plans were inadequate. Charts contained generic
boiler-plate plans. For example, each of the cases Dr. Ruiz reviewed contained the same
first two treatment goals, “Will voice an understanding of how he can kite a clinician for
support” and “If prescribed medication, will take any medication prescribed by his
psychiatrist as indicated reporting any changes, concerns, or side effects.” In several
cases the psychiatrist had clearly decided not to prescribe the patient medication, yet the
treatment plan goal remained to discuss medication with the psychiatrist. For example,
Dr. Ruiz reviewed the record of a patient who had previously been on an anti-depressant,
but was currently off the medication. He was described as having a labile (abnormally
fluctuating) mood, being anxious, and doing sexual favors for others so that they will be
his friends. He also had a history of self-injurious behavior. Thus he had complex
mental illness and was not stable. Proper care demanded that he have a specific treatment
plan to address these needs. Instead, his treatment plan contained the same generic plans
cited above without any additional plans specific to this patient’s individual needs. His
other problems were simply not addressed. While it is not wrong for a patient’s treatment
plan to contain some generic elements, the entire plan cannot be generic; treatment plans
must be individualized. Lack of individualized planning and coordination contributes to
poor outcomes.

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 6 of 23

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Group therapy treatment is not documented in patients’ medical records. Thus any
pertinent mental health information the group therapist generates is not available to the
rest of the patient’s health care team.
Conclusion 4. Maintenance of accurate, complete and confidential mental
health treatment records
ISCI does not maintain complete – and therefore accurate – mental health
treatment records of care delivered during acute suicidal events, of treatment
plans for SMI patients, and of treatment provided during group therapy. It is
impossible to deliver constitutionally adequate care if pertinent patient
information is not recorded so that it can be shared among the care team.
5. Administration of psychotropic medication only with appropriate supervision and
periodic evaluation
I have described elsewhere the challenge faced by psychiatric prescribers due to
significant understaffing. The following example illustrates how this challenge impacts
ISCI’s ability to administer psychotropic medications with appropriate supervision and
periodic evaluation.
Dr. Ruiz learned that due to time constraints, psychiatric practitioners sometimes write
orders for psychotropic medications without face-to-face visits and without stating
definite time limits, e.g. “Risperidone 4 mg orally nightly until next visit.” Since some
patients do not get a “next visit” (i.e. a face-to-face encounter) scheduled with the
psychiatrist, a patient can continue for a long time on psychotropic medications without
examination by the psychiatric prescriber. Psychiatry cannot be safely practiced without
occasionally “laying hands” on the patient for whom medications are prescribed. The
practitioner must assure that medications are working, that their dosages are appropriate,
and that patients are not developing serious medication-related side effects. Thus
psychotropic medications are not always provided at ISCI with appropriate supervision
by a psychiatric prescriber.
Conclusion 5. Administration of psychotropic medication only with
appropriate supervision and periodic evaluation
Psychiatric prescribers cannot routinely provide adequate supervision of
medication administration without the time to conduct initial and periodic patient
evaluations. In the absence of such evaluations, patients are deprived of a
qualified medical opinion, rendering care unconstitutional.
6. A basic program to identify, treat, and supervise inmates at risk for suicide
Dr. Ruiz identified five areas of deficiency in the basic program for self-injurious
behavior and/or suicidality management. I have discussed three of these deficiencies in
depth elsewhere: (a) inadequate medical records such that relevant information about
suicidal behavior and suicide observation periods is missing from the medical record and
not routinely available to key people who need to know, e.g. the patient’s psychiatrist; (b)
lack of treatment for the most acutely ill patients at risk of suicide: those on suicide
watch; (c) placement of patients in suicide watch or close observation, sometimes in dry

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 7 of 23

cells, for extended periods of time, amounting to inhumane conditions without access to
adequate mental health care.
Two additional areas of deficiency, described below, are: (d) inadequate suicide
prevention training for staff, and (e) unsafe use of Companion Offenders during suicide
watch.
d. Inadequate suicide prevention training for staff
The suicide prevention training program addresses three constituencies: Corizon health
care staff (medical and mental health), ISCI (IDOC) mental health care staff, and custody
staff. There are deficiencies in training provided to all three.
IDOC provided documentation that Corizon conducted suicide training for its staff during
a staff meeting in December, 2011. The length of the training could not be verified.
When questioned about the training, two key front line staff could “not recall” having
been trained in suicide prevention during 2011. Assuming that some training did occur,
the intensity/quality was therefore of questionable effectiveness.
Training for ISCI mental health care staff was provided in 2011. It was provided as
“self-study” training in the form of pamphlets and take-home test; there was no video,
CD or interactive component. In Dr. Ruiz’s estimation, this training would require an
investment of less than 15-30 minutes annually of an employee’s time, which in
insufficient.
For the entire two-year period ending in December, 2011, ISCI provided a single training
session on Suicide Risk Management in April 2010 to 110 of 283 of their custody
officers. This training is inadequate both in the amount of training per officer and the
number of officers trained. In terms of the amount of training, when training was
provided, it was a one hour long presentation. In Dr. Ruiz’s estimation, this is
insufficient. By comparison, many law enforcement agencies (an environment where
suicide prevention and treatment are less germane than prison) provide one to two hours
of training per year. Mr. Lindsay Hayes, one of the nation’s foremost experts in suicide
prevention in prisons and jails, recommends eight hours of training for general duty
custody staff.
In terms of the number of officers trained, this too is problematic. Every officer should
receive the training, at a minimum, annually. Thus less than half of the custody staff
received mandated training in 2010 and none of the custody staff received mandated
training in 2011. Further, certain custody officers require more frequent training. IDOC
policy states, “Because of the high risk for suicide attempts in restrictive housing, staff
working in these units will receive supplemental training once each quarter. If a staff
member has not attended restrictive house supplemental training within the previous
quarter, they must complete it before working on the unit.” Thus, at least some officers
should have received eight training sessions (quarterly over two years) during this same
time period; none of them did.

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 8 of 23

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e. Unsafe use of Companion Offenders during suicide watch
ISCI utilizes a Companion Offender Program whereby trained inmate volunteers help
monitor patients during suicide watch or close observation. The program, as operated,
has three serious flaws. First, the program operates without adequate screening of the
participants. In contrast to the current policy and principles of safe patient care, some
applicants chosen have significant mental illness themselves. This puts the inmates they
work with at risk. The second serious flaw concerns the way in which the volunteers are
utilized. According to ISCI policy and standards of correctional care nationally,
volunteers are used “to supplement” monitoring. During a suicide watch, a patient
should be under constant, direct, in-person, visual observation by a staff member.
Instead, inmates provide this observation and officers only come by periodically to check.
In other words, inmates are used in place of professional staff rather than to supplement
them. To compound this, the officers’ periodic check is not conducted according to
policy. Officers are instructed to check on the inmate at random intervals 28 not to exceed
15 minutes. Instead, based on officer logs I reviewed, many checks are done at exactly
15 minute intervals; some checks are done at intervals longer than 15 minutes, some as
long as 25 minutes. Finally, in violation of IDOC policy 29 and minimally acceptable
medical practice, there is no medical record documentation of clinical observation during
suicide watches and close observation.
Conclusion 6. A basic program to identify, treat, and supervise inmates at
risk for suicide
There are serious flaws in the basic program to identify, treat, and supervise
inmates at risk for suicide, including: insufficient staff training, incomplete
medical record documentation, inhumane conditions of confinement, lack of
adequate mental health treatment, and use of inmates in place of staff to monitor
patients. These system flaws either harm suicidal patients or place them at
significant ongoing risk of harm and therefore violate their constitutional right of
access to health care.
7. Systems to support a constitutionally adequate mental health care delivery system
In Section V.9. of this report I addressed three ancillary systems which support health
care delivery (policies and procedures, inmate grievances, death reviews), and which are
dysfunctional at ISCI. The deficits in these three systems extend to mental health care
and thus the contents of Section V.9. are included here by reference.
A fourth support system that Dr. Ruiz found dysfunctional in the mental health arena at
ISCI is quality control (or Continuous Quality Improvement, CQI). To assure that key
elements of any health care operation are functioning as planned, there must be a system
(or systems) in place to continuously collect key pieces of data, monitor that data,
recognize deviations from acceptable levels, and make course corrections when needed.
Unfortunately, at ISCI there is no integrated CQI system monitoring the effectiveness of
the mental health treatment program overall. As with the first three support systems,
28

Random intervals make it more difficult for a patient contemplating suicide to plan how much time he
has until the next check.
29
Directive 315.02.01.001, Page 9

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 9 of 23

absence or dysfunction of the CQI system does not in and of itself mean a system of care
is constitutionally inadequate. However, CQI is so important that when it is absent or
dysfunctional, it is hard for a correctional health care system to provide constitutionally
adequate care.
The backbone of a CQI system is data collection. Prior to our visit, Dr. Ruiz identified a
number of key pieces of data she required to conduct her evaluation of mental health
services (Appendix G). Most of these pieces of data are the same basic data that would
be used in a mental health CQI program. ISCI staff do not collect and monitor any of
these important metrics (and, as shown in Table 2 of Appendix G, staff were not
equipped to generate some of these metrics, even upon our request). Appendix G is not
meant to imply lack of helpfulness on the part of ICSI staff; indeed ICSI staff members
were very cooperative and willing to try to accommodate our requests. Rather, it
demonstrates that the ISCI mental health program (including both the IDOC
psychological and the Corizon psychiatric components) does not routinely collect key
data, data that is necessary for the safe and effective management of a constitutionally
adequate mental health system.
CQI activities can and should be brought to bear on each of the six major domains of the
mental health treatment program addressed in this report. For example, in Section VI.1.,
I described the failure of intake screeners to refer newly arrived patients with SMI to
mental health professionals and the serious effect this has had on patient safety. A simple
CQI activity, commonly conducted at other prisons, is to periodically review a random
sample of intake forms to assure that nurses are filling them out completely and correctly.
ISCI does not do this. If they did, they would discover the problem and be able to correct
it.
In addition to collecting this kind of statistical information, an adequate CQI program
also examines serious or “sentinel events,” most notably deaths, in more detail. ISCI
does not do this consistently. As previously discussed in Section V.9., IDOC does not
request or receive policy-mandated death reviews from Corizon (including deaths due to
suicide or other mental illness). Mental health staff do conduct a psychological autopsy
after mental illness-related deaths. However, based on the two such autopsies reviewed
by Dr. Ruiz, these reports do not address key CQI topics such as potential errors in
patient management and areas for improvement. Mental health staff also have begun
having regular meetings over dinner at which time they discuss a variety of cases.
However, these meetings have no structure and generate no documented record or formal
outcome and action plan.
One of the two psychological autopsies Dr. Ruiz reviewed involved a patient who
recently experienced a successful suicide (also described in Section VI.1). This death
may have been preventable had there been appropriate referral to mental health staff upon
the patient’s arrival at ISCI and adequate response times to the acute event. 30 However,
30

This patient was found hanging at 19:20. He was cut down. However, there was miscommunication and
the automatic external defibrillator was not applied until approximately 19:45, more than 25 minutes after
his hanging.

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 10 of 23

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in the absence of any review, there was no mechanism to indentify and remedy these
possible errors. In other words, ISCI is challenged to learn from and remember the
mistakes of yesterday; system errors thus have a high likelihood of remaining and, when
they do, they are destined to be repeated.
Conclusion 9. Systems to support a constitutionally adequate mental health
care delivery system
The state of guiding documents, the inmate grievance system, death reviews, and
a mental health CQI system at ISCI is poor. While not in and of themselves
unconstitutional, it is important for the Court to be aware of this and its possible
contribution to other unconstitutional conditions.

Marc F. Stern, MD
Special Master
Appendix A: IDOC Response to Exit Brief
Appendix B: Compliance Plan, Presumptive, Special Diets
Appendix C: Compliance Plan, Presumptive, Medical Care
Appendix D: Compliance Plan, Presumptive, Mental Health Care
Appendix E: Photograph of sick call window
Appendix F: Isoniazide MAR
Appendix G: Mental Health Program operational data

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Appendix A
Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 11 of 23
Response to the Special Master's Preliminary Findings
AREA OF CONCERN
Sick Call
1. Quality
2. Follow up
3. Confidentiality

PLAN
1-3.Quality:
There is daily oversight of the
sick call nurse and the sick call
nurse functions by the nurse
supervisor.
The sick call nurse is trained in
the use ofthe protocols.
Nursing assessment skills are
reviewed on a routine basis by
the DON .

STATUS
1-3.There is daily supervision and
oversight by the nursing
supervisor. The nursing
supervisor conducts regular
audits to ensure that protocols
are in use for every sick call and
that performance ofthe sick call
nurse meets the standards.

COMPLETION DATE
1-3.Complete.

The sick call nurse will use
nursing protocols for every sick
call visit.
Follow up:
Follow up appointments are
made for offenders at the time
of the sick call visit. There is a
plan to audit referrals on a
routine basis to ensure the
appropriateness of the referral.

Follow up appointments are
initiated at the time of the sick
call visit and before the patient
leaves. There is a review of
cases to determine
appropriateness of referral.

To be completed by January 13,
2012.

Confidentiality:
The sick call assessments occur
within the confines of the sick
call office.

Completed.

Completed. See Attachment A
for detail.

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Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 12 of 23
AREA OF CONCERN
Urgent and Emergent Res(1onse
1. Staffing
2. Staff development
3. Equipment and supplies
4. Review and follow up

PLAN

STATUS

1-4. Health Service Administrator
(HSA) has assumed oversight of
the emergency room staff
development, competency,
assessment, and operations.

1-4.The Health Services
Administrator (HSA) now has
oversight of the Emergency
room process and staff. She is a
Certified Emergency Room
Nurse and a Certified Public
Health Nurse. She has years of
emergency room management
experience that will add to the
value of the emergency
response service functions at
ISCI.

COMPLETION DATE
1-4.Complete .

The Emergency Room facility is
scheduled to be updated with
appropriate equipment and
supplies. It will then be
organized to facilitate
emergency management.
Additionally there are plans in
place to investigate the
feasibility of connecting an EKG
to phone line for interpretation.

Currently in process .

February 27, 2012 will be the
completion date.

Specific team will be appointed
as the emergency response staff
and aSSigned on a consistent
basis. Each staff person will
complete an emergency care
curriculum and complete
monthly training.

Currently in process. The t eam
has been identified and the
curriculum is attached
(Attachment B).

March 5, 2012 the team will be
appointed and have the training
completed . This will be an
ongoing process.

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2

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 13 of 23
AREA OF CONCERN
Urgent and Emergent Res~onse
(Con't)

PLAN
The RN/HSA or designee
reviews all emergency
responses to evaluate care and
identify opportunities for
improvement. As reported
above, the RN/HSA is a Certified
Emergency Nurse and a
Certified Public Health Nurse.
An Emergency Assessment and
Report is completed for every
emergent call. Emergency
Responders complete and
maintain an ongoing Emergency
Log containing the ca se
demographics, description of
the event, the outcome, and the
follow up for each emergency
response.

STATUS
Initiated.
Emergency response sheets are
reviewed by the RN/HSA or
designee for appropriateness.

COMPLETION DATE
Current practice and this will be
ongoing with feedback to staff
as appropriate.

The ER form is faxed to the
Regional Medical Director
(RMD) daily for all ER offender
patients.

An emergency cart with storage
space for emergency supplies
and safe transport has been
purchased for the exclusive use
by the emergency response
staff.

The cart has been purchased.
The cart is due to be delivered
the week of January 16, 2012.
Once the cart arrives it will be
stocked with appropriate
emergency supplies and
equipment. The cart and its
supplies will be maintained by
the designated emergency staff.

Awaiting arrival. The cart is for
ER response only. Should arrive
the week of January 16, 2012 .

Full oxygen tanks have been
separated from used tanks.
Tanks will be marked
appropriately.

Initiated.

Completed .

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3

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 14 of 23
,-----'

AREA OF CONCERN
Urgent and Emergent Res~onse
(Con't)

PLAN
The RMD will continue to
review clinical pathways with
each provider to ensure that
there is continuity and
consistency of care, The RMD
reviews cases as needed to
ensure that appropriate
pathway was followed.

STATUS
The RMD will continue to work
with each provider to assure
that clinical pathways and
guidelines are followed and
formal training is provided
quarterly to the provider group.
Each ER report is faxed to the
RMD daily for review and
follow-up.

COMPLETION DATE
The RMD documents education,
training, and outcomes, and
evaluates provider care on an
ongoing basis, The RMD reviews
all emergency cases daily, This is
current and ongoing.

All patients returning from the
ER outside the facility return to
the infirmary for evaluation and
disposition decisions. A white
board is maintained in the
infirmary listing all offender
patients going off site so that
they can be tracked and receive
follow up.

Security staff will continue to
return all offender patients with
off site visits to the infirmary for
assessment prior to returning
them to their designated
housing. Continue to use the
white board for tracking
outgoing and returns.

There were white boards placed
in the infirmary on December
27, 2011 to track offender
patients going off site as well as
their return and follow up
status. Ongoing.

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4

-.

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 15 of 23
AREA OF CONCERN
LTC{ Long Term Care)
1. Activities of daily living
2. Hospice management

PLAN
1-2.A dietary log for each meal and
each offender patient is
maintained every day.

STATUS
1-4. Staff document dietary intake
for each meal. Trends are
reviewed and any trend s that
would indicate a compromise in
nutrition are reviewed by the
RN for care management.

COMPLETION DATE
1-2. Initiated on January 4,2012.
The documented meal intake is
maintained and reviewed daily
by the DON or RN nursing
supervisor on an ongoing basis.
Conduct care planning as
needed based on the outcomes
of the dietary monitoring to
assure proper nutrition needs
are met. Ongoing.

Medical Records
Filing current

The current policy and practice
is for offender patients in the
terminal pha se to be moved to
designated area in the infirmary
for hospice care and pain
management.

Offender patients are moved to
designated area in the infirmary
for hospice and pain care.

Nursing management staff
currently oversees hospice care
with contracted hospice
organization and site Medical
Director. Ongoing.

The nursing staff and IDOC
clinical staff meets weekly to
staff each offender patient who
is receiving hospice care to
ensure appropriate
management.

The infirmary RN staff will work
in concert with the hospice
management organization to
assure there is a current and
complete plan of care in place.

Within 1 week of the next
offender patient assigned to
hospice care, a Hospice Care
Staffing will be scheduled and
there will be a care
management plan developed.

Staff is currently in place to
ensure that filing is maintained.

Since June 2011 staff has been
in place and will continue to be
maintained.

Ongoing.

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5

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 16 of 23
AREA OF CONCERN
Pharmacy

Segregation
1. Staffing
2. Welfare checks
3. Intake assessment
4. Medication management

PLAN
The DON/nursing supervisor on
days and nursing supervisor on
eves will review Medical
Administration Records (MARs)
daily to ensure documentation
completion and accuracy.
The DON/nursing supervisor on
days and nursing supervisor on
eves will assure that missed
meds are managed
appropriately and that the
referral log is current and
complete .
1-4.An experienced segregation
staff nurse has been hired to
replace the previous
segregation nurse. This nurse
continues to have responsibility
for management ofthe care of
the offender patients in the
segregation unit.
The segregation staff nurse
provides sick call, medication
management, intake
assessments, regular welfare
checks, and patient education.
The nurse is located in Unit 8
and is accessible to conduct
daily rounds as indicated. The
welfare checks are done
routinely three times per week
per NCCHC standard P-E-09.
The offenders in the segregation
unit are out of their cells for one
hour each day for exercise and
socialization.

COMPLETION DATE
Daily oversight and feedback to
staff and other follow up as
needed.

STATUS
Medical Administration Records
(MARs) are audited on a daily
basis per unit. One audit
rotation takes one week. These
audits are conducted by RN
nursing management. RN
nursing management provides
one-on-one staff education and
counseling as needed to assure
documentation is complete and
current.

1-4.A medical room is set up in the
segregation unit for medication
management, sick call as
needed, and chart and
documentation management.

See Attachments A, B, C and D
for more detail.
Process is ongoing.

1-4. Continue daily rounds of
segregation by the DON/
HSA/nursing supervisor to
assure that expectations are
met and provide feedback to
the nurse as needed.

The medical staff is assigned
exclusively to the segregation
unit to assure that sick call is
offered daily, that medications
are in place, and that emergent
care is accessed as needed.
Additionally, the segregation
staff nurse administers daily
medications, conducts welfare
checks, assessment, and
provides patient and security
staff education as needed.

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Ongoing.

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D

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 17 of 23
AREA OF CONCERN
Grievance System
1. Monitoring
2. Tracking
3. Follow up

PLAN
1-3.An ombudsman is currently
employed and working to
enhance the previous practice
of the IDOC contract monitor in
the review, follow up, and
response to all concerns and
grievances for medical. This
includes offender patient
involvement as needed. The
concerns and grievances are
tracked, monitored, and
evaluated for trends and
patterns.
In addition to reviewing each
grievance the Health Service
Director will now be responsible
for the Level III reviews instead
of Corizon management staff.

STATUS
1-3. The ombudsman staff is in place
and the process is evolving. All
concerns and grievances are
logged and reviewed regularly
by the contract monitor and the
ombudsman to identify any
emerging trends and patterns.
In the event there is opportunity
for improvement, this staff
would involve the key staff that
would facilitate the
improvement.

COMPLETION DATE
1-3.ln place and ongoing.

The Health Service Director will
be the primary reviewer for
Level III beginning January 9,
2012.

Change made January 9, 2012
and ongoing.

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7

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 18 of 23
AREA OF CONCERN
Receiving and Diagnostic Unit
Sick Call
a. Nurse
b. Provider

PLAN
Sick call is provided daily in the
RDU by the nursing staff. The
nursing staff utilizes established
nursing protocols that are
reviewed and approved
annually by the site Medical
Director, the Director of
Nursing, and the Administrator.
The assigned Provider reviews
the completed assessments and
protocols for each offender
patient seen by the nurse.

STATUS
Open sick call in place in the
RDU 7 days per week with the
nurse.

Sick call is offered daily to the
offenders housed in unit 15, the
RDU.

Standard and current nursing
protocols are in use by the
nursing staff.

The nurse refers the offender
patient to the provider assigned
to the RDU if necessary. The
provider is available in the RDU
5 days a week for sick call.

A Provider is available for sick
call and follow up 5 days per
week.

COMPLETION DATE
In process and ongoing.

The provider reviews the
protocol for each offender
patient seen by the nurse.
There is a Provider on call 24
hours a day 7 days a week for
emergent cases.

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8

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 19 of 23
AREA OF CONCERN

Mental Health
Screening & Evaluation

PLAN

COMPLETION DATE

STATUS

There is an initial Mental Health
and Evaluation process in place
and defined in the Correctional
Mental Health Service Manual.
The Initial Screening Form is
reviewed by the primary
clinician within 24 hours. To
augment the existing process
and formalize documentation, a
Clinical Case Note will be
attached to the Initial Mental
Health Screening Form
documenting in a SOAP format
the findings ofthe clinician.

An email was sent by Clinical
Supervisor, Shell Wamble-Fisher
to all clinicians at ISCI instructing
the clinicians to include a Clinical
Case Note to document in SOAP
format any findings by the
clinician. The documentation will
include any follow up needed.

An email was sent January 11,
2012 and the practice is now in
place.

The Initial Mental Health
Screening Form is a propriety
form of Corizon. Corizon and
IDOC will work together to
update the form over the next 90
days to include a comment
section so clinicians can use the
section to document their SOAP
note in lieu of a separate Clinical
Case Note. Once the form is
updated, the clinicians will use
the comment section for
documentation.

A meeting is scheduled for
January 12, 2012 to review and
amend the Initial Mental Health
Screening Form . Training on the
uSe of the form is provided to all
new employees and bi-annually
as refresher training. Corizon Dr.
Eliason provides the training.

A meeting is scheduled and the
Initial Mental Health Screening
Form will be available by March
1,2012.

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D

9

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 20 of 23
AREA OF CONCERN
Mental Health
Groups and Non-Medical Modalities

PLAN
The need for non medical Clinical
Groups in Restrictive Housing
(Unit 8) was identified in
December 2011. The outline for
the group was developed and
approval was given to start the
groups in Restrictive Housing.
(see email attachment MH-A)

STATUS
Groups are scheduled to begin
the week of January 15, 2012 in
the Restrictive Housing Unit (Unit
8).

COMPLETION DATE
Start date week of January 15,
2012 and ongoing.

The Restrictive Housing groups
will start the week of January 15,
2012. Dr. Eliason has been
making referrals to the group
during the past few weeks. These
offenders will be included in the
group. (See Group Outline MH-B)
Currently there are five clinical
groups provided in general
population at ISCI. There are two
clinicians assigned to general
population. The number of
groups will be increased from
five groups to eight groups
during the next 90 days.

Clinicians will start a Mood
Management/Coping Skills
Group in Restrictive Housing
(Unit 8) the week of January 15,
2012. There are currently groups
in general population (Mood
Management and PTSD) More
groups(Depression, Living with
Bipolar, and Co-Occurring
Disorders) will be started during
the next 90 days.

Group therapy is the preferred
treatment modality for
individuals who are incarcerated.
One-on-one therapy is offered by
exception (See attached list of
those offenders receiving
individual therapy, MH-C).

Continue current practice with
focus on ensuring the needs of
the offenders are met.

By April 15, 2012 groups will be
increased. Ongoing.

Ongoing

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10

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D

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 21 of 23
AREA OF CONCERN
Mental Health
Tracking Information about Suicide
Watches

PLAN
The ISCI Clinical Supervisor
tracks the Daily Suicide Watches
for da ily revi ew by the ISCI
clinician and Dr. Eliason and PA
Barrett.

STATUS
Beginning January 11, 2012 the
Daily Suicide Watch Log is used
to communicate with Dr. Eliason
and PA Barrett information
about suicide watches . This
information supplements the
Suicide Risk Assessment (SRA)
located in the medical file.

COMPLETION DATE
January 11, 2012 and ongoing.

The Daily Suicide Watch Log
(see attached MH-D) is used to
review suicide watches for the
week prior. On Wednesday,
during the regularly scheduled
Mental Health Staffing, the Daily
Suicide Watch Log is reviewed
for the w eek prior to identify
trends, placement concerns,
and intervention ideas. This
information is documented in
the meeting notes.

Starting January 11, 2012 the
Daily Suicide Watch Log will be
reviewed during the already
existing Wednesday MH Staffing.
Notes will be taken at the
meeting.

January 11, 2012 and ongoing.

Once a calendar quarter
beginning in January, Dr. Eliason
and ISCI Clinical Supervisor will
review the Suicide Watch Log to
determine trends, concerns,
outcomes, length of stay in
holding cells, and interventions.

Beginning January 18, 2012 the
past quarter Suicide Watch Log
will be reviewed for trends.
Findings will be available for the
next MAC meeting.

January 18, 2012 and ongoing.

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11

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 22 of 23
AREA OF CONCERN
Mental Health
Holding Cell #1 and #2 Unit 15 & 16
- "Dry Cells"

PLAN
Unit 15 & 16 #1 and #2 Secure
Holding Cells do have an area for
elimination. There are
provisions for hand wa shing.
Sanitary Hand Towel dispensers
have been installed to simplify
access. Unit Post Orders have
been updated.
While offenders have had an
opportunity to wash their hands
before meals and after toileting;
however, the Sanitary Hand
Towels will make the practice
more practical.
Unit 15 & 16 #1 and #2 Secure
Holding Cells are used for
behavioral situations that pose a
ri sk to the safety of the staff
and/or offenders. These cells are
used only in extreme situations
for a short duration (see
attached Placement Guide MHE). If an offender needs to be
placed in a secure holding cell,
security staff will contact the
IDOC Clinical Supervisor or Chief
Psychologist for the initial
Mental Health Assessment and
conduct a telephonic follow-up
every two hours until the
offender can be moved to a less
restrictive environment.

STATUS
Sanitary Hand Towel dispensers
have been ordered and installed.

COMPLETION DATE
Completed January 11, 2012
and Ongoing.

The Unit Post Orders have been
updated and submitted for
approval. The update provides
the staff directions to offer the
sanitary towels after toileting,
before meals, and at request.
The Security Log will reflect the
action taken.

The Placement Guide was
updated and effective January 9,
2012. The Correctional Mental
Health Manual will be revised by
April 1, 2012 to reflect the
changes.

On January 12, 2012, the
Placement Guide was emailed .
The Correctional Mental Health
Manual will be updated by April
1,2012.
Ongoing.

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12

Case 1:81-cv-01165-BLW Document 822-1 Filed 03/19/12 Page 23 of 23
AREA OF CONCERN
Holding Cell #1 and #2 Unit 15 & 16
- "Dry Cells"
(Con't)

PLAN
Three additional Close
Observation Cells were identified
(Unit 16 A 26, 27, and 28). There
are five Suicide Watch Cells and
three Close Observation Cells,
providing more cells available for
mental health situations.

STATUS
These Close Observation Cells
were identified and usage
started on January 6, 2012. A
formal email was sent January 9,
2012 (see Attached).

COMPLETION DATE
January 6, 2012 and ongoing.

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13

Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 1 of 24
AREA OF CONCERN

Mental Health
1. Approximately 144 Offenders in
General Population do not have
Treatment Plans

2.

Treatment Plans are Generic

PLAN

COMPLETION DATE

STATUS

1-2.There are two clinicians
currently available to offenders
living in general population. In
November 2011 the ISCI Clinical
Supervisor did a review of the
records finding approximately
144 offenders who have Levels
of Care needing treatment
plans. The clinicians have been
trained and have already begun
a roster to track the offenders
and treatment plans (see
attached MH-F). They are
currently meeting with
offenders and developing
treatment plans.

1-2.A roster will contain the names
and IDOC numbers of offenders
with a current Level of Care. The
clinician assigned will develop a
treatment plan according to the
Mental Health System Manual.
All Treatment Plans will be
completed by April 15, 2012.

1-2.Due April 15, 2012 and ongoing.

,

Initial Treatment Plans will be
developed in RDU upon arrival.

The ISCI Clinical Supervisor met
with the RDU Clinician on
January 11, 2012 to ensure
Treatment Plans are initiated in
RDU. This is currently being
done.

Ongoing.

Treatment Plans will be
individualized and a quarterly
audit on a random sample will
provide feedback to clinicians
about the quality ofthe
Treatment Plans. This feedback
will be provided during monthly
Clinician Meetings and
documented in the meeting
notes.

The IDOC Clinical Supervisors will
conduct a quarterly audit of 8-10
percent of Treatment Plans to
gather information about the
quality of the plans, providing
feedback to the clinicians.

Due Quarterly starting January
2012.

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14

Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 2 of 24
AREA OF CONCERN
Mental Health
Suicide Risk Training and Refresher
Training

PLAN
Suicide prevention training is
completed for all new employees
and refresher training is
conducted annually thereafter
for medical, treatment, program,
education, and security staff.

STATUS
All new hires will receive Suicide
Risk Prevention Training and this
is documented. The Elevate Learning Tool is available to
provide an avenue for annual
refresher training for alllDOC
Staff.
ISCI Security Staff will participate
in Suicide Risk Refresher Training
(Policy 315) starting February 1,
2012.

Mental Health
Monitoring of Pill Call Lines

Mental Health
Companion Program

Pill call times are tracked and
these reports will be discussed
during the monthly Medical
Management Committee (MAC)
meetings.

Current practice.

Currently the tracking is in place
and the results will be reviewed
during the monthly Medical
Management Committee (MAC)
meeting starting January 2012.

Current practice.

There is now a check list to
ensure that the medical record is
reviewed prior to hiring a
companion and the process is
overseen by the Deputy Warden
of Operations or Designee
(attached MH-E).

o
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Pill call lines in the mental health
unit are tracked (see attached
MH-G) and this information is
assessed and the outcomes
reported at the monthly Medical
Management Committee (MAC)
meeting.
Security officers monitor
offenders on suicide watch per
policy 315 with irregular checks
with a frequency of no more
than 15 minutes between
checks. These checks are
documented on the Holding Cell
Contact Sheet (see attached MHH for examples for Oct, Nov and
Dec) . Offender companions
supplement but never substitute
the monitoring. Companion
checks are documented on the
Companion Log located in the
medical file. Companions are
screened and used as support for
the offender on watch .
15

COMPLETION DATE
Medical, treatment, program,
security and education currently
provide and track training. All
written tests will be stored for
future reference and tracked on
an Excel Spreadsheet updated
monthly and submitted to the
Warden by the ISCI Training
Sergeant.

.
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D

Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 3 of 24
AREA OF CONCERN
Mental Health
Offender originated Mental Health
Request

PLAN
Continue to track and monitor all
requests to be seen by the
Mental Health Provider.

STATUS
Continue to adjust daily
schedule to accommodate any
urgent or emergent cases.

COMPLETION DATE
Current practice.
Currently patients are seen
within 10 days in general
population and within 7 days in
BHU unless urgent or emergent
and those are seen within 24
hours.

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16

Case 1:81-cv-01165-BLW Appendix
DocumentB822-2 Filed 03/19/12 Page 4 of 24

DEPARTf.1ENT
OF

CORRECTIONS

FIELD·

MEMORANDUM

SECTION NUMBER:

PAGE NUi"18ER

404-02

1 of

SUBJECT:
~

.

ADOPTED:
REVISED:

Food Service ISCI
Nutritional Adequacy

References
Idaho

Depart~ent

of Corrections Administrative Policy and Procedure Manual

~

Sections

403, 404.
Standards for :Adult Correctiona'l Institutions, S'econd Editio.n; StMd,prds'2:-4238"

2-4239, 2-4243, 2-4253, 2-4254.
Procedures

1.

General Statement
All inmates will be served a nutritionally adequate diet. The Food Service Bureau
Ch·i ef shall ensure thi s nutri tional ad~quacy by prov'; di ng general di reet ion for
. foods served:·to··meet-or excee'd dletary" al'lciwances as stated in the recommended
dietary allowances, National Academy of Sciences. This general direction from the
. Food Serv:iced~~r:'eau Cbj€~f.shaJ]J,fu;lfihl-, th.e~ fbllQwi;.ng~equi rem~nts: .

A.

. B.

C.
D.

Documentati on of an.; ,a:~~ual; r.~y:i e\'j'i by'? d~etitjan Tegi.~J:eIi5~~' re~.Jg.~~ 1e"Jor reg-'
istration with the American, Oietetic::Association"'or' who -hAs" fhe 'documented
equi val ent educat ion, trai ni ng and experi ence, of all menus served to inmates
to: ensure.·compliance,;with·,nu;tritional standards. ,.:.
. ...,,',... :,;_,,'

Mana'~~~en:~t'b§

at'°ieast
vice operation.

on:~:~'~ugl'i fi ed ,f~iJ;:ti~E{staff

member of the Food Ser-

Accurate records of all menus served.
B'udgeting', purchasing, and ·ac.cQunting systems used by "the

~ood

Service Program ' ..

to include the following!

2.

1.

A food expenditure cost accounting system which \1ill identify the cost per
meal per inmate;

2.

,1I,n

3.

Purchase of supplies at wholesale prices;

4.

Regular

5.

Adequate refrigeration and storage procedures for all food items.

estimate of advance Food Servi ce requi r eiTIe rats ;

surveys

of the eating habits

of the institutional

population;

Daily standard food ration allo\'/ances for each inmate are the cornerstones of an
adequate food program. Each inmate shall be provi ded foods from a fifteen (15)
category grouping with daily allowances for each grouping. Establishment of these
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.'

Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 5 of 24

oEPARTt1ENT
OF
CORRECTIONS
'~

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SECTION NUMBER:
404-02

FI ELD

MEMORANDUM

0,

\f~~.~
~<"I::'>': t?i ...~'
~.e-:, o~

. i

ADOPTED:
SUBJECT:
REVISED:
Food Service ISCI
Nutritional Adequacy

allowances in terms of pounds per person per
normal preparation. All ration allowances are
meats and fresh produce whil e alJ canned foods
daily standard allowances for foods for inmates

1._

Food Al-lpwance
Detai 1
01

02
03
04
05
06
07
3.

Meat, Poultry,
Fish
Beef
.20
Pork
.30
Others .10
Fats
Starches
a. Mi lk
b. Cheese
Eggs
Sweets
Beverages

08
09
10
.60
.18
.70
.84
.02
.12
.30
.05

day considered waste incidents in
based on standard retail cuts for
are i ncl uded as net wei ghts. The
in the agency are:

Food Allowance
Detail

Lbs. Per Person
Per Day
,

PAGE NUi"lBER
2 of 15

11

12
13
14
15

Lbs. ,per Person
Per Day

Potatoes
Other Roots
Leafy Green &
Yellow Fresh Veg
Tomatoes
Dri ed Beans,
Peas & Nuts
Fruits
Citrus Fruits
Adjuncts, Spices
'TOTAL:

.75
.10
.65
.20
.08
.30
.10
.10
5.• 09 1bs.

I

Food Service Management
The Food Service area will be operated with at least one (1) regular staff Food
Service Manager to supervi se food preparation duri ng all operat ional hours. IN
NO CASE wi 11 it be operated with only inmate staff in attendance.

4.

Food Service Records for the Standard Ration
Records will be maintained to doculTlent information related to 'the service of the
minimum dietary requirements.

5.

A.

The Food Service office will maintain an annual budget plan by quarters for
the procurement of foods, supp1 i es, and equipment needed to provi de the daily
food allowance;

B.

An up-to-date daily record of foods served which includes allowance detail and
a compari son of the actual poundage served with the standard rat ion all owance.

Food' Service office records shall be maintained to document the following food
operations, at a minimum:
A.

Food expenditure costs which identify 'per capita costs per meal;

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 6 of 24

FIELD

MEMORANDUM.

SECTION Nut·1BER:

PAGE Nur'lBER

404-02

3 of 15
ADOPTED: -

SUBJECT:

REVISED :

Food Service ISCI
Nutritional Adequacy

B.
6.

Records indic:ating proof of effective procurement procedures which result inthe purchase of supplies at competitive wholesale prices.

Meal Service Records
Records- shall-inclLiif~~--a:t)i miflfmum;lhe following information:
A. - Number-of mealS served dafTy--to-lnin'ates' a'n(r staff;--B.

Menus for last year;

C.

Food cost per plate, month1y basis;

P•. Records of food consumption.
7.

Food Service Survey
'l
:

;,

.

'.

'
~ ;

The Food Service Bureau Chief' shall bi-anh~~lly conduct a su~vey of inmate response
to·.the-;food",Service. 'It shaJJ:~!include items regarding:
A~': Mer~~'i;:'''~'~'c
c~
....... .. -..... -.- _- ...... ..-. -- ..... --- -..! ....'

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_.or;._:·
_ '.
", .-..,; •• .:.

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Sani tat.ion

D. Special diets
8.

Program Review
The dietitian shall review the mehus of each institution •.
~t

These reviews sQall:

A.

Be held

least annuallY;

B~

Compare :the nut'ritio;n-~Y: v~iU~s' of the m~nuswit;h agency standards and ration
allowances. A I-'/ritten report to follow from dietitian;

C.

Incl ude

quarterly

reports

by

the

Food

1.

Standard r~tion c:omplia~~e;

2.

Menu plans;

3.

Survey results regarding Food Service;

Servi ce

Bureau

Chi ef

eval uating:

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 7 of 24

DEPARTt-1ENT

SECTION NUr1BER:

OF

FI ELD

CORRECTIONS

MEMORANDUM

404-02
SUBJECT:

PAGE NUii1BER
4 of 15
ADOPTED :

REVISED:

Food Service ISCI
Nutritional Adequacy

4.

Costs;

5.

Staffing patterns (inmate and civilian);

6.

Equipment needs;

7.

Special problems.

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 8 of 24

DEPARTMENT
OF
CORRECTIONS

0b

~
;-~ _",,-,,0;

(\.J 'l!;: ,: ...........,.
~"
!:!·¥~ta:·
~~~i 0,
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"ttl

.

'.oj'::

SECTION
404-02

FIELD

MEMORANDUM

{.'''pl
....
,S'~~ - ~ .~'.
~,.:"
l"e_:: o~

Definitions

NU~1BER :

PAGE NUt<IBER
5 of 15

ADOPTED:
SUBJECT:
REVISED :
Food Servi ce ISCI
Menu Planning & Meals

~:~

The following definitions shall apply:
1 •. Therapeutic Diets - Special meals or foods prescribed by a physician or dentist

as part of the patient's treatment;
2.

Religious Diets - Meal(s) and/or dietary restrictions required by a religious deweekends and holiday variations;

References
Idaho Department of Corrections Administrative Policy and Procedure Manual, Sections
403,404.
Standards for Adult Correctional Institutions, Second Edition, Standards 2-4240,
2-4241, 2-4242, 2-4249, 2-4250~ 2-4251, 2-4252
Procedures
1.

General Statement
All inmates are provided meals which are nutritionally adequate, properly prepared
and served in' pleasant surroundings in the least regimented manner possible. To
accomplish these goals, this policy outlines basic menu requirements and dining
room services mandated for the institution. These mandates require:
A.

Food Service staff prepare

advanc~

B.

Menu pians

substantially without major or

are

followed

menus;
frequent

changes.

C.All meal planning and preparation strives to the highest possible standard
relative to flavor, texture, temperature, appearance and palatability.
Therapeutic diets as prescribed by physician or dentist .are served;

E.

Religious diets as ordered by the Chaplain and approved by the Deputy Warden,
Security;

F.

Group dining rooms are available to all p·hysicallY able inmates, except for
those housed in the close custody and segregation units;

G.

All inmates 9-re provided three meals daily, including two hot meals, except
for weekends and hol i day vari at ions, or when security condit ions di ctate otherwise.

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 9 of 24

DEPARTt-1ENT
OF
CORRECTIONS

SECTION NUMBER:

FIELD
MEMORANDUM

PAGE NUNBER

404-02

6 of 15
ADOPTED :
REVISED:

SUBJECT:
Food Service ISCI
Menu Planning & Meals

H.
2.

3.

Food will never be withheld as a form of punishment.

Menu Plan - Menus shall be develIDped which consider available personnel, equipment
and the layout of the physical plant. Effective menu planning recognizes needs of
the general inmate population and specific needs of the inmate group attributable
to ag,e, physical activity, sex, medical status, etc. The Food Service· Bureau
Chief will develop an institutional menu within the following framework:
allocations~

A.

Menus shall be based upon budget

B.

Menus shall ensure that each inmate is provided access to the minimum poundage
allowance as per ration standards;

c.

Menus shall be designed to provide meals which are not only nutritionally adequate, but also a balance of color, flavor and texture which will add to meal
enjoyment.
.

Therapeutic Diets - Diet menus shall be provided to inmates:
A.

When prescri bed by competent medi cal authority and approved by the Chi ef of
Medical Services;

B.

Never as a reward;

C.

As di rected by the di etiti an or medical staff member;

D.

For a specific number of days (not to exceed thirty).
viewed "or continued upon approval of the Chief Medical

E.

As a complete meal service and not in supplement to or as a choice between
di etary meal sand regul ar meal s;
"

F.

Diet trays will be prepared under the supervision of a Food Service Supervisor
in accordance with appropriate guidelines supplied by' a dietitian and/or
competent medical authority;
".

G.

Each inmate placed on a special therapeutic diet will sign for his/her meal
tray at the time of receipt;

. H.

A staff "member will sign the appropriate fonn attesting to the inmate's receipt
of the tray and the inmate wi 11 -recei ve a copy of the form wi th the ori gi nal
copy being "retained in the Food Service office;

Diet orders may be reOffic~r;

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 10 of 24

oEPARTt'lENT

SECTION

OF
CORRECTIONS

FIELD

PAGE NUMBER

NU~lBER:

7 of 15

404-02

MEMORANDUM

SUBJECT:

ADOPT~D:

REVISED :

Food SerVice ISCI
Menu Planning & Meals

1.

4~

All therapeutic diet meals'will be eaten in the area in Pendyne set aside for
individuals requiring special diets unless the inmate is classified and/or
ho~sed in a manner req~3ri~g that he receive his meals in his housing unit.

Religious~Diets

,.

-

"

For special occasions as specifically approved in writing by the Chaplain and
Deputy Warden, Security;

B.

To utilize regular menu items unless specifically approved by the Chaplain and
Deputy ~Jarden, Security. These menu items shall not exceed the quantity and/
or quality provided to the general population;

C~

Spectal.relig;·ous dl'et !rays'will be prepared under the supervlslon 'ofa Food
Seryi C(O! Supe rvi sor i naccordance with appropri ate gui del i nes supp 1i ed by the
ISCI Chaplain;

D.

Eachinmate,.:requicr:,lng'C'cf'religious 'diet 'will present his/her memo and sign for
his/her meal. tray at the time of receipt;
;'~~2n
.' :" :.~ ~:,:.r t'1 t)(:.'C :.<f C c:<~:e t!::;: f. .;~~';(i l'C ,:;
::";~.i L r: _ ~, ,"" ,
r: r:-~~ :;:',~) ....~~ ... -i~~'! :-: \' . ~.: ,"
........

E.

Ji.:'stiaff:member"'will
ceipt of the tray.

'l;:'.~.,~ .. :'

F.

':.:;

r.~

sign the appropriate form attesting to the inmate's re-

('\:~Vf~(d~

All religious diet meals will be eaten in the area in Pendyne set aside for
individuals requiring special. diets unless the inmate is classified and/or
housed ina manner requi ri ng that he recei ve hi smeal s . in hi s housi ng unit.

Staff Dining - Staff meals shall always be prepared and served in the same manner
and
quantity as those '
served
to inmates.
and of the. same quality
.:...,
..- '.
..
.
.

6.

.-

.

A.

!-:

5.

- Religious diets are served:

~

Food Preparation - All meal s shall be designed to provide inm,ates with the best
possible:meals, consistent with the budget plan and daily ration allowances. Food
preparation shall:
.
A.

Utilize a stand~rd recipe system available to all Food Service staff and in-'
rnatesresponsible for the preparation of meals ~sing a standard recipe system

to:' ", . ..., "

. - ' .

.

l.

Standardi ze cos.ts;

2.

Enhance and rese rve fo6d fl avors;

3.

Improve appearance;

4.

Provide optimum

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 11 of 24

DEPARTr-1ENT
OF
CORRECTIONS

FIELD

MEMORANDUM

SECTION NUMBER:

PAGE NUi<lBER

404-02

8 of 15

ADOPTED:
REVISED:

SUBJECT:
Menu Planning

7.

& Meals

B.

Provide maximum utilization of the equipment available to enable service of
high quality products.

c.

Be

in

compliance with

the

safety

and

sanitary conditions

of

the

State.

Meal Servi:ce - The manner in which mools are presented influences the entire atmosphere of the institution si nce meal s assume a magnifi ed importance in the dai 1y
routi ne of the inmate. The foll owi ng criteri a shall estab li sh mi nimum standards
for the institution:
A.

All inmates shall be provided with three meals Honday through Friday except
for holiday variations or when security conditions dictate other arrangements;

B.

At 1east two meal s, Monday through Friday, shall be served hot, except when
security conditions dictate other arrangements.

c.

Holiday and weekend schedules may be developed to provide for a more variable
meal schedule to coincide with visiting activities, recreational programming
or similar functions. Only two meals will be served on holidays and weekends.

D.

Dining rooms shall be operated to reduce regimentation as much as possible;

E.

No restrictions regardi ng normal conversation shall be imposed;

F.

All inmates in the general
utensils.

G.

Food or Meals shall never be withheld as a punishment;

H.

MeaJs served to inmates in segregation. shall
meal served to the ge~eral population;

I.

All foods should .be served at the appropriate temperature to maintain quality,
taste appeal and texture.

population will

be provided appropriate eating

be representative of the same

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 12 of 24

OEPARH-1ENT

OF

FIELD

CORRECTIONS
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PAGE NUi'lBER
gof 15

SECTION NUMBER:
404-02

MEMORANDUM

SUBJECT:
Food Servi ce ISCI
Safety & Sanitat i on

....

~~~I
-l~e~. oi'''

ADOPTED:
REVISED:

-

-"

..

'

..

.. .

--

. .. ."
"

-~.'"

Outside Source Inspection - Inspections by a person or persons not regul arly employed
by the i nstitut ion. State empl oyeesfrom·other agenci es, representat i ves of federal
agencies or independent qualified contractors shall be considered outside sources.
~.

References
Idaho Department of Corrections Administrative Policy and Procedure Manual, Sections
306, 404, .506.

Standards for Adult Correcti onal Instituti ons, Second Edi ti on; Standards 2-4244,
2-4245, 2-4246, 2-4247, 2-4248.
. ,",-

:;J ,.

Procedures
1.

General Statement

.. '.:' :

.... -

'.~

,.

...

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. ".-

-

..

-: .

The facil ity··-.shall.:operate . a; Jood- s.er~ice'pro·gram \'Ihich will; ensure the. highest
possible level of' safety and sanitary practices. Federal and State occupational '$Q.fety'-and health codessnall.· serve as standa.rd· requi rements for--all food service
programs. At a minimum, this policy requires the institution to provide the fol-

lowi ng :.

.

.,

".~

.-." .'- .-,

. ,~- -'

.": . \' ". - " ;", -

A.A physical examination by qualified medical staff members to ensure that all
employees and inmate workers in the food service area are free from transmi ssible disease. This examination shall be completed prior to job entry.~

B.

Food handlers shall be required to comply with standard personal hygiene requi rements. These requi rements shall i ncl ude:
1.

Use of clean clothing, hairnets, caps;

2. _J1aintenance of clean hands and fingernails by washing hands after using
toilet facilities;
3.

c.

Freedom from open or infected wounds.

The i nstituti on shall mai ntai n sanitary, temperature contro 11 ed storage facilities. These controls shall provide regulation to comply with the following
temperature ranges:

1.

Dry shelf storage ••••••••••• 45 to 85 degrees Fahrenheit;

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 13 of 24

DEPARHiENT
OF
CORRECTIONS
~
'<-."" ~., ""«. -

FIELD

rf\ MEMORANDUM
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2.

-l~~ ~_ -o~

SUBJECT:
Food'Service 1SCI
Safety & Sanitation

PAGE NUi'"'lBER
10 of 15
ADOPTED :
REVISED :

2.

Refrigerated areas •••••••••• 35 to 40 degrees Fahrenheit;

3.

Frozen food areas •••••• ~_.~. 0 degrees Fahrenheit or below.

D.

Toilet shall be located in close proximity to all food preparation and serving
areas· 'and mai ntai ned in good worki ng ordef1>'.

E.

The institution will regularly inspect the food preparation and service areas to
ensure compliance with appropriate health and safety rules.

F.

Effi ci ent safety and sanitary operations of a food service department are extremely complex. Therefore, this section sets forth basic requi rements which
are mandatory.

Physical examinations - Food Service inmate and staff employees shall:
A.

Receive pre-entry on duty physical examinations by a member of the medical
staff to:
1.

Provide protection to the employee by locating restrictions of duty as-signments;
.

2.

Prevent spread of communicable disease to diners.

B.

Be exami ned regul arly (at least biannually) by an appropriate health authori ty
to ensure continued compl i ance with worker health safety standards.

C.

Comply with all health related regulations required by an appropriate author--.
ity. These rules include:

D.
3.

SECTION NUMBER:
404-02

1.

Adequate personal hygiene;

2.

Compliance with grooming rules regarding unifonns, hair care, use of caps
or hairnets and aprons;

Be provided with clean clothing.

Physical Plant
A.

Food service facilities are important ingredients of a safe and sanitary pro. gram. Facilities shall minimally be designed to comply with National and
State safety codes.

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 14 of 24

DEPARnlENT
OF
CORRECTIONS
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SECTION NUi'1BER:

FI ElD

MEMOR·AND.UM

SUB.JECT:

2.
. 3.

".

ADOPTED:
REVISED:

Food Service ISCI
Safety & Sanitation

Be designed to enable 'efficient cleaning;
Be operated and maintained in accOiMhce with the manufacturer's instruc-

~1o~~;

~

Be

cleaned. after each

thoroughly

use

and/or

on

a

regul ar

schedul e.

Minimum Facility Reguirements

1.

Provide toilet and wash basins available to all

2.

Provide fi;,e safety.protection ancl avenues for ex.it if), c.aseof emergencies;

3 •. Provide for adequate. storage areas., with

Food Service workers;

appropri~te temp.~~!1turecontrol ~:'
0"

4.

- .. -".

Eguipment Sanitati on- Food Service equipment and areas shall:

1.

C.

11 of 15

404-02

..t.;.; ~-!-? v
~~:::.o~~

B.

PAGE NUrlBER

. . . . .:

Safety and Sanitationlnspections - Inspections of the food service area are vital
to ensure regular compliance with appropriate health and safety rules. The facility shall make the following inspections at' a minimum:
A.

Weekly~s~,fety a,nd\.~aq1tp..~5~n,-jp?pe,~ti9[ls.;.~9n,d.uct~d.:"Ql the Food Servi.ce Bureau

Chief

inCl~ding:

....,..

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~

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.,

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1. " Inspetfion""of a'; iarea's of the department including the storage areas and
toilet facilities;

B.

5.

2.

Examine the daily inspection fonns for the previous week;

3.

Visit the department on a regular, pre-announced schedule;

4.

Prepare a written report of sanitary conditions and safety practices observed.

Outside source inspections shall be conducted at least quarterly.

Training Related to Safety and Sanitation - Training for Food Service employees in
the areas of safety and sanitation shall be conducted on a regul ar basi s and records kept regarding course content and participation. At a minimum, both inmates
and civilian employees sh~ll be trained regularly in the following areas:
Department fire plan;

B.

First Aid procedures;

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 15 of 24

oEPARTt,1ENT

SECTION Nut·1BER:

OF
CORRECTIONS
~
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,,'

FI ELD

404-02

MEMORANDUM

SUBJECT:

~

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1"/: .'. oi:
~

C.

Food Serv ice 1SC1
Safety & Sanitation

PAGE

NU~lBER

12 of 15

ADOPTED:
REVISED:

Use of safety devices for equipment in the department;

D. Use and storage of hazardous tools;
!~.

E.

Use of .fire extinguishers;

F. Accident prevention techniques regarding scalds, falls, burns, and related
injuries.

----:----

G.

Proper storage techniques for food service areas;

H.

Proper report procedures for accident and/or hazardous conditions.

--------

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 16 of 24

DEPARH<1ENT
OF
CORRECTIONS

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FIELD

"'"<

MEMORANDUM

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NU~lBER

13 of 15

404-02

~!
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.

PAGE

SECTION NUt·1BER:

... .

--~~.~ -.~

.

"

.-

.. -

SUBJECT:
ADOPTED:
Food Service ISCI
REVISED;
Control of Tools, Equipment
and Hazardous Materi al s
........ -... ..,. -"'-.",

,',

References
Idaho Department of Corrections Administrative Policy and Procedure Manual, Sections

404, 509.
Standards for Adult Correctional Institutions, Second Edition; Standard 2-4197.
Procedures

1.

General Statement
The Food Service Bureau Chi ef, under the general direction of the Deputy Warden,
Security, shall be responsible for enforcing the tool control pol icies for the
Food Service Department.
Thi s responsibil ity shall incl ude:
Auditi n9 of tool
inventories, marking of tools, location of tool storage, the security of tools and
overall tool accountabil ity and use. The Food Service Bureau Chi ef may del egate
this responsibil ity as he/she deems appropriate.

2.

Supervision of Tools
Unl ess under direct and constant superv1 s10n, inmates shall not use C1 ass K Tool s.
All tools and supplies stored in a Food Service area shall be kept iii a secure,
locked location, when not in use.

3.

Quota of Tool s
The Fooet Service Bureau Chief shall establ ish a tool quota ·for the Food Service.
Food Service Managers shall maintain and account for all tool sin their areas •. Employees shall maintain only required toois. If any tool is determined to be in
excess of the daily needs, it will be transferred to the Food Service Bureau Chief
for his disposition.

4.

Receipt of Tools
All tools received from ariy source by the Food Service Bureau Chief will be
for inventory prior to issue. No tool shall be procured or del ivered to.
Service area wi thout the approval of the Food Service Bureau Chi ef who wi 11
that it has been properly logged in, marked and assi gned to an appropri ate
tory.
.

5.

marked
a Food
assure
i nven-

Tool Inventory Lists
A.

The Food Service Bureau Chi ef shall maintain a master inventory 1 i st of all
tools and their assignment location.

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 17 of 24

':'"1JEPARTr·1ENT
OF
CORRfC-T-1ONS

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SECTION

FI ELD

MEMORANDUM

O"<

-

.•.. "::.'=.

-

NU~1BER :

PAGE NUi'IBER

404-02

14 of 15

ADOPTED:
SUBJECT:
Food Service 1SC1
REVISED;
Control of Tool s, Equi pment
and Hazardous Materi al s

-

B. An inventory list of tools will be prepared for each work location as to which
----tt:-eool s are stored where and/or used. These inventories shall be current and
_... _:::~:a~i1y_a~ailable for daily inventory and accountability.
6.

Tool Inventory Control

:-A: ':A -cfaily
~_

c ','

~~

check of tool s will be made by the area supervisor of his/her tool

,~inventory.

All

Class K tools, i.e., knives (except table knives), cleavers, icepicks,
meat saws, etc., shall be stored in a steel knife and tool
box equiped with a secure locking device. This box will be located in the
food supervi sor ' s office when in use, in the Food Service area, and stored at
~:::IS~lcontrol when not in use.

~-knHe-sharpeners,

C. ~Ortly TSClemployees shall have access to this box. At time of issue, em.' -' ployees .shall record the number of the kni fe or other item, time of issue,
-the'riame and number of the inmate it is issued to (by use of inmate ID card)
.. and the name of the issuing employee. Any item issued will be returned to the
-'---b-cX--as soon--as the work is compl eted, with time of return recorded and initialed by the receiving employee.

'''''':H:''~~E;t~a rr;-~at:saw blades, knives, etc., shall be stored in secured storage elsewhere withi'n. the institution and issued as required.

7.

.

E.

Any tool noted as lost shall be reported immediately to the Food Service Bureau Chi ef and the securi ty shi ft supervi sor and then by written report, as
soon as possible, to the Food Service Bureau Chief and the Deputy Warden, Security. This report shall identify the missing tooHs) and the circumstances
surrounding the absence. This report shall be maintained until the tool is
---found or, after three months, removed from the inventory.

F~

When a Class K too1(s) is lost or misplaced, any inmate(s) who had access to
the tooHs) will be held at that location until a thorough search has been
c.ompleted.

Control of Fl ammab 1e, Hazardous, and Poi sonous Materi al sand Chemi Cill s
A.

The propane powered steam cleaner will be stored in a secured area unless in
use in a Food Service area. When, to facilitate its use, it must be left in
a Food Service area during non-operational periods, the tank shall be removed
-~nd stored at ISCI control.
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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 18 of 24
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foxicor caustic chemicals used in cleaning will be brought to a Food Service
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Appendix
C Filed 03/19/12 Page 19 of 24
Case 1:81-cv-01165-BLW Document
822-2

)

Response to the Ryan Decision #3
I.

Page 1

In accordance with American Correctional Association Standards
2-4276, 2-4279, and American Medical Association Standards 134,
151, 154, the Idaho Department of Corrections shall provide onsite 24-hour health and emergency care for the inmate population.
See Idaho Department of Corrections Policy and Procedure Manual,
Section III, page 20. (see attached)
An on-site Correctional Medical Specialist shall be present 24
hours a day, seven (7) days a week. In additi on to thi s, he/she
shall be available for the Psychological Unit 1 facility 24 hours
a day, seven (7) days a week for their medical coverage. (See
Correctional Medical Specialist job description, attached.)
On-call coverage by a physician shall be 24-hour and shall include a full time medical doctor or equivalent and/or his designate.
The Department of Corrections shall have in its employ two (2)
additional part-time medical doctors, who will also be included in
an Emergency Call-Out Roster. (See attached Form R-1)
This roster
shall be published monthly and shall be made available to the medical staff and security chief and lieutenants for reference.

)

At present the medi cal staff pub 1i shes a 24-Hour On-Call Roster
which includes off-duty Correctional Clinical Specialists. (The
Physician's Assistants and Nurse Practitioners fall under the heading of Correctional Clinical Specialist.) The present On-Call
Roster also includes a rotation of Correctional Medical Specialists,
(CMS's) to be notified in medical emergencies at the Institution.
(See Form R-2, attached, and CMS Job Description, attached.)
Form R-3 exempl i fies a revi sed 24-Hour Oo-Call Roster For Correctional Clinical Specialists and Correctional Medical Specialists.
(See attached) This shall be issued to all Program Managers and
Shift Lieutenants.
Fonn R-4 exempl ifies a 24-Hour On-Call Roster for dental coverage.
The full time dentist or his/her designate shall be a~ailable for
any "dental emergency".

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 20 of 24

Response to the Ryan Decision #3

II.

Page 2

In accordance with the recent decision by Federal Judge Ryan, the
following proposal for installation of first aid boxes in the housing units and othel" locations in the Institution and Community Work
Centers is submitted.
Boxes to be located in:
Unit 7
Unit 8
Uni t 9
Uni t 10
Unit 11
A Block
Pendyne Hall
Correctional Industries
Motor Pool
Warehouse
Auto Body Shop

Gymnasi urn
Administration Building
Uni t 2!
Uni t 3' RDU
Unit 4
Ryder's Hall
MCF Control
Building 25
Sl aughterhouse
Dairy
CWC-Nampa and Boise

The first aid boxes shall be permanently mounted to the wall in
the control office in each of the housing units. The other boxes
shall also be mounted to walls located in a supervisor's office or
in an area that is readily accessible and visable. The boxes shall
be locked with a padlock, and the keys shall be on a key ring kept
by the officer or supervisor on duty. There shall be also a seal
affixed to the box to insure that the boxes are not pilfered. An
inventory sheet shall be rna i ntai ned in each box, and inventor; es
shall be conducted weekly. Boxes shall be restocked the same day
that the supplies are used accordingly.
The responsibility for conducting inventories and restocking the
first aid boxes shall be part of the duties of the CMS on the graveyard shi ft.
The cost of the first aid boxes will be $29.24 each for a total
of $731.00.
Attached are floor plans of the specific buildings and areas where
the boxes will be mounted and available.

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 21 of 24

Response to the Ryan Decision #3

(

Page 3

III.A series of changes will be instituted in the Medical Request
system. This shall be done to eliminate the suggested impeded
access. (See attached pol icy)
Medical Request Form boxes,are being constructed at the Correctional Industries. A specific number will be fastened toa wall or
support beam in each cell house unit. The boxes shall be placed
as to allow easy access of any inmate within that housing unit or
ti er.
A. As described later in this report those individuals who do
not have access to movement shall be offered the opportunity
for one-on-one contact with a designated member of the medic a1 sta ff da il y •
l

Also attached is a schematic of the Medical Request Form boxes
to be used for the Medical Request system, and a floor plan of each
housing unit which depicts the placement of each box. These boxes
will cost $20.88 each, with the total being $417.60 for the entire
number of boxes ordered. The locks cost $8.95 each, which would
add $179.00 to the total amount. (see Capital Outlay Proposal)

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 22 of 24

Response to Ryan Decision #3
IV.

Page 4

It is the responsibility of the Medical Services Manager or his
designee to supply the Infirmary and the Medical Services Program
with a procedure manual for health care regimens.
The following is a standardized format of care instructio~ which
will be made available for our staff to review and follow concerning
in-house infirmary care. Also attached is a copy of the Protocols
Manual available for medical staff review concerning specific complaints an inmate might have or present clinically .

.~'

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 23 of 24

Response to Ryan Decision #3

v.

Page 5

Listed on the attached pages of Policy and Procedure are the
Security procedures for patients being transferred to a community
hospital. Included in this Policy and Procedure are the security
procedures to be used while inmates are under the care of the
communi ty ii nsti tutions.

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Case 1:81-cv-01165-BLW Document 822-2 Filed 03/19/12 Page 24 of 24

Response to Ryan Decision #3

Page 6

YI. The following is the staffing pattern that presently exists for the
Idaho Department of Corrections main-site infinnary. (See the
attached staffing flow chart and seven-day staffing pattern.)
A.

Physicians
1. We have medical doctor coverage a total of 16 hours per
\~eek.
A contract physician is on-site Monday morning for
four (4) hours and Thursday morning for four (4) hours.
One of these physi cl ans is ass i gned the responsibil ity of
medical director every two (2) years. The physicianns
four (4) hour coverage consists of:

a. Inpa ti ent (i nfi rmary) care and eval uati on
b. Medical Records review of all medical charts with
new entries
c. Pharmacy list and order review
d. Outpatient consultations
e. Coordinate with the Medical Services Manager old and
new business
f. Revi ew of surgi cal procedures ordered by the contract
special consultant physicians
g. Assist ·in surgical procedures as t~equested by the Correctional Clinical Specialists on-site or the consultant
physicians in the community
2. Included in the 16 hours a week is psychiatric coverage of
four (4i hours on !'1onday and four (4) hours on Thursday;
four hours of service provided by each of the two contract
psychiatrists. This is discussed further in the psychiatric
care program with Order #5.
B.

Dentists
1. Dental coverage is presently four (4) days a week. The dentist implements and conducts all forms of the dental health
program.

a. Presently the dent·ist has a part-time dental assistant
working with him. (See Job Description) He/she is
presently under contract services and is not a fulltime state emp·' oyee.
b. Twoodays a \-Ieek there is an on-site hygienist for ora"/
hygiene programs. (See Job Description) Again, he/she
is not a fun-time employee but follows our code guide1 i nes.
C.

Physici an Extenders
1. The main portion of the present medical coverage is by the

physician extenders. These members of the staff are graduates
of accredited Physicianns Assistant or Nurse Practitioner
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I

Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 1 of 23

Response to Ryan Decision #3

Page 7

programs, certified by the Idaho Board of Medicine and the
Idaho Board of Nursing to practice under the guideline set
up by these organizations. These staff members have passed
a national certification examination and are obligated to
be recertified every six (6) years. To maintain this certification, a minimum of 100 credit hours in continuing
medical education every two (2) years is required.
D.

Support Staff
1. tl\edical records in the infirmary are kept by the full-time

secretary/records manager and a part-time clerk. At present,
the part-time records cl erk is working aimost full-time to
try to maintain the records.
2. The remaining members of the staff are the ~1ed;cal Services
Manager, two (2) Correctional Medical Supervisors, one (1)
Registered Medical Technologist, and seven (7) Correctional
~1edical Specialists. Following are the employees' descriptions of their personal job duties as vJell a-s the State
Personnel Coded Job Descriptions.

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 2 of 23

Response to Ryan Decision #3

Page 8

VII. Addition staff needed to comply with standards and the Federal
Court Order are as follo\'Js.
A. One full time medical doctor or the equivalent
(See attached job description)
1. In addition to this, the Department win continue to employ

two contract physicians for coverage during leave and sick
time that might occur with the full time medical doctor.
B. One full time dentist or the equivalent. This will increase
our capabilities and expand the dental program to provide commitment examinations and followup for all inmates.
C. The Medical Service shall increase its dental assistant coverage
to full time. The plan is to employ a full time person for the
fundamental assistant and clerical duties. (See attached job
descri pti on)
D. Although a hygienist has not been recommended, it is the feeling
of the Medical Services Manager that such a position is greatly
needed. The hygienist could identify and evaluate the dental
needs of inmates that would normally require the time of a denti st. It is the bel i ef of the Manager and the Admi ni strati on
that all new commitments need a full dental examination. With
the addition of a hygienist to the dental program, these necessary examinations could be provided.
E. The Deparbnent of Corrections shall have a full time pharmacist
or the equivalent. Th-is will greatly improve our credibility
with the Idaho Board of Pharmacy. In additi on, accou.ntabil i ty
wi th the use of a computer system is bei ng proposed;- not to
mention the savings that we will realize by the practice of
stocking our own medications. Note: stock medication$ will not
be stored on the mainsite ground within the fen~es.
1. A secure pharmacy will have to be constructed in an area
designated in the Infirmary Building. (See description in

Order #4)
F. The Deparbnent of Corrections is going to hire qn additional
1.5 Medical Records Clerk. This will greatly speed up the addition of documents to the medical charts.
G. There will be a full time therapeutic dietician added to the
medical staff for improvement in meeting the special dietary
needs of concerned inmates. (See Dietary Order #1) This
individual wi 11 be assigned to the Infi rmary and wi 11 work under the auspices of the medical doctor and the Medical Services
t·1anager.
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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 3 of 23

Page 9

Response to Ryan Decision #3

H. There will be an additional three (3) Correctional Medical Speccialists added to the mainsite staff to fulfil the needed 24 hour
coverage recommendation. Additionally) there will 5.2 Medical
Special ists hired to give the Unit 1) Idaho Security Medical Facility and the Minimum Custody Facility 24-hour coverage. This
will result in a minimum of one and possibly two medical staff
members on duty for the evening and graveyard shifts.

VIII. The following list is additional monies by position that the Depart~
ment of Corrections has requested to fulfil the order for more onsite licensed staff and 24-hour coverage. This is proposed as a
medical package.
A. Med; cal Doctor ••.....•.••• ~ ••.•..•••..•••. $ 62.).600.00
B. Dentist ................................... .

C.
D.
E.
F.

PhD Psychologist ...•••.••••••••.•.•..•••••
Social Worker •••..••••.•.•..•••....•••••••
Three Psychologists @ $29.900 each •.•.••••
Correctional Medical Specialists @ $19~300

G. Pharmaci st ........................................... "" .............. .

H. Dental Assistant ...••••....••....•••••••••

62.,600.00
39,500.00
28).600.00
89 •. 700.00
19).300.00
30).000.00
18.300.00
26,.200.00
1.0.171.00

I. Dietician .................................................... .
J. One Records C1 erk @ $10.,.171. ............. .
To ta 1 ............................................................. $ 359.,929.00

All of the above requested salaries are comparable to the surroundi ng area except one. and that is the proposed sal ary for a medical
doctor. I believe this salary is somewhat low and should be approximately $70,000.00.
Additionally~ Operating Expenses of $46,100.00 have been requested to
cOver Travel~ Training, Wearing Apparel~ Office Supplies, Dental Suppl ies~. and Repairs and Maintenance. Not requested but greatly needed
is an allocation for Capital Outlay. This would include equipment
and furnishings for a medical doctorls office~ additional filing cabinets for a filing system which is already very full.~ and added
equipment to enable the laboratory to become more self-sufficient.
An estimated figure would be $50~000. This would breakdown as follows:

1. Out-of-State Travel
Additional $
2. In-State Travel
..
3. Printing
4. Subsef; pt1 ons
5. titiployee Training
.
6. Med1cal txpenses Needed
(aut not included in reguest)
.
1. Professional Servi ces
8. Housekeeping
9. Medi ca 1 Supplies
.1 O. Offi ce Suppl i es
ll. Repai rs & t~aintenance Equiprnt.

7).000.00
2,.000.00
500.00
100.00
1,100.00
250~.000. 00

II

II

II

4).500.00
1.).000.00
1 ).000. 00
2).000.00
2,.000.00

II

II

II

II

$

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===-==

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I

Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 4 of 23

Response to Ryan Decision #3

Page 10

The preceding total of $46.200.00 excludes the needed $250.000.00
for Major Medical costs. The hospital section continually ends up
in the red in this Major Medical category. The specifics of this
category is unforseen medical emergencies and necessary surgeries
which are very costly.
Following is a breakdown of needed Capital Outlay:
1. SMAC Blood Analyzer ....••......•••.•....••.•••..• $ 15,000.00.

•

2. AMES Flurostat for Dilantin levels, Theo
1 evel s, and Phenobarbital 1evel s ................ .

5,000.00

3. Glucometer to analyze blood glucose ••••.••••••••.

1,000.00

4. First Aid boxes for emergencies in units •••••..•.

750.00

5. fYledical Request boxes .......................... ..
(locks for boxes)

417.60
179.00

6. Office furnishings for M.D.~s office including:
'cabinets (nurses). exam table. desk, chairs,
office medical equipment. head lamp. instruments.

20.000.00

7. Office furnishings for dietician.................

2,000.00

8. Medical Equipment to properly supply the medical
staff for examinations .......................... .

2.500.00

9. Needed furnishings for physical examination
ro om i n Un i t 4" ................................ '" ........

0

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2,000.00

10. Needed furnishings for Med Room in Satellite
Fac i 1 i ty ......... "......................................

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...................... 0

11. Added medical fil i n9 system......................

2,000.00
1.500.00
$52. 346. O(J

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' J 03/19/12
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Case 1:81-cv-01165-BLW Document
822-3'I Filed
Page 5';, of 23
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Response to Ryan Deci si on #3'

Page 11

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IX. The atta~hed information is submitted as assigned regarding'Goals
#3 and #5 of the mission answering Order #3!of Judge Ryar)'s decision.
The hourly requirements listed are mandat~d:by the appropriate licensure boards for' each position and' by: ,the Department of Corr~ctions
training policies_:
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The ratio, of career-oriented training and Departmental trail')ing is
7~%/25% respectively,: as suggestedlby ~he Me,~ical Ser,vices Manager.
Training for Continuing Medical Education wa$'bu~getep as being; held
locally as much as possible, t~ere~y:k~~pin~"traye1 at a minimum. ,
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,Training Schedules from the Dep~rt~ent O'fijCor;-rectiqns Traini,ng Academy are attached. They exempllfy New, Employee and Current Staff i
Medical Training Regimens that we will follow to 'keep: our ellJployees
up-to-date on Emergency Treatment.,: Following that'isour, own schedule of In~ervice Training.
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I

!' 23
CaseResponse
1:81-cv-01165-BLW
:, Page 12
to Ryan DeciDocument
si on #3 822-3 Filed 03/19/12 Page 6 of

X.

It will be the responsibility of the Medical Services Manager to implement hiring medical staff to fill the needed positions. This can
be accomplished by an immediate temporary hire basis, as soon as the
budgetary allowances are made available, and a directive from the present Administration is presented. If enough personnel cannot be found,
to fulfill this program, an advertising circumstance occurs, and the
routine recruitment plan will have to be.followed.
Recruitment of the required additional staff for the Medical Services will be as follows:
1. Request and review appl ications of ,any individual s on the

hiring register maintained by the Personnel Department
2. Requi sition of announcements for the Perso'nnel Commission on
applicable positions
3. Formulate and run public service announcement$ on radio and
television
4. Contact nursing schools on

(

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availabl~ ne~

job positions in Idaho

5. Announce and advertise in 'at least two local and international

medical journals
6. Write and run advertisements in local and out-af-town newspapers

7. Notify the Idaho Board of Medicineiand the Idaho Board of Nursing announcing new positions available
XI. The medical staff, ~edical Services Manager~ and contract physicians
for the Department of Corrections are pr~sently working on a plan to
use the Family Practice Residency Progr~~ tflrqughthe University of
Washington Medical School for M.D. coverag~ at ~he Institution.
There is a total of 18 medical doctors rQ~6ttri9'throU~h·this residency
program. At present, Dr. John Mohr is fqn!1uhtinga coverage program
that' woul d enabl e the on-siteinfi rmary 't9 MVfJ th~'~quiv~l ent of a
full-time physician. With the help of our two (4) p~rt-time contract
physicians, I believe fulltime coverage is within our grasp.
,

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Note: T~ese resi~ents a:e 1 icensed. M.D, 'jsanq ~re active in a th:eeyear Famlly PractlceResldency~ ThlS r€$ults in a turn.-over of S10
(6) new M.D. I s to the program each year~ " The other 12 physicians in"
volved will have one or two y~?rs of exp.~ri.~Dg~,.~i,th ~~Lfl iente1e!
so that we would have to orient only six indivlauals 'ln one year s
time.
Additionally, arrangements are being made to employ a Dr. Guarino, who
is presently on the staff at the Veterans Hospital. We would use him
on a part-time (20 hours a week) basis, if only a part-time coverage
situation is achieved through the Resident Program above.

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Case Response
1:81-cv-01165-BLW
Document
to Ryan Decision
#3 822-3 Filed 03/19/12 Page 7 of 23 . Page 13

Utilization of the additional proposed support staff (CMS) will be
as foll ows:
1. One additional CMS' (Correctional Medical Special ist) will be

assigned to the yard during the a.m. shift. This will result in
an increased coverage of the units, allowing the medical staff to
spend more time with each inmate's medical complaint •• (more contact time per inmate). The CMS who is assigned Units 7, 8, and 9
will do daily review and one-on-one contact with those individuals
in a restricted custody classification. The other CMS will cover
Units 10, II, and A Block for their medical needs.

••

2. Ideally, one of the present CMS positions can be upgraded to Unit
Charge Nurse during the day shift and provide the Unit 1 facility
with licensed coverage. Presently, we have a eMS who is an LPN
and has a great deal of experience in the mental health field. I
plan to offer her the proposed position and add a CMS position to
that unit on the day shift. This added position will provide improved medical coverage and upgrade the number of medical contacts
in Units 2~ 3, and 4 on the Mental Health Facility compound. This
would also correct our deficiencies in physical examination time
we now experience. Occasionally the medical staff has some difficulty in IIkeeping Upll with the physical exams. There are instanc~s
when a new commitment is overlooked in the medical screening process, and he/she is transferred to the yard or satellite facility
without proper review.
.

i

3. The swing shift will also have CMS coverage in the Mental Health
Facility. Presently there is no Assessment and ReceiVing Center
medical staff in Unit 1 (mental Health), Unit 2, U~;t 3, or Unit 4
in the p.m. hours. With Our geriatric and chrO,oic care patients
and new commitments, the added CMS coverage is well warranted.
4. Another CMS will be assigned to a swing ~hift position with his
days off during the week. This will provide a double coverage
situation during Sa-turday and Sunday <lnct ~arly afternQon and evening hours when sports, visiting, and all Qtn~r. ~xtr~curriculQr
activities are at a peak.
- .
5. Two positions will be staffed on graveyard shift,;Th~se individ ..
uals will have staggered days off. The staffing pattern will be
arranged so as to give double coverage on Friday, ~aturday, and
Sunday night. This will Rrpvide the required cQv~rage for those
evenings when the greatest number of assdul ts· of"'lnciClents occur.
6. The eighth and last CMS position will be assigned the duties of
IIrelief eMS to cover annual leave, sick leave and comp time off.
Il

The remainder of the requested staff positions will be part of the
on-site infirmary support team. These will be as follows:

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Case
1:81-cv-01165-BLW
Document
23Page 14
Response
to Ryan Decision
#3 822-3 Filed 03/19/12 Page 8 of
ii
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a.
b.
c.
d.
e.

Full
Full
Full
Full
Full

time
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or equivalent M~D.
or equivalent dentist
dental assistant
records cl erk
pharmaci st

See the attached graph.

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 9 of 23

Response to Ryan Decision #3

Page 15

XU. Orientation of new commitment inmates is of great importanc~.

I This can be accomplished rather easily by assigning to the

medical staff members performing the physical examinations the
responsibility for that orientation. Listed below are the areas
that will be di scussed between the medical staff and the new
commitment contact.
1. Medical Request system (sick call)

2. Services provided
a. M.D.
b. Correctional Clinical Specialists (P.A. &F.N.P.)
c. Denti st
d. Optometrist
e. Psychologists
;
I

Addendums, changes, or Medical Service adjustments in procedure can
be! published on the daily call-out sheet, the Warden's inmate newsletter, and through officers' briefings when.applicable.
,
XIII. One of the biggest problems/obstacles confronting the Medical
Services and the inmates regarding unimpeded access is the escorting process. On any given day, due to circumstances beyond the
control of both secur; ty and medical staffs, ; nmates have to' be rescheduled because of a shortage of escort; ng personnel.: Custody
levels are such that many of our patients requirea.certain amount
of protection or control during any movement on the yard. When a
shortage of security personnel arises, that e~cortEld movement suffers for these particular inmates who are ~Chp~~lEld o~ the Medical
Services call-out.
.
As shown on a listing of desirable staff presente~ to the Governor
and Legislature, additional yard escort officer~ hav~ b~en requested. (See attached) When this request is fu1filled, then one of
the problems of impeded access will be ~OlvQd. This will reduce
greatly the number of re-schedules by the Medical Service for sickcall, increase the patient load, and increa,se the number of inmate
medical contacts.
. " .
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Ryan
Decision Order #4Document 822-3 Filed 03/19/12 Page 10 of 23
Page 1
Case
1:81-cv-01165-BLW
In accordance with American Correctional Association Standards
2-4301. 2-4300. 2-4275. 2-4279 and American Medical Association Standards 146 •. 147. 134) 154) and 151) the Idaho Department of Corrections
shall make requested changes and adjustmentsi n -its Medical Program.
(See attached standards)
Note: Also attached are the proposed Policy and Procedures the
Department of Corrections medical staff shall adhere to. Keep in mind
that these policies are not finalized) and proper revisions in committee along with operational addendums will be added or deleted. After
all revisions are made. the final draft is to be typed by Norma Clemens
of Word Processing to comply with Department of Corrections format.
The order to provide a full time) or equivalent) medical doctor is
being followed. (See M.D. proposal in Order #3) In addition to this)
we are requesting the following:
1.
2.
3.
4.
5.
6.
7.

Full time dentist
Full time dental assistant
One Records clerk (additional)
Full time registered pharmacist
One Correctional Medical Specialist
Full time registered dietician
Additional security escort staff

Items 1-6 are covered in Order #3.
Item 7 is covered in security staff policy of desired and needed
additional staff.

)

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 11 of 23

Page 2'

Ryan Decision Order #4

Budgetary needs are di scussed in Response to Order #3.
package of additional costs is as follows:

The

Medical personnel salaries ••••.•••• $ 577,000.00
(Not included, but ne~ded)
Hygienist ......................... .

19,200.00

Operati ng Expenses ••• .' •••••.••.•••• 46,100.00
(Not included, but needed as a
mi nimum amount)
Capi ta 1 Outl ay •••••••• ,•.
50,000.00
Total ••
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$ 692,300.00
0

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The Business Office and Administration 'have proposed a total of

$577,000.00, whi ch is a 1esseramount.,!' , That amount waul d not supply

the staff with equi pment or offices to' function. : If the medical staff
is to better utilize its physical plant and increase its coverage
ability, the above reccommended allocation is greatly needed.
Staffing and organization again is discussed in Order #3. (See
the attached organizational chart)

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 12 of 23

Ryan Decision Order #4

Page 3

Development of training is of utmost importance for the new employees and for current staff, including those in security and
admini stration. Attached is a submitted exampl eof a proposed trai ning schedule to be instituted by the Department of Corrections Training
Academy. (see Order #3)
Also attached is a schedule of in-service programs which will be
conducted at the Infirmary fon the medical staff members for improvement of pati ent care and emergency care. (See Order #3)

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 13 of 23

Page 4

Ryan Decision Order #4

Some changes in the Infirmary physical plant are recommended and
wi 11 soon be started. These recommendations wi 11 requi re some modifications and construction to the building and will decrease impeded
access while improving medical services.
,

As mentioned in Order #3~ w~ are requesting a full time pharmacist.
This means a serviceable pharmacy unit will have to be constructed.
This will eliminate the time lag presently experienced by the patients
in receiving medications. At present there is a one-day waiting period
for medications from the time they are recommended and ordered until the
patient picks them up. This is true of most medication orders,excepting those of an emergency nature. In emergencies, the patient is issued
one day's medication while those, prescribed are being ordered and picked
up. A functioning pharmacy with !,stocks on hand will el iminate this.
probl em.
.
There will be two dispensing windows available.
1. Daily, controlled abusable medications will be dispensed
from the window adjoining the waiting room, and weekly
medications will also be distributed from this window.
2. Other recommended prescriptions will be picked up by the
patient immediately following his examination during sick
call and the daily call-out at the north dispensing window
adjoining the hall. (See attached Floor Plan #1)

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 14 of 23
\',
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Ryan Decision Order #4

Page 5

Construction in the inmate waiting room will be necessary. A
special security "cage" waiting area will be built. This is to allow
an increased number of special custody patients to be escorted to the
Infirmary for medical evaluation. It will require fewer security personnel to guard several Administrative Segregation inmates in this area
while they are awaiting examinations or testing than the present one
officer per inmate method that is presently used.
Note:

The area specified is readily visable from the officer's desk.
Also~ there will be a second security officer to provide additional
control of inmate movement and behavior during regular sick call hours.
(day shift) Extra security staff are being assigned to the Infirmary
during the day shift to increase safety for the special custody inmates,
and to increase access and movement to receive medical attention. (See
attached floor plan)

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 15 of 23

Ryan Decision Order #4

Page 6,

Modification of a wall in the inpatient ward is recommended by
the Medical Services Manager. Presently there is a patient wardroom
which has no immediate bathroom facility. If there is a need to
. mi cturate or defi cate by a pa ti ent or pa ti ents in thi s room, medi cal
and/or custodial supervision is required. To eliminate this custodi a·1 prob1 em and improve the accessability for the inmate, a door vJi 11
be made in one wall adjoining the bathroom and shower.
See the attached documents:
1.
2.
3.
4.

Request for patient room construction
Floor pl an
Cost breakdown of all construction in this section
Work request for construction

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 16 of 23

Ryan Decision Order #4

Page 7

Accomodations for our additional professional staff will have to
be created in the Infirmary Building.
1. An office and examination room will have to be made available
for one medical doctor. This can be accomplished by minor shifting of
supplies and room modification. As previously mentioned in the resPQnse,
the pharmacy supply room will be moved to the newly tJuilt pharmacy and
dispensing room, leaving this area available to become a physician's
office. The medical supply room next to this office will be changed to
an examination room.
2. The medical supply and dental supply will' be combined into a
central supply room in an area which is now a janitor's area with storage
for cleaning supplies. The present dental supply room when it is vacated,
can be converted into an office for the dietician. (See Order #1)
3. With funding available, the Medical Services Manager will have a
vacant room converted into a whirlpool bath area for our physical therapy
and orthopedic patients.

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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 17 of 23

Page 8

Ryan Decision Order #4

Medical records at the Idaho State Correctional Institution are
unique compared to record keeping systems in the community. They contain not only out-patient care records ~uch as those kept in a private
physician's office, but also contain the in-house Infirmary care entries
and medical care documentation.
I
As the medical chart is opened, one finds on the left entries by
the Social and Psychological staff members. This ,is kept separate from
the medical side of the chart. The right side of ,the file is separated
in categories as follows:
I
,
II

,

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1. Identification sheet from with a brief 1.0. and social history
and a picture of the i nma te taken by the 1. 0 • office
'
2. Listings (white copies) of all Medical Request Forms the medical
staff has received from the patient ,
:
3. Physician's Orders-contained in this isection are medication pr'escri ptions, orders for treatment, recommendations for fol10w-u'p
consultations. X-ray, and lab test requests, and special needs
orders for the inmate. Also in'this ~rder section are the
requests for memorandums covering special 'diets, clothing, or
bedding required by the patient.
4. Outpatient Treatment Record-all medical contact entries are made
here. Most patients are seen on an outpatient basis by the M.D.,
P.A., or the F.N.P. When there is a medical conta~t,' the entry
follows the S.O.A.P. format as follows:
S. Subject's complaint or prese~tation
O. Objective finding by examination
A. Assessment or impression of the problem, combining
the findings of presentation, history and exam
P. Plan of action to be started to t~Ke care of or
remedy the medical probl em
" .
5. Consultation-Entries of specialist's examinations. These include
orthopedic, dermatologic, neurologic. uro1Qgic,'or any other
special interest examination given by eith~r contract or communitybased physicians who are not in a general pract1~e category.
6. Lab and X-ray-Thi s category i ncl udes all forms of 1aboratory, radiological or electro studies, CBC's, 'ZSR's,UA's~ ~8 channel
screens. computerized axial tomographies, electromyographics, all
X-ray studies, etc, etc, etc.
.... .
7. Prior Medical Records-All p~st
including medical contacts and

record§tr~t have been
hospitaliiations"~ ' ..

requested,
,
.

8. History and Physical Examination-This includes the physical exam.
Medical Questionnaire, and Patientls Questionnaire.
The medical charts are confidential and are kept in the Medical
Records section of the Infi rmary under lock and key. A copy of a medical
file is made available to the patient upon receipt of a Medical Release
when he/she is discharged or paroled, or when a Medical Release Form
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Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 18 of 23

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Ryan Deci.sion Order #4

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signed by the patient is received from his/her attorney. These medical
files are not made available to security or other institutional staff
unless the legality of such is established.
Attached is the audit procedure for the, medical records and an :;
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exampl e' of a medical record.
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Appendix
D Filed 03/19/12 Page 19 of 23
Case 1:81-cv-01165-BLW Document
822-3

STATE OF IDAHO
BOARD OF CORRECTION
Idaho State Correctional Institution
April

19~_

BOX 14
Boise, Idaho 83707
(208) 336-0740

1985

M E M 0 RAN 0 U M

FROM:

Ralph Pierce., Deputy Warden of Programs

TO:

Robert Gates,,, Deputy Attorney General

SUBJECT:

Psychiatric Services at the Idaho State Correctional
Insti tuti on

The following information is provided regarding the advisability of
obtaining a full-time psychiatrist to provide for the needs of inmates
with mental health problems at the Idaho State Correctional Institution.
1. Presently~ Dr. Michael Estess and Dr. Cantrill Nielsen are each
provi ding four hours care each week for a total of eight hours.
Dr. Nielsen holds Clinic on Monday mornings and Dr. Estess holds clinic
on Thursday mornings. Appointments are triaged by the psychologists
and psychiatric nurse assigned full -time to the Mental Health Un-it.
2. The Mental Health Unit is a separate facility which nonnally
houses approximately ten patients. Patients are admitted to the unit
only with approval of a psychiatrist and the Director of Corrections.
The cri teri a for admi ttance is that the pati ent is currently diagnosed
by a psychi atri st as bel ng actively psychoti c and~- additi onally~, that
the patient is exhibiting behavior which is considered to be dangerous
to himsel f or others. Patients assigned to this unit are nonnally seen
at 1east once each week by a psychi atri st.- and twice each week if
needed. Additi onally~, the psychol ogi st and/or psych; atri c nurse have
access to both psychiatrists by telephone for emergencies or conferences
concerning symptoms or problems.
3. In addition to the average of ten patients treated i~ the Mental
Health Unit~ outpatients from the general inmate population are seen at
the Mental Health Unit as necessary to monitor outpatient treatment programs-and--medi-c-a-tt-on--l-evels--of--a-l-l---p-a-ti--e-n-t-s--arraer--psydl-otro·pTE-med-fcations. Inmates receiving psychotropic medications are seen by a psychiatri st at 1east once every two months T and more frequently if indicated
and call ed for by the psychi atri st. An average of 35 outpati ents are
bei~g monitored by the staff of the Mental Health Unit.

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EQUAL OPPORTUNITY EMPLOVRR

Case 1:81-cv-01165-BLW Document 822-3 Filed 03/19/12 Page 20 of 23

Rob~r_'LGC!t~sx

.Deputy ,Attorney General

4. Inmates who exhibit mental health symptoms within the general
inmate popul at; on are referred fi rst of a 11 to a psycho 1ogi st for an
evaluationlfconditions permit. The psychologist refers the inmate'to
be seen by a psychiatrist if deemed necessary by confering with the
MentalHealth Unit psychologist.
In emergency situations this evaluation and referral can take pl ace in the same day .. and the inmate
admitted to either the Mental Health Unit or the Medical Clinic as
conditi ons warrant.

5. The above system of mental heal th care has been functioning
quite well for. the past five years. With the increase in inmate popu1 ati on.., it is proposed to add four more hours of psychi atri st coverage
by schedul ing another four" hour plock one morning of the week. This
wi'll prOVide fora'psychiatrist {ri the. Unit three days per week. With
the number of inpatients and outpatients within the inmate population v
this should provide sufficient psychiatric~coverage.
6. It must be understood that the services of the psychiatrists
are primarily to monitor psychotic patients and to prescribe appropriate
treatment programs,,,; ncl ud; ng therapy modal ity as well as chern; cal
modal ity. The actual. treatment is admini stered by the psychologica1
and medical full-time' staff. :' . ,.'
-' , -'.
'.. '.. .,';-,
.' .

. To improve'the delivery of mental health .services and follow-up
cqtirisei ing prqgrams' prestrib~d'by 'the psychiatrists~ the Oepartmei1;f; Of
Corrections has been'functedfo'rtw6'-more psychologfsts\> one' ~ofwhom
will be an Idaho State licensed Ph. O..Thi s amounts to a forty.per.cent
fikrea:se in psycnorogi cal sta ff v 'from three to ffve members.' .:,'.' ·.,in I....
Attached are copi-es' :of'a treatment plan'prepared . for"'every:-;pat"fent
seen by . the' psych; atri sts' whi ch s d.e~1gnatetreatment modal iti estobe
followed; and a form presently used in the initial receiving unit for
develop; ng a· program for every sexual offender.
The Sex Of.fender
Checklist is prepared by a staff psychologist after interviewing the inmate and reviewing past history information.

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Case 1:81-cv-01165-BLW
Document
Appendix
E 822-3 Filed 03/19/12 Page 21 of 23

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Form: H6/31

Appendix
F 822-3
Case 1:81-cv-01165-BLW
Document
Filed 03/19/12 Page 22 of 23
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G 822-3 Filed 03/19/12 Page 23 of 23
Case 1:81-cv-01165-BLWAppendix
Document

Mental Health Program Operational Data
Table 1: Mental health operational data that is not routinely collected but was ultimately
assembled and available to us
-average number of inmates on psychotropic medications
-average number of inmates in group therapy
-average number of hours of group therapy per patient housed in Unit 16 per week
-average length of time psychiatrist spends per patient encounter
-average length of time psychiatric physician assistant spends per patient
encounter
-average number of inmates seen for suicidal ideation or placed on suicide watch
per month
-list of deaths secondary to self-injury or impulsivity in last 2 years
-average number of inmates in Administrative Segregation who screen positive
for mental illness
-list of patients receiving psychotropic medications on an involuntary basis in the
previous two years
-analysis of inmate grievances related to mental health care, e.g. according to
nature of complaints, type of service, identity of provider, etc.
Table 2: Mental health operational data that is not routinely collected and was not
available to us
-average number of inmates screening positive for mental health issues at intake
-average number of patients who have submitted sick call slips
-list of inmates placed on suicide watch within 72 hours of admission to ISCI
-list of inmates placed on suicide watch in the previous month
-list of patients transferred out to a higher level of psychiatric care than available
at ISCI
-average length of stay in such higher level psychiatric care bed
-list of inmates requiring urgent care due to self-injurious behavior or impulsivity 1

1

Although this information was not provided, two separate interviews with staff indicated that
approximately five inmates had been transferred out during 2011 due to self-injurious behavior.
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Case 1:81-cv-01165-BLW Document 822-4 Filed 03/19/12 Page 1 of 2

MARC F. STERN, MD, MPH
SPECIAL MASTER

UN1TED STATES DISTRICT COURT
FOR THE DISTRICT OF IDAHO

WALTER BALLA, et aI.,
Case No. 1:81-cv-1165-BLW
Plaintiffs,
AFFIDAVIT OF MARC F. STERN

v.

IN RESPONSE TO ORDER 806

IDAHO STATE BOARD OF
CORRECTIONS, et aI. ,
Defendants,

STATE OF WASHINGTON
ss.
COUNTY OF THURSTON
MARC F. STERN, being first duly sworn, deposes and says as follows :

AFFIDAVIT OF MARC F. STERN - 1

Case 1:81-cv-01165-BLW Document 822-4 Filed 03/19/12 Page 2 of 2

1.

I am submitting a final report to the Court, pursuant to Order 806, containing my

opinions regarding health care delivery at the Idaho State Correctional Institute.
2.

I bereby attest under penalty 0'£ peIj ury that to the best of my knowledge the facts

therein contained are true.
3.

Further your affiant saith naught.

DATED this

J d-day of February, 2012.
MARCF. STERN

SUBSCRIBED and SWORN BEFORE ME TIllSOZ

AFFIDAVIT OF MARC F. STERN - 2

rd

day of February, 2012.