Coleman Special Masters Report on Adequacy of Inpatient Mental Health Care 5-30-14

354 Pages·2014·1.47 MB·English

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IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF CALIFORNIA

RALPH COLEMAN, et al.,
Plaintiffs,

v. No. CIV S-90-0250 LKK DAD PC

EDMUND G. BROWN, JR., et al.,
Defendants

SPECIAL MASTER’S REPORT ON
ADEQUACY OF INPATIENT MENTAL HEALTH CARE
FOR INMATES OF THE CALIFORNIA DEPARTMENT OF
CORRECTIONS AND REHABILITATION

Matthew A. Lopes, Jr., Esq.
Special Master
PANNONE LOPES DEVEREAUX & WEST LLC
317 Iron Horse Way, Suite 301
Providence, RI 02908
[phone]
Fax: [phone]
May 30, 2014

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SPECIAL MASTER’S REPORT ON
ADEQUACY OF INPATIENT MENTAL HEALTH CARE
FOR INMATES OF THE CALIFORNIA DEPARTMENT OF
CORRECTIONS AND REHABILITATION

Introduction

On April 11, 2013, plaintiffs in this matter moved for enforcement of orders relating to
treatment of those Coleman class members who are receiving mental health care at the inpatient
level at the six programs that provide treatment for CDCR inmates requiring that level of care.
[Motion for Enforcement of Court Orders and Affirmative Relief Related to Inpatient Treatment,
Docket No. 4543, filed April 11, 2013]. Among other things, plaintiffs argued that access to, and
provision of, care at these programs had reached a “crisis point” due to mismanagement of wait
lists and discharges, staffing shortages, excessively restrictive custodial policies and resulting
deprivation of care, and lack of basic amenities.
Beginning on June 19, 2013, an evidentiary hearing on plaintiffs’ motion took place over
the course of three and a half days. Testimony was taken from nine witnesses. On July 11,
2013, plaintiffs’ motion was granted in part and denied in part. [Order, Docket No. 4688]. On
August 12, 2013, defendants appealed the July 11, 2013 order to the United States Court of
Appeals for the Ninth Circuit, and moved the trial court for a stay pending the appeal. [Motion
to Stay, Docket No. 4742]. After duly filed opposition by plaintiffs, the motion to stay pending
appeal was denied. [Order, filed September 5, 2013, Docket No. 4784]. As of this writing,
defendants’ appeal remains pending.
In its July 11, 2013 order, the court directed the Special Master to monitor all six of the
inpatient mental health programs for CDCR inmates, and to “report to the court on their
adequacy and whether any modifications to defendants’ remedial plan are required to ensure that
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members of the plaintiff class are receiving adequate inpatient mental health care.” [Order,
Docket No. 4688 at 11-12]. From August 2013 through March 2014, members of the Special
Master’s staff of clinical experts and monitors toured the six programs and gathered the relevant
information which is discussed in detail below.1
Two of the six programs are run exclusively by the California Department of State
Hospitals (DSH) and also treat patients who are not CDCR inmates. These programs for CDCR
inmates are at Atascadero State Hospital (ASH) and Coalinga State Hospital (CSH). At three of
the six programs, clinical services are provided by DSH to only CDCR inmates at locations
within CDCR prison facilities. These are the Vacaville Psychiatric Program (VPP), which is
within the CDCR prison California Medical Facility (CMF); the Salinas Valley Psychiatric
Program (SVPP), which is at the Salinas Valley State Prison (SVSP); and the mental health
inpatient program at the California Health Care Facility (CHCF), which also provides inpatient
medical care as well as dental care to only CDCR inmates. At the Psychiatric Inpatient Program
at the California Institution for Women (CIW PIP), inpatient care is provided for female CDCR
inmates exclusively by CDCR. ASH, the CHCF, and CIW PIP are accredited by the Joint
Commission; SVPP, VPP and CSH are not.
The court ordered the Special Master to report first on the adequacy of staffing levels at
the SVPP, and on whether so-called cuff or orientation status, either as designed or implemented
at that program unduly interfered with or delayed the provision of necessary care to class
members, as well as other matters deemed by the Special Master to require urgent attention by
the court. Plaintiffs’ request for additional orders was denied without prejudice, pending the
Special Master’s monitoring and reporting.

1 As in prior reports by the Special Master, the experts and monitors on his staff who toured the inpatient programs
shall be referred to collectively as “the monitor,” or, as applicable, “the Special Master’s expert.”
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As ordered, the Special Master’s report and recommendations for orders with respect to
SVPP was filed first, on September 24, 2013. Special Master’s Report on the SVPP, Docket No.
4830, filed September 24, 2013. In that report, the Special Master recommended:
1. That the SVPP be directed to fill remaining staffing vacancies and consider
modifying its planned staff-to-patient ratio of 1:35. Priority should be given to filling
psychiatry, psychology, and social work positions.

2. That the SVPP be directed to increase significantly the amount and quality of
individualized and group therapy provided.

3. That the SVPP be directed to reconsider and re-evaluate its use of Orientation Status
to automatically require patient cuffing whenever out-of-cell and withhold mental
health programming or treatment other than a daily cell-front contact by a member of
the interdisciplinary treatment team (IDTT).

4. That the SVPP be directed to eliminate the use of Cuff Status to require automatic
cuffing of patients when out-of-cell, overriding of patients’ stage designations, and
barring of patients’ access to out-of-cell individual and group treatment.

5. That the SVPP be directed to begin tracking all patient bed assignments, and admit
referred and accepted patients as quickly as bed availability permits so that all beds
are utilized to the fullest extent possible, and in no event beyond 72 hours following
bed assignment and 30 days from the date of the referral.

6. That the SVPP resolve any and all remaining issues with, and obstacles to, providing
patients with the full complement of clean clothing, towels, and bed coverings, and
make these provisions available to patients on a timely basis according to established
schedules.

Defendants filed objections to the Special Master’s report on SVPP and moved to strike
or modify it in part. Plaintiffs filed a response with a request for additional recommendations
and orders. On November 13, 2013, the Coleman court denied defendants’ motion to modify the
Special Master’s findings in his SVPP report and adopted them in full, and denied without
prejudice plaintiffs’ motion for additional orders. [Order, Docket No. 4925]. Insofar as the
Special Master’s recommendations in his SVPP report, the court ruled as follows:
1. In light of defendants’ representations concerning their efforts to recruit and hire staff
and improve the quantity and quality of therapy, and the continuation of monitoring
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SVPP and the other DSH programs, any orders on staffing and the quantity and
quality of therapy were deferred pending further reporting and recommendations from
the Special Master.

2. CDCR and DSH shall review and re-evaluate the use of orientation and cuff status at
SVPP to determine whether these policies as designed and implemented achieve the
proper balance between legitimate security needs and access to necessary inpatient
mental health care. This shall be carried out under the guidance of the Special Master
and his staff, with participation and input from plaintiffs. The Special Master shall
report to the court on the results of this review and re-evaluation in the report to be
filed on March 31, 2014. In addition, defendants were ordered to report to the court
within 15 days whether there was any inmate-patient at SVPP on cuff status without
required supporting documentation.

3. Defendants must forthwith begin tracking all patient bed assignments at SVPP, and
admit referred and accepted patients to SVPP as quickly as bed availability permits
and in no event beyond 72 hours following bed assignment and 30 days from the date
of referral (i.e. the date which the completed referral packet is received by DSH by
facsimile or overnight mail).

With regard to laundry issues, the court noted defendants’ representation that a
committee had been formed to inventory and resolve any problems with the program’s supply of
clean laundry leaving it to the Special Master to report any failure to solve this problem.
The following is the Special Master’s composite report of his findings and conclusions
across the six inpatient programs, plus individual reports on each of the six programs. This
report was prepared with great effort to present the Special Master’s findings clearly and in the
most organized and readable fashion possible. However, the Special Master’s tours of these
inpatient programs revealed that they vary widely in their respective policies, practices, and
operations in nearly every aspect of inpatient mental health care administration and delivery.
From facility to facility, the Special Master found differences, with seemingly no discernible
semblance of coordination or consistency among any of the DSH programs, as the reader will see
below. Because of this unevenness, thorough and consistent monitoring, and coherent and
helpful reporting, on these programs was a challenge. To the extent the reader finds any
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apparent disconnectedness among the program reports which follow, it is more likely the result
of actual differences among these programs than it is the result of gaps in monitoring strategies
and practices.
In this report, discussion of the programs’ performance in the various examined areas is
organized according to the three general categories into which the six programs fall, as described
above. Individual dedicated reports on each of the programs are attached as Exhibits A through
F, and program-by-program case reviews by the Special Master’s clinical experts are attached as
Exhibits G through L. A list of all acronyms appearing in this report is attached at Exhibit M.
I. STAFFING
A. ASH and CSH

As of February 10, 2014, there were 207 Coleman class inpatients at ASH. Psychiatry
staffing at ASH was severely low, with a vacancy rate of 61 percent, which was mitigated to a
still-low 39 percent with use of contract coverage. The detrimental effect this had on the
program’s ability to treat its patients was significant. It led to limited participation of
psychiatrists on IDTTs, which in turn limited the efficacy of these teams for patient treatment
planning and follow-up, which is particularly important at the inpatient level of care for seriously
mentally ill persons. Staff reported that other disciplines attempted to bridge the gap in
psychiatry but were crossing into psychiatry’s traditional clinical role, affecting the quality of
care provided. Staff also reported a perceived lack of support for psychiatry leadership at ASH
in that the lack of overtime pay for supervisors created a disincentive for psychiatrists to seek
supervisory posts. As a result, supervisory positions were filled predominantly by non-
psychiatrists, placing staff psychiatrists in the position of being, in effect, supervised by nurses,
rehabilitation therapists, and psych techs who occupied the supervisory positions. The staff-to-
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patient ratio in the admission unit at ASH was insufficient, at 1:25. Cognizant of its problems
with psychiatry staffing, ASH did seek a site-specific hourly pay increase for psychiatrists, but
approval by the California Department of General Services (DGS) had not been given as of the
time of the Special Master’s most recent visit to ASH.
As of March 18, 2014, 2014, there were 49 Coleman class patients at CSH. Its two
psychiatry positions in the program for CDCR inmates had been vacant since the unit opened
and remained vacant, but CSH did manage to cover them with contract psychiatrists. Like ASH,
CSH covered its psychology positions, albeit with unlicensed psychologists who were supervised
by the senior psychologist supervisor. ASH also filled all of its social work positions. CSH
filled two-thirds of its social work positions, with unlicensed social workers. CSH filled its
rehabilitation therapist positions, while ASH filled only three-quarters of them. Conversely,
ASH filled all of its psych tech positions, but CSH had a 17-percent vacancy rate among psych
techs.
At ASH, staffing levels were adequate in the admissions unit for psychologists, social
workers, and rehabilitation therapists. In its intermediate care treatment unit, CSH maintained a
ratio of 1:25 for psychiatrists and rehabilitation therapists, and ratio of 1:15 for psychologists and
social workers.
B. SVPP, VPP, and CHCF

At the time of the Special Master’s Report on SVPP, filed on September 24, 2013,
staffing was problematic at that program. It remained problematic through the time of the
Special Master’s visit to SVPP in March 2014. The program continued to rely on
registry/contract staff and second positions held by existing staff to cover core roles, including in
some instances both line and supervisory positions being covered by the same staff. The result
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was over-extension and inability of staff to carry out all of the attendant responsibilities of more
than one position.
As of March 4, 2014, SVPP housed 224 Coleman class patients. Like ASH, SVPP was
understaffed in psychiatry. While it had four of its five psychiatry positions covered, one of
these psychiatrists was on extended leave, three were registry staff, and two were on loan from
other DSH facilities, for a level of less than optimal stability in this important discipline in an
inpatient program. Recruitment efforts were reportedly underway.
As of March 14, 2014, there were 406 Coleman class patients housed at VPP. VPP was
the only one of the six inpatient programs to have its own established staffing ratios of 1:15 in
acute care units and 1:35 in intermediate care units. However, VPP failed to satisfy its own
ratios in a number of its units. VPP covered all of its psychiatry positions with a combination of
full-time and registry staff, yet it did not satisfy its own program-established staff-to-patient
ratios in psychiatry in one acute care unit and three intermediate care units. At the CHCF, the
shortage of psychiatrists was so severe as to delay activation of five housing units in the mental
health program, with only nine of the 35 psychiatry positions filled, for a 74-percent vacancy
rate.
In psychology, SVPP filled ten of its 12 positions, but three of the psychologists were on
extended leaves, making a total of five or 42 percent of psychology positions functionally vacant.
VPP covered all of its 23 psychology positions, but did not satisfy its own staffing ratios in six of
its acute care units and two of its intermediate care units.

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SVPP filled ten of its 12 social work positions, but again, extended staff leaves reduced
the number of covered positions to eight, for a 33-percent functional vacancy rate. VPP filled all
of its 23 social work positions, but it did not meet its own staffing ratios in three of its acute care
units and one of its intermediate care units. SVPP and VPP fared well in staffing rehabilitation
therapy positions, with SVPP filling nine of its ten positions, and VPP filling all 23 of its
positions. In nursing, SVPP covered 26 of its 36 RN positions, while VPP covered all of its RN
positions.
At the CHCF, the average daily census of Coleman class members for the month of
January 2014 was 279.2 The CHCF struggled with filling its psychology positions, with a 36-
percent vacancy rate. It filled 29 of its 35 social work positions, for a 17-percent vacancy rate,
but it filled only 21 of its 35 rehabilitation therapy positions. The CHCF did better with staffing
its RN positions, with only an eight-percent vacancy rate.
C. California Institution for Women Psychiatric Inpatient Program (CIW PIP)

As of February 21, 2014, there were 38 Coleman class members housed at the CIW PIP.
Staffing levels were adequate to support functions at the CIW PIP, with all psychiatry and
psychology positions filled, and three of the four social work positions filled. Of the four
recreation therapist positions, three were filled, as were 29 of the 32 psych tech positions. Staff-
to-patient ratios for psychiatrists, psychologists and social workers were adequate.

2 Source: Department of State Hospitals Report, Staff Levels for Coleman Patients, January 1, 2014 through January
31, 2014, submitted February 1, 2014.
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II. TREATMENT AND CLINICAL SERVICES

A. ASH and CSH

1. IDTTs

Not surprisingly, ASH’s shortage of psychiatrists meant that IDTT meetings were not
always conducted with a psychiatrist present, which meant that patients’ treatment plans did not
always have the benefit of a psychiatrist’s input. The quality of the treatment team meetings
varied across units in terms of clinical and patient-team interactions. Treatment plans were
somewhat generic and lacked clarity of treatment goals and/or behavioral therapy-based
interventions. However, teams did appear to know their patients and had the relevant patient
information at hand.
Unlike at other inpatient programs, treatment team meetings at CSH were typically led by
psychologists, and the role of psychotropic medications and psychiatry in general were given less
emphasis in treatment plans. Conduct of observed IDTT meetings appeared to be more rote than
truly responsive to the patient and his needs expressed at the meetings. Treatment plans were not
modified in accordance with clinical information being provided by the patient at his own
treatment team meeting.
2. Group Therapy

Group therapy was the primary treatment modality at ASH, and was occasionally
supplemented by some individual therapy. This was problematic because the amount of group
therapy was very deficient. In 2011, the average number of provided weekly group hours was
12.94, but in 2013 it had fallen to only 7.23 hours. More concerning was that the average
number of group hours actually attended by patients was only 4.6 hours per week, as of the time
of the Special Master’s September 2013 visit. Group offerings remained limited at five to eight
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