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Maricopa County's Jail Health Care in Question.
By azcentral.com
Published: 05/31/2009

Jail health care a chronic problem

Despite repeated warnings, county takes little action

by Yvonne Wingett and JJ Hensley - The Arizona Republic

Maricopa County's sprawling jail system holds an average of 10,000 inmates on any given day.

The Correctional Health Services department is supposed to treat the sick, track medical conditions and prevent the spread of disease inside the six jail facilities.

County officials repeatedly have been told that CHS operations are inadequate and pose a danger to inmates. Over the last 10 years, faced with hundreds of lawsuits, a federal court order and the loss of accreditation, the Board of Supervisors has paid more than $250,000 to consultants to find solutions.

The board has ignored much of the advice.

As a result, CHS lost its accreditation in January for failing to meet national health-care standards.

An Arizona Republic investigation into Correctional Health Services reveals a system with chronic problems and top county officials who seem unwilling to fix them. And since 1998, the county has paid $13 million in legal fees, settlements and jury verdicts to inmates and their families for injury and death claims against CHS.

Dozens more lawsuits are pending against the county. And the loss of accreditation is a serious problem for almost any legal defense.

Today, in the first of a two-part series, The Republic examines the role of the Board of Supervisors and other top county officials.

The five-member board is ultimately responsible for ensuring the system has the funding, staffing and equipment to provide adequate health care for inmates. Failure to provide adequate care to inmates can constitute cruel and unusual punishment, a violation of the U.S. Constitution.

During interviews with The Arizona Republic, two supervisors, Andrew Kunasek and Max Wilson, would not talk in depth about systemic problems affecting Correctional Health Services. Two supervisors, Don Stapley and Fulton Brock, did not respond to interview requests.

Mary Rose Wilcox was the only supervisor who talked in detail about the county's lack of attention to the problems.

CHS Director Betty Adams denied multiple requests from The Republic to speak with doctors and nurses who provide daily inmate health care, citing ongoing lawsuits. She did approve interviews with several CHS administrators.

Court documents, consultant reports, and interviews show how the correctional health-care system struggled and how supervisors failed to respond.

Consultants hired by the board have been clear about what CHS needs:

• An electronic medical-records system tomanage inmate health care.

• Better staff ratios so doctors, nurses, psychiatrists and technicians can adequately screen and treat inmates.

• Staff-retention measures to combat high turnover and an expensive reliance on temporary staff and local hospitals.

• More stable leadership at the top. CHS has had more than five directors in the last 10 years.

But county supervisors who agreed to interviews said they were not fully aware of chronic problems at CHS.Now, Wilcox says she and the other supervisors should have done more.

"We didn't get the full story on CHS, quite frankly, to the degree I would've liked," Wilcox said.

Wilcox said supervisors generally leave specifics about county agencies to department heads and administrators. High-level county officials filtered information on CHS, Wilcox said.

"The board doesn't want to hear it," she said. "The board doesn't want to get into that detail."

Warning signs

The Maricopa County Board of Supervisors directs policy for the fourth-largest county in the nation. Supervisors oversee a budget of about $2.2 billion and about four dozen departments, which provide everything from environmental services to animal control for about 4 million residents.

Correctional Health Services was created in the early 1990s at the request of then-Sheriff Tom Agnos, who wanted someone else to take over jail health care from the Sheriff's office.

The current Board of Supervisors has been in place for seven years.

In 2007, Betty Adams became the latest of five directors at CHS in the past decade. She was appointed by County Manager David Smith with a mandate to fix the system. A county employee since 1991, Adams has a reputation for turning around departments in crisis. Adams reports to Sandi Wilson, the deputy county manager who oversees the county budget. Wilson reports to the county manager, who reports directly to the supervisors.

Smith and other county leaders have had plenty of warnings about trouble at CHS, going back to the mid-1990s.

They include:

• A 1996 warning from the U.S. Department of Justice that health care provided in the jails fell below constitutional minimums.

• A 1999 agreement between Maricopa County and the U.S. Department of Justice that required the county to improve health care in the jails with more staff and better record keeping.

• A series of studies from outside consultants in 1998, 2000 and 2003 that recommended hiring more staff, increasing retention rates and improving record keeping with an electronic system.

• More than 250 lawsuits filed against Maricopa County and CHS in the past decade, including 41 that resulted in payments to victims and their families. Award amounts in more than a dozen of those cases exceeded $100,000, with one for $1 million. The $13 million taxpayers have paid during the past 10 years include legal fees, settlements and jury verdicts to inmates and their families for injury and death claims against CHS.

• The National Commission on Correctional Health Care, which provides accreditation for correctional health systems, conducted a routine review and placed the Maricopa County jail system on probation in February 2006. NCCHC said the county failed to meet "eight essential standards and six important standards," according to a portion of an NCCHC report obtained by The Republic. County officials refused to release the full 2006 report.

• Over the next two and a half years, the county made some improvements in staffing but still fell short. In September, NCCHC said it would withdraw accreditation, citing the county's failure to meet five essential standards, including performing assessments on inmates, answering medical requests in a timely fashion and tracking and treating chronically ill inmates, according to portions of a report. County officials refuse to release the full 2008 report.

• County officials challenged the decision, and in November NCCHC conducted a second review. In January, upholding its decision, the agency formally removed the accreditation.

Wilcox said the loss of accreditation was the point supervisors became "acutely aware" of the problems at CHS.

Since then, Wilcox said, "the board has been in crisis mode dealing with CHS," scrambling to shore up the system.

One reason is the legal exposure. Experts and county officials say accreditation provides an independent assessment of the quality of health care in jails and is an important defense against lawsuits built around charges of inadequate care.

NCCHC accredits 500 prisons, jails and other facilities throughout the nation. President Edward Harrison said his organization rarely withdraws accreditation. Instead, it prefers to put facilities on probation and work with health-care employees to correct problems.

That's what NCCHC tried to do during the years CHS was on probation.

After losing accreditation in January, CHS officials defended their performance and said the loss of accreditation was based on incomplete information and unrelated testimony from a federal civil-rights case involving conditions in Maricopa County jails.

In an e-mail response to The Republic, Harrison said, "Unfortunately, from their (the site review team's) perspective, our team found there to be a lack of compliance in a number of areas and existing throughout the (three-year probation) period."

Although NCCHC had placed Correctional Health Services on probation in February 2006, Supervisor Max Wilson said he "wasn't informed of it, that I'm aware of. At some point in time, I became aware of it. But I'm not sure I was aware of it that year."

Biggest problems

Two problems cited repeatedly in audits, consultant reports and lawsuits are CHS' antiquated records system and low staff numbers.

The old records system makes it difficult to quickly collect and track inmate health care across the six jail facilities. Inadequate staffing also makes it harder to provide effective care in a jail system of 10,000 inmates.

The county at one point did contract for an electronic-records system, but pulled out, citing concerns the system wouldn't be cost-effective nor deliver the results administrators wanted.

Supervisors have made recent progress on staffing.

In 2006, 10 years after the Department of Justice noted the need, the supervisors gave CHS $6 million to hire more than 100 additional medical workers.

Margaret Green, CHS' director of nursing, said the staffing situation was dire when she arrived in 2004.

"I don't want to say we were desperate," Green said. "But we were desperate. We needed to get more staff, and these outside consulting companies had not been able to achieve that."

CHS added more than 200 doctors, nurses, pharmacists and clinical workers during the last five years. CHS now has more than 450 full-time employee positions authorized and has more than 400 of those positions filled, with an annual budget of about $50 million.

Despite staffing improvements, NCCHC points to the heavy use of temporary staff as a problem.

In its second assessment, NCCHC noted: "While CHS uses agency (temporary) personnel to cover some vacancies, it is apparently not sufficient to ensure that health assessments, nurse sick call, and provider visits are conducted on a timely basis."

The county spent more than $5 million in 2007 to pay for temporary staff in the jails. Officials also created "Correctional Health Technician" positions to help screen the 350 inmates who arrive at the jails daily. The position requires a high-school diploma and some health-care experience, but no medical licensure. Read more.

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