IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF PUERTO RICO

CARLOS MORALE FELICIANO,

et al.,

 

Plaintiffs,

vs.

 

PEDRO ROSSELLO GONZALEZ )

et al.,

 

Defendants.

------------------------------------------------- )

ORDER

On March 30, 1993, defendants filed a motion seeking the amendment of Section 58 of the Medical Plan. Plaintiffs have not objected to defendants' request for an amendnent to the plan.

In their motion, defendants explain that although Section 58 of the Medical Plan permits physicians and nurses to dispense medications, the laws of Puerto Rico only allow an authorized pharmacist to dispense medication. Physicians and professional nurses may administer medication which has been dispensed, but they may not dispense it.

Furthermore, although the Medical Plan provides that only a pharmacist or a pharmacy assistant under the direct supervision of a pharmacist may dispense medication, the laws of Puerto Rico also permit pharmacy aide trainees and pharmacy interns to dispense medication under the direct supervision of a pharmacist. Thus, defendants seek to amend Section 58 so that it conforms to Puerto Rico law in both respects, i.e., so that the provision that physicians and nurses may dispense medication is deleted and so that the provision that pharmacy aide trainees and pharmacy interns may dispense medications under the direct supervision of pharmacists is added.

Deferdants suggest, and the court will approve, the following amendment.

Beginning immediately, only pharmacists and, under the direct supervision of a pharmacist, pharmacy assistants, pharmacy aide trainees, or pharmacy interns may dispense prescribed medications. Licensed physicians and dentists may prescribe and administer medications. Professional nurses will be responsible for the medication maintained at the nurses' station. Only specialized, general and associate nurses, collectively referred to as professional nurses, and the licensed practical nurses, under the supervision of a professional nurse, a dentist, or a physician may administer medications. These medications must have been dispensed by a licensed pharmacist or, under the direct supervision of a pharmacist, by a pharmacy assistant, pharmacy aide trainee, or a pharmacy intern as per the written orders of a licensed physician or dentist. The Institutional Medical Administrator shall implement appropriate procedures to ensure that this policy is followed. No correctional officer or inmate may be involved in the delivery or administration of any prescribed medication.

Wherefore, the court ORDERS that the Medical Plan shall be amended as set forth above.

In San Juan, Puerto Rico, this 9th day of July , 1993.

JUAN M. PEREZ-GIMENEZ

United States District Judge

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF PUERTO RICO

CARLOS MORALES FELICIANO,

et al.,

 

Plaintiffs,

 

Civil Case No. 79-4 (PG)

vs.

 

RAFAEL HERNANDEZ COLON,

et al.,

 

Defendants.

 

AMENDED SIXTY-SECOND REPORT O THE COURT MONITOR

REPOT RECOMMENDING APORTION OF REVISED MEDICAL PLAN

AND MENTAL HEALTH PLAN

On December 2, 1988, the Court Monitor filed his Sixty-Second Report, which recommended adoption of medical and mental health plans that were submitted with that report. On February 21, 1989, after consultation with counsel for the parties, the Court Monitor applied for an indefinite extension of time for the filing of objections to those plans, and that application was approved by the Court in an order entered on February 27, 1989. The instant report recommends adoption of medical and mental health plans that have been modified as a result of lengthy consultations among the Secretary of Health and his staff, the Administrator of Corrections and her staff, the Secretary of the Department of Anti-Addiction Services (DSCA), counsel for plaintiffs and defendants, expert consultants employed by the Court Monitor, expert consultants employed by plaintiffs' counsel, and the Court Monitor. The Medical Care Plan and the Mental Health Care Plan to which this report relates are attached as Appendix A and Appendix B, respectively.

It is important for the Court to be aware of the history underlying the submission of these plans. By order of June 11, 1987, the Court approved the Monitor's employment of Dennis F. Koson, M.D. to serve as the Court's psychiatric expert consultant. On June 24, 1987, the Court entered an order approving the employment of John M. Raba, M.D. to serve as the Court's medical care consultant.

Dr. Roson, Dr. Raba, and the Court Monitor first met with Dra. Otero on July 20, 1987. On the same date, they met with then Secretary of Health Dr. Luis Izquierdo Mora. At the meetlng with Dra. Otero, the Court Monitor indicated that the expert consultants were prepared to make an overall evaluation and written report of the state of medical and mental health care throughout the correctional system. Dra. Otero, however, made clear her preference that the consultants not tell her what she already knew at the time -- that systems for delivery of medical and mental health care to prisoners throughout Puerto Rico were in near total disarray. Rather, she requested that the consultants provide her with a plan containing proposed solutlons to the problems that had been brought to her attention through prior evaluations and her own observations of the correctional system.

Dr. Koson visited Puerto Rico on July 19-25, 1987, August 18-22, 1987, September 13-19, 1987, October 28-31, 1987, May 18-19, 1988, March 8-9, 1989, June 21-23, 1989, July 2-7, 1989, July 23-26, 1989 and October 30 through November 1, 1989. During these visits, he met frequently with representatives from the Administration of Corrections and the Department of Health and toured numerous AOC facilities, the Forensic Hospital and the Therapeutic Community at Guerrero. These efforts resulted in the production of the initial mental health plan that was filed on December 23, 1988, as well as the final plan that is being filed with this report. In addition to his on-site activity in Puerto Rico, Dr. Koson spent numerous hours conferring with the Court Monitor and Dr. Raba about the plans, and he spent one day meeting with expert consultants employed by plaintiffs' counsel.

Dr. Raba visited Puerto Rico on July 19-25, 1987, August 14-16, 1987, May 15-17, 1988, March 7-9, 1989, July 9-16, 1989 and October 30-31, 1989. Like Dr. Koson, Dr. Raba conferred with administrators, physicians and other health care providers employed by the AOC, DOH, and DSCA, and he toured almost all of the prisons. Dr. Raba's on-site work in Puerto Rico was supplemented by numerous hours of drafting and conferring with the Court Monitor. He also engaged in meetings with plaintiffs' expert consultants and Dr. Koson. Dr. Raba’s efforts culminated in the medical care plan filed on December 23, 1988, as well as the revised plan that is being filed with this report.

After consultation with staff employed by the AOC and the DOH, substantial revisionq were made to preliminary versions of the plans prepared by Dr. Raba and Dr. Koson before those plans were filed by the Court Monitor in December 1988. Many of these revisions followed conferences among the consultants, the Court Monitor, Dra. Otero, the Secretary of DSCA, counsel for both parties, and staff from the Administration of Corrections and the Department of Health on May 16-19, 1988. Following the filing of the original plans, the Court Monitor met with Dr. Enrique Mendez Grau on January 26, 1989 shortly after his appointment as Secretary of Health, to discuss the status of the plans, and both, Dr. Koson and Dr. Raba met with Dr. Mendez and members of his professional staff on March 8-9, 1989. The revised version of the plans were the subject of additional meetings among the consultants, the Court Monitor, Dra. Otero, Dr. Mendez, counsel for both parties, plaintiffs' mental health consultant, the Secretary of DSCA, and staff from the Administration of Corrections and the Department of Health in San Juan on October 30-31, 1989. Those meetings led to further significant revisions, and a final meeting of counsel and the Court Monitor was held on December 11, 1989. Revisions discussed at that meeting have been incorporated into the text of the final plans that are being filed with this report.

In summary, at every stage in the development of the final medical and mental health plans, professionals and agency leadership from the Administration of Corrections, DSCA, and

the Department of Health were directly involved in the process of identifying and articulating xsolutions to the serious problems relating to the provision of medical and mental health care in Puerto Rico's correctional institutions. The plans recommended by the Court Lmonitor in this report, therefore, reflect a synthesis of the profssional judments of the Administrator of Correction, the Secretary of Healh and his staff, the Secretary of DSCA, consultants employed by plaintiff's counsel, and consultants to the Court Monitor, and they have been carefully reviewed by counsel for all parties. These plans are the culmination of more than two years of effort on the part of all involved to costruct a framework within which to remedy the deficiencies addressed by the Court in its September 5, 1980 Preliminary Injunction and recorded by numerous observers thereafter.

The Court Monitor cooperative efforts that have resulted in the formulation or the cooperative plans that are being filed with this report. He recommends that the plans be approved in all respects and that defendants be directed to implement the terms of those plans according to the timetables set forth therein

Respectfully submitted,

Vicent M. Nathan

Court Monitor

APPENDIX A

MEDICAL CARE PLAN

The Administration of Corrections

The Commonwealth of Puerto Rico

MEDICAL CARE PLAN

I. Departmental Responsibilities

A. Primary Responsibility -- Deparment of Health

1. The delivery of health care services to inmates in the custody of the Administration of Corrections (AOC) shall be directed by and be under the authority of the Department of Health (DOH). Within 90 days, a written agreement clarifying this authority and the mutual responsibilities for the delivery of health care by the two agencies shall be developed jointly and signed by the Secretary of Health and the Administrator of Corrections and submitted to the Court. This agreement shall include, but not be limited to, mutual responsibilities for development, construction, renovation and designation of space for medical care and services, including the coordination of medical and correctional aspects of the intake screening process, mutual responsibilities for classification and housing of prisoners with medical and surgical problems, ongoing health training of correctional officers, equipment, guarantee that no inmate will be transferred to another institution without medical/mental health clearance or without his complete medical records, transportation and movement of inmates for medical care, payment for prostheses and medical apparatuses, (e.g., walkers, crutches and braces), confidentiality of medical records, and reporting mechanisms.

2. All health care provided to inmates in the AOC shall be delivered by employees of the DOH or by groups or individuals under contract or by formal agreement with the DOH. Within six months, the involvement of the Department of Services Against Addiction (DSCA) shall be detailed in a written agreement signed by DOH, AOC, and DSCA. This agreement must reflect the understanding that the DOH Correctional Health Services is fully responsible for all health care needs of the inmate population except for the substance abuse related treatment of alcohol and substance abusers, which will be provided by DSCA pursuant to Law No. 60. This agreement shall also provide that (1) DSCA will provide services in the correctional facilities in cooperation with the DOH, (2) the medical management of mild to moderate withdrawal will be consistent with correctional health services and DSCA policies and procedures, (3) the medical care provided by DSCA will be entered into the individual's medical chart, (4) inmates in severe, life-threatening withdrawal will be referred for hospitalization, (5) according to exact criteria for infirmary admissions developed and set forth in the agreement, individuals with moderate withdrawal will be managed in DOH medical infirmary settings or in other appropriate medical settings managed by DSCA, and t6) inmates housed in units managed by DSCA will have access to the same privileges and programs (e.g.,, medical and psychiatric screening and treatment, exercise and visiting) as other inmates, except when participation in one or more of these privileges or programs is contraindicated for treatment purposes. The agreement also shall specify that appropriate mental health staff and DSCA staff jointly coordinate mental health and drug screening, substance abuse diagnosis and treatment, and other decisions with respect to patients who have both mental health and substance abuse treatment needs.

B. Table of Organization

3. No later than 90 days following the Court's approval of this Medical Plan, defendants shall file a table of organization for the delivery of medical care. DOH may modify the table of organization and the supervisory relationships required by this Plan, or both, when deemed necessary for reasons of administrative efficiency or effectiveness. The Court will be notified within ten business days of such action, describing the change and i-ts rationale. For a period of at least three (3) years, however, defendants shall employ a Chief Medical Coordinator, who shall be a person with extensive experience in correctional health care and who shall be responsible for coordinating compliance with the provisions of this Medical Care Plan and the Mental Health Plan and for overseeing the recommended revision of the correctional health care program. The Chief Medical Coordinator shall report directly to the Secretary of Health and shall provide necessary guidance and supervision of defendants' activitieR to achieve compliance with the provisions of this Medical Care Plan and the Mental Health Plan.

C. Interdepartmental Cooperation

t 4. The Administrative Director of Correctional Health

r Services (ADCHS) and the Medical Director of

2

Correctional Health Services (MDCHS) shall meet with the Secretary of Health and the Administrator of Corrections no less than quarterly to discuss issues of health care in the AOc. Minutes or summar$es of the discussions, as well as recommendations and actions resulting from these discussions, shall be kept and distributed to all involved parties. Problems noted shall be followed up at subsequent meetings. Complete health care statistics (e.a., numbers of physician sick call visits, specialty clinic appointments, hospitalizations, incidence of emergency transportation outside each facility, inmate mortalities, prescriptions, dental contacts and x-ray examinations) shall be provided to the AOC and filed with the Court on an annual basis.

5. At each correctional facility, the Institutional Medical Administrator, the Chief Physician, and the Correctional Superintendent shall meet no less than quarterly to discuss issues of health care in that specific facility. Minutes or summaries of the discussions, as well as recommendations and actions resulting from these discussions, shall be kept and distributed to all involved parties, with copies forwarded to the regional and central office correctional medical authorities and the Administrator of Corrections. Complete health care statistics for the facility shall be given to the Superintendent and filed with the Court on an annual basis.

6. Commencing six (6) months following the Court's approval of this Medical Care Plan, defendants shall file every six (6) months comprehensive reports detailing their progress toward compliance with each provision of the plan. Copies of these compliance reports will be filed with the Court.

II. Objectives of the Health Care Delivery System

7. All inmates in the Administration of Corrections (AOC) shall be provided with medical, mental health and dental services designed to maintain and restore their basic health. The objectives of the correctional health services will include the following: (1) to integrate health care services in the penal institutions throughout Puerto Rico; (2) to provide necessary health care services which meet contemporary standards of professional practice, emphasizing prevention services to the entire inmate population; (3) to create a system that guarantees ascessibility to health care services for all inmates; (4) to establish a health education program degigned to improve the

3

level of understanding of sound health; (S) to establish a program designed to monitor diagnosis and treatment of communicable diseases, including tuberculosis and sexually transmitted diseases, with special emphasis on HIV infection.

8. Although formal accreditation by the Wational Commission on Correctional Health Care (NCCHC) shall not be required by this plan, the DOH and the AOC shall develop a single written plan to achieve compliance with NCCHC standards. Following a finding by the Court that defendants have achieved compliance with this Medical Health Plan, monitoring of defendants' continued compliance by the Court Monitor will not be required if (a) defendants actually achieve compliance with NCCHC accreditation of all of the Regional Intake Facilities and of at least 50 percent of the remaining correctional facilities and (b) defendants maintain this accreditation for two successive periods.

9. Within twelve (12) months, a comprehensive manual of written policies and procedures governing health care services shall be developed for the correctional health care program in accordance with this Medical Care Plan. The procedures shall include written protocols for the delivery of medical, dental and mental health services in the system including protocols for the management of severe chronic, acute, and infectious illness. Each policy, procedure and program shall be reviewed annually and revised as necessary under the direction of the responsible health authority. Such review and any revisions resulting therefrom shall be documented. Any policy that requires changes in AOC policy or practices shall be reviewed and signed by the Administrator of Correct$ons.

III. Organization of the Health Care Delivery System

A. Regional Intake Pacilities - Overview

10. Within twelve (12) months, policies and procedures shall be developed and implemented that allow for new admissions to enter the AOC through no more than six (6) regional facilities, including Vega Alta. Each of the regional intake facilities shall provide enhanced on-site health care serviceg which, at a minimum, shall include the following:

a. 24 hour per day intake medical and mental health screening capability by trained, licensed medical personnel;

4

b. 24 hour per day physician staffing ( for select regional intake facilities DOH may submit an acceptable alternative plan which ensures reasonable and timely access to a physician);

c. 24 hour per day graduate (registered) nurse staffing;

d. a convalescent unit or infirmary (but see, paragraph 20, infra);

e. at least weekly on-site specialty clinics in internal medicine and general surgery (and obstetrics-gynecology at any institution housing female Drisoners);

f. timely referral for other medical needs to of fsite specialty clinics; specialty clinics with high utilization rates (e.g., dermatology, orthopedics, urology, podiatry, ophthalmology, ENT, neurology, etc.) or excessive delays (more than one (1) week for urgent referrals, more than four (4) weeks for elective referrals) in obtaining or keeping off-site appointments shall be established on-site in the regional intake facilities;

g. physician-staffed ambulatory care clinic five days per week, and access to a physician by inmates (including new admissions) 24 hours a day, 7 days a week for emergency medical care;

h. access to timely laboratory services seven days per week;

i. access to timely pharmacy services seven days per week:

j. a medical records department supervised by a full-time Certified Medical Record Technician;

k. a dental clinic staffed by an appropriate number of dentists and dental assistants five days per week;

1. radiology services staffed by a qualified radiology technician. Onsite radiology shall be staffed for ag many hours as needed depending on patient needs and the size of the institution. Procedures for the timely provision of offsite emergency radiology serviceg must be developed and implemented;

s

1

visits to all living units by a physician at least once monthly for the purpose of eliciting and reviewing inmate requests for medical care;

at least two (2) full-time administratiVe secretaries/office clerks;

a full-time individual, probably the chief physician, who will be the health authority for all health care delivered in the regional intake facility with the exception of detoxification services, which will be offered by a DSCA physician specialized in drug and alcohol detoxification who will work in close coordination with the DOH physician;

a full-time chief physician, if not the designated health authority, who has final medical judgment regarding the care of inmates in the facility with the exception of detoxification services, which will be offered by a DSCA physician specialized in drug and alcohol detoxification who will work in close coordination with the DOH physician;

a full-time Institutional Medical Administrator, if not the health authority, who will coordinate the administrative aspects of the health care delivered at the intake facility.

B. Intake and Screening -- Regional Facilities

11. Within six (6) months, policies and procedures shall be established and, within twelve (12) months, a system shall be implemented that aIlows for medical receiving (intake) screening to be performed by qualified, licensed2 health care personnel on all new admissions

2 The DOH currently utilizes in the correctional health care system and in the public health care system unlicensed graduates of qualified medical schools who have not yet passed the licensing board examination of the Commonwealth of Puerto Rico. The clinical duties of these @~medical auxiliaries" in the Correctional health care system must be specifically defined in writing and limited to primary intake screening, seven-day history and physical assessments, and routine health maintenance evaluations (periodic screening). The clinical work of the medical auxiliaries must be reviewed and co-signed by a licensed Physician within 24 hours. The medical auxillaries are not to Provide medical care, make diagnoses, initiate diagnostic Workups, or perform medical procedures.

6

upon their arrival at the regional intake facility. The screening shall consist of the following:

a. oral inquiry into current illnesses (including chronic, acute and infectious disorders), medications, health problems and conditions (including, for females, pregnancy, timing of last menstrual period, contraceptive medications, vaginal discharges), and suicidal ideation;

b. complete examination of vital signs, including weight;

c. observation for clinical abnormalities (e.a., behavior, appearance, injuries, deformities, and psychotic behavior);

d. placement of a skin test for tuberculosis, with timely follow-ups; and

e. documentation of the disposition of the inmate (e.a., referral to physician, to general population or to a psychiatric team) in the inmate @ s medical record.

1Z. Medical intake screening shall be performed in a physical location (proximate to the correctional booking area) that i5 suitable in size and space to allow for the orderly and sufficiently private interviewing and examination of the new admissions. The DOH and AOC shall tointly coordinate the selection and designation of the medical intake screening area.

13. If not performed at the time of admission as part of the initial medical screening (see, paragraph 11, supra), a full health assessment shall be performed for each inmate within seven (7) days following his admission. This assessment shall be performed by a licensed physician or by another qualified, licensed health care provider. As directed by written policies and procedures, the health assessment shall include a review of the inmate screening results, expansion of the initial medical history, laboratory and diagnostic tests to detect communicable diseases (including syphilis and gonorrhea) and other conditions, genital examinations, physical examinations, and initiation of required treatment and immunizations. In addition, for females there shall be further inquiry into their menstrual cycle and unusual vaginal bleeding, breast masses and nipple discharge, vaginal discharge and other obstetrical and gynecological conditions, testing for pregnancy, a PAP smear for cancer, evaluation of

7

vaginal discharges (lf not performed at intake) and a breast and pelvic examination. When performed by a qualified health care provider other than a physician, the health assessment shall be reviewed and co-signed by a licensed physician.

14. No individual shall be transferred from a regional intake facility until his intake health screening, initial history and full health assessment are completed unless the transfer is to another regional intake facility.

15. Effective immediately, and until compliance is achieved with paragraphs 11-14, sucra, the following temporary intake screening procedures shall be followed:

a. The "Forma De Admision Y Cernimiento" shall be completed by health trained correctional officers at the time of admission of all inmates. Written policies and procedures developed by the medical authority shall direct the intwke correctional officers in their decisions concerning the need for emergency and non-urgent referral of an inmate for medical or dental care. All correctional staff completing the "Forma" shall have received documented training in intake screening, visual observation, and recognition of indications for emergency referral. All completed "Formas" shall be reviewed and co-signed by qualified health care personnel no later than the beginning of the next shift when medical personnel are on duty.

b. Within 30 days, certifications shall be filed with the Court specifying compliance with each requirement of this paragraph 15 at all institutions at which new admissions are received.

C. Primary Care/Sick Call -- (All facilities)

16. Within 8iX (6) months, policies and procedures, to be filed with the Court, shall establish a standardized system for the daily handling of non-emergency requests for medical or dental care by inmates. All inmate housing units shall have avallable sick call sign-up lists or medical request slips that shall be gathered by a DOH employee and assessed on a daily basis by trained, licensed health care personnel. Written guidelines shall direct the actions and decisions of the health care providers assigned to triage and handle sick call requests. Disposition of~ these medical requests shall be documented and maintalned for quarterly review by the Quality Assurance Committee.

8

In lieu of a written sick call request system, trained licensed health care personnel shall walk through each housing unit on a daily basis for the purpose of receiving verbal requests for medical or dental care and triaging of complaints. The only exception to these two (2) systems shall be at those facilities (e.g. La Pica, Guavate) where inmates are allowed free and unimpeded access to the medical areas. Dispositions resulting from any verbal requests shall be documented and maintained for quarterly review by the Quality Assurance Committee.

ff 17. All housing units shall be visited by a physician at

i least once monthly for the purpose of enhanced triage

S and review of complaints. Inmates shall be allowed to

9 speak directly to the physician, and appropriate

g documentation of all inmate contacts shall be made by

# the physician.

4

18. Physician-staffed ambulatory care clinics shall be scheduled and documented as required by this paragraph 18:

a. Ambulatory care clinics staffed by a licensed physician shall be scheduled with sufficient frequency to assure that inmates are seen in a timely fashion according to treatment priorities and established clinical protocols. Inmates who request to see a physician shall be scheduled as soon as necessary, as indicated by the qravity of the complaint. Access to these clinics shall be determined exclu_ively by medical staff. Correctional officero and inmates shall not control or limit the access of inmates to medical or dental services.

b. A uniform appointment system shall be established in all facilities and shall be utilized to schedule initial and follow-up clinical visits. All individuals who fail to keep a scheduled ambulatory care clinic vi_it shall be rescheduled automatically unless they have refused to be seen and their condition does not warrant medical follow-up.

c. All appearances at an ambulatory care clinic shall be documented in the medical chart. Complete vital signs, including weight, shall be recorded at each Physician visit.

9

D. Secondary Care -- Infirmary Care

Facilities)

(Regional

19. Within six (6) months, a written plan establishing

policies and procedures for the provision of licensed

physician care and skilled nursing or infirmary care in

each of the designated regional intake facilities shall

be developed and submitted to the Court for review and

approval. The plan shall include the following

components:

a. sites and number of beds, and the criteria used in

t making these determinations;

b. a level of nursing care provided in each infirmary

sufficient to provide twenty-four (24) hour nurse

staffing and to allow nursing notes on each shift

for every patient;

t c. daily supervision by a registered nurse;

d. sufficient physician staffing to provide

twenty-four t24) hour per day coverage (but see,

g paragraph lO(b), suDra);

t e. daily physician rounds, with no less than a weekly

f (or whenever there has been a change in therapy,

; diagnosis, or status) progress notes for each

t patient, including complete vital signs and

r weight;

# f. detailed admission criteria;

g. admission and discharge only by a physician's order;

h. housing of all patient-inmates within sight or

hearing of health care personnel at all times;

i. provision of handicapped toilets and bathing facilities; and

j. a policy stating that infirmaries are not hospitals and shall not substitute for needed hospitalization.

20. Within twelve (12) months, infirmaries shall be established in all regional intake facilities in accordance with this Medical Care Plan. If the demonstrated demand for this level of care i8 infrequent at a particular regional intake facility, the requirement may be met by expedltiously

10

transferring patients to a convalescent unit in another facility.

21. Effective immediately, written policies and procedures shall be developed and implemented that establish guidelines for the use of intravenous fluid therapy in correctional facilities. Intravenous fluid therapy or intravenous medication therapy shall be given only in infirmaries or in emergency care areas under constant, direct observation and supervision of gualified health care personnel.

E. Referrals (Specialty Clinics)

22. Within three (3) months, written policies and procedures that outline in detail a standardized system of referring individuals for specialty care shall be developed and disseminated. The policies shall guide referrals to specialty clinics on-site, in regional intake facilities, in any centralized correctional health facilities or in designated secondary and tertiary care medical facilities. Wherever feasible, a regionalized referral system io to be developed with smaller correctional facilities sending referrals to specialty clinics in regional intake facilities. The DOH shall develop detailed written agreements with designated hospitals or specialistq for the delivery of both on-site and off-site specialty care.

23. Inmates who leave an institution for the purpose of receiving medical care shall be accompanied by a medical consultation sheet to be completed by the consulting physician and to be returned for review by the institutional physician and placement in the inmate's medical record.

24. Whenever possible, all off-site appointments shall be scheduled by telephone. A uniform appointment system and calendar (log) shall be instituted in all facilities. The calendar shall note the date of the appointment, the name and correctional identification number of the inmate being referred, the specialty clinic, the date the referral was requested, the outcome (e.a., cancelled, kept, inmate refused, corrections unable to transport), the return of a completed consultation form, and the date of any return visit scheduled by the consulting physician.

25~ The specialty clinic referral system shall be monitored regularly, and monthly statistics shall be sent to the Regional Medical Administrator, the Regional Medical Director and the Office of the Administrative Director

11

Of Correctional Health Services. Qual$ty Assurance audits of the specialty clinic referral system and the clinical quality of consultations shall be performed reqularly.

g. Chronic Care

26. within six (6) months, a written plan and detailed policies and procedures shall be developed and filed vith the Court for initiating the concentrated housing of inmates with select chronic illnesses or diseases (not requiring infirmary care).

27. Facilities selected to house inmates with chronic illnesses shall provide the following:

a. nursing staff to provide sufficient twenty-four (24) hour nursing coverage for the chronic care unit and adequate coverage for other medical activities within the facility, taking into account its size and functions;

b. physician-staffed ambulatory care clinic at least five (5) days per week (each chronically ill inmate shall be seen in clinic at least once monthly);

c. physician on call during off hours, unless a physician already is on duty 24 hours per day (e.a., regional medical facilities);

d. at least one weekly internal medicine clinic and referral to other specialty clinics as needed;

e. reasonable proximity to a tertiary care hospital of the Department of Health;

f. capability of providing special diets; and

g. appropriate emergency medical equipment to care for this at-risk population.

28* Withln six (6) months, specific written policies shall be developed that detail those illnesses, diseases and conditions that warrant housing in these chronic care facilities. The following illnesses shall be included:

a. diabetes mellitus (insulin and non-insulin dependent);

b~ stable AIDS and ARC not requiring hospitalization;

12

c. cardiac disease;

d. hemophilia;

e. renal failure;

f. complicated hypertension;

g. complicated seizure disorder;

h. anti-coagulation therapy;

i. significant emphysema;

t. active tuberculosis treatment;

k. cancers requiring irradiation or chemotherapy; and

1. other diseases as determined by the responsible health authority.

29. Within twelve (12) months, inmates with chronic illnesses, diseases and conditions, as outlined in the policies required by paragraph 28, supra, shall be identified and be housed in those facilities with enhanced medical services as set forth in paragraph 27, suDra .

30. Within six (6) months, general and disease-specific therapeutic and clinical guidelines shall be developed that standardize the care of patients with chronic illnesses or conditions requ-iring special medical, rehabilitative, or diagnostic services.

a. Within three (3) months, specific therapeutic guidelines shall be developed that define the delivery of prenatal care (prenatal laboratory work-up, frequency of prenatal visits, provision of prenatal diet, and special housing), post partum care ant, for the short-term incarcerated female, the continuation of contraceptive medications. Specific therapeutic guidelines also shall be developed defining access to electiVe abortion. These guidelines shall comport with the laws of the Commonwealth of Puerto Rico and the Constitution Of the United States.

G. Tertiary Care

31* The tertiary care hospitals to be utilized for elective, urgent, and emergency care shall be specifically noted for each facility. Within six (6)

13

months, the guidelines and process for the hospitalization of inmates shall be detailed in written policies and procedures. The responsibilities of the medical and correctional staff shall be clearly delineated.

32. Within eighteen (18) months, a written plan shall be submitted to the Court that reviews the benefits and the feasibility of establishing a combined secure medical-surgical in-patient unit and out-patient holding area at Centro Medico of sufficient bed capacity to meet adequately the elective and urgent hospitalization needs of the AOC population. At a minimum, this plan shall be developed with input from the DOH, including Correctional Health Services, the AOC and the Centro Medico Administration.

H. Emergency Care

33. Within twelve (12) months, there shall be 24-hour emergency medical and dental care availability at each institution, as outlined in a written plan that includes arrangements for emergency evacuation of an inmate from a facility, use of an emergency vehicle, use of designated hospital emergency rooms or other appropriate health care facilities, and security procedures providing for the immediate transfer of inmates.

34. Within eighteen (18) months, all facilities shall have on duty twenty-four (24) hours per day health trained and currently qualified (First Aid, CPR) staff who are capable of respondin to emergencies. In the absence of|medical personnel there always shall be available sutficient numbers f health trained correctional officers who can initiate basic emergency medical care including cardio-pulmonary resuscitation.

35. The availability of emergency equipment shall be standardized throughout the correctional system. Within six (6) months, all facilities shall have at least the following emergency equipment: oxygen tanks and oxygen delivery systems, ambu bag, long back board and neck stabilizers, splints, dressings, slings, oneway valve CPR masks, stretchers, wheel chairs, intravenous fluid and administration setups, dispoSable gloves, and face masks. Regional intake facilities and other facilities selected to house chronic medicallY ill patients also shall have crash carts with emerGenCy medications, suction machineq and intubation equip

In the absence of medical personnel, first aid kit<, stretchers~ and other appropriate emergency eqUlPment

14

shall bs readily available to health trained correctional staff, who shall initiate basic emergency care pending the procurement of professional medical assistance.

36. Within twelve (12) months, each correctional facility the location of which precludes the use of Emergency Medical Services Ambulances shall have an enclosed multipurpose van that can be used to transport safely emergency patients requiring stretchers, intravenous fluid, or the continuatlon of cardio-pulmonary resuscitatiOn .

37. Within three (3) months, first aid kits shall be readily available in designated areas of each facility. The contents, number, location, procedures for use, monthly inspection, and restocking of the kits shall be approved by the responsible health authority. Monthly inspections shall be documented. The first aid kits shall be situated for use by the correctional staff pending the procurement of professional medical assistance.

38. Within twelve (12) months, written policies and procedures that outline the medical staff's response to an institutional disaster (e.a., riot, hurricane or fire) shall be prepared, approved, and disseminated. The medical care components of the disaster plan shall be tailored to each individual facility and shall be practiced at least annually. Disaster drills shall be fully documented, and reports of drills shall be submitted to the Quality Assurance Committee. These policies and procedures shall be approved by the responsible health authority and the Administrator of Corrections. The medical disaster plan for each facility shall be signed by the Institutional Medical Administrator, the Chief Physician, and the Superintendent.

I. Physical Therapy

39. Within twelve (12) months, basic physical therapY services shall be available for no less than twenty (20) hours per week at a facility to be designated by defendants. Physical therapy services, as ordered by a physician, shall be provided by an appropriately trained and licensed physical therapist and other appropriately trained and 1 4 censed personnel~ As needed, additional off-site physical therapy services shall be arranged by the medical staff.

15

J. Physical Examinations

40. Guided by written protocols, routine health maintenance evaluations and examinations shall be performed no less than annually for all inmates. Within twelve (12) months, a standard form shall be developed and introduced for the purpose of conducting these physical examinations. In determining the specific exams and tests to be performed, the protocol for annual evaluations shall take into account the inmate's age and risk factors. The guidelines of the American Cancer Society shall be incorporated into the annual evaluations. The standard form and evaluation shall include the following:

a. oral inquiry into the status of current medical and dental health;

b. complete vital signs, including weight;

c. hands-on physical examination;

d. vaccination update (diphtheria-tetanus, rubella, influenza, and others as indicated by the Medical Director of the Correctional Health Service);

e. indicated laboratory tests;

f. health education (e.co, AIDS, cancer, smoking, cholesterol);

g. examination and testing for tuberculosis and sexually transmitted diseases;

h. genital examination for all males; and

i. in the case of females, pelvic and breast examination and a Pap smear;

rv. Traininq and Staffing

A. Training

41~ In order to insure that minimally adequate constitutional medical treatment is afforded to prisoners, all medical employees shall conform to all Commonwealth laws concerning training, licensure~ and scope of activities.

42~ A health related training program including the C°mponentA set forth in this paragraph shall be developed and implemented.

16

a. Within three (3) months, the AOC shall implement a health related training program for correctional officers. Correctional Health Services (DOH) must review and approve the content of this training program, which shall include at least the followinq areas:

b.

I,>o, - ,-,, 9 }

. .?

1. first aidi

2. cardio-pulmonary resuscitation; / < P R

3. recognition of -life-threatening -emergency situations and acute manifestations Or chronic - illnesses, -¢including mental illnesses:

4. procedures for disposition and referral;

5. -intake screening, including indications for immediate referral of an inmate for medical or ~ a ip~ and t

6. AIDS and its prevention.

Health related training will be provided to all correctional officerq employed by the AOC on the schedule set forth in this subparagraph. Within six (6) months and at all times thereafter, all new correctional officer trainees shall receive health related training. Within -two-(2) yesrct 50% of all correctional officers in the AOn rhs1 1

the CInlFIir--or in-related vrainingLLproqram, and-wi

eears. 75% of all correntl procedures to be submitted to the Court $n twelve (12) months.

43. within six (6) months, a program of initial orientation and ongoing in-service training shall be initiated for all primary care health care providers. Part-time staff and all shifts shall be mandated to participate. There shall be a minimum of 12 hours of annual inservice training (e.a., one hour per month presentations). Doqumentation -~(topic,~-date,~y participants) shall be maintained on-site and in thej office of the Administrative Director of>Correctional > Health Service~s,_as well as -in tndividual personnel \ files.

44. systenwide and regional clinical and administrative meetings shall be scheduled regularly. The regional and systenwide meetings may include all health care provider groups or may be divided into separate sessions for clinical, administrative, pharmacy, medical records and other staff.

4s. Within twelve (l2) -months,ttall clinical h S th rcare providers f(physicians, nurses, dentists,> ~ )tshall have been wtrained --in rbasic -~life ~<support CardioPulmonary Resuscitation (CPR);:--and documentation of current CPR certification shall be maintained in their personnel file.~

46. Within twenty-four (24) months, correctional or medical personnel with basic training and current qualification in first aid and basic life support CPR shall be posted continuously within voice or visual contact of all inmates in housing or service units.

B. Staffing

47. As soon as possible, but at the latest within one (1) year, each correctional facility shall have a designated Chief Physician responsible for all clinical aspects of the facility's health care system and for coordinating with DSCA treatment of alcohol and drug abuser5. An Institutional Medical Administrator, who may be the Chief Physician, will be hired to manage the administrative aspects of the system. The chief physician at each of the regionalized intake facilities shall be board eligible or certified in a primary

medical care field (internal medicine, family practice or emergency medicine) to the extent that this can be accomplished through reasonable and good faith efforts by DOH. The Institutional Medical Administrator at each of the regionalized intake facilities shall have

18

shall have

tlhLs target is reached7~d- endants shall continue to provide a program of health related training for untrained officers in order to achieve the objective set forth in the first sentence of this rubparagraph.|Pocumentationtof completion of the health ~relateS training- progr

orre-ct-io~nair~ officers who have succ-~st-ully completed all aspectq of health training and are currently qualitied will be required to wear health certification Datches.;

c. The health related training program shall be an integral, ongoing component of the training and re-training of all correctional officers. The retraining interval, not to exceed three (3) years, shall be governed by written policy and

17

experience in health-care administration. Each region may have a correctional health area supervisor who will supervise all aspects of health care at all correctional facilities in that reqion.

48. As soon as possible but at the latest within t2) two years, minimum staffing levels consistent with this Medical Care Plan shall be achieved. The following guidelines shall be supplemental to other guidelines that are set forth in this plan.

a. Regional intake facilities with intake medical screening, infirmary care, and chronic illness

programs shall have 24 hours per day nursing and physician coverage 7 days per week (but see, paragraph lO(b), supra). The evening physician coverage may be provided by medical residents-in-training who have medical licenses and appropriate primary care qualifications.

b. Campamentos and institutions not included in paragraph 48.a, supra, with populations Of 300 or more inmates shall have 24 hour per day nursing coverage 7 days per week and S day per week physician sick calls with a physician on call ln tha off hnursx.

c. Campamentos and institutions with populations of less than 300 shall have 16 hour per day nurse staffing on weekdays and no less than 8 hour per day nurse staffing on weekends and holidays, and 5 day per week physician sick calls, with a physician on call in the off hours.

d. Campamentos and institutions with populations of less than 100, but with immediate access to local hospitals, shall have 8-12 hour per day nurse staffing on weekdays and 4-8 hour nurse staffing on weekends and holidays, and 3-5 day per week physician sick calls with a physician on call in the off hours.

e. Tn addition to the minimum staffing requirements set forth in subparagraphs (a) through (d) of this paragraph 48, the exact number of nurses, physicians, secretarial and clerical personnel required to provide reasonable access to health care and adequate coverage Of emergencies shall be

- determined with due consideration of the total population, location, physical plant and the medical needq of a facility's inmate population.

19

f. A sufficient number of supervisory and support staff shall be assigned and, when necessary or appropriate, employed in a tlmely manner for the purpose of implementing this Medical Care Plan. In determining the appropriate staffing level for this purpose, top priority shall be given to meeting each and every objective and timetable set forth in this plan.

49. Within 9O days, the DOH shall prepare and submit to the Central Personnel Office (OCAP) a reimbursement schedule for physicians, dentists and nurses whose services are required to achieve the purposes and objectives of this Medical Care Plan. The schedule, a copy of which shall be filed with the Court, shall take into consideration travel allowance, malpractice insurance, and continuing medical education. The reimbursement schedule for professionals shall be at a level sufficient to recruit and retain ;qualified professional staff including specialists.

50. The DOH shall endeavor to establish affiliations between the Correctional Health Care Service and the medical, dental, and nursing schools and residency training programs in the Commonwealth of Puerto Rico and, if necessary, elsewhere. The relationship established may include allowing appropriately trained and licensed residents to provide evening staffing ot select correctional facilities or to provide staffing of primary care or specialty clinics. It also may include contracting for the delivery of primary and secondary care in a facility or region and arranging clinical rotations for students.

51. No inmate shall be employed in the medical and dental care delivery system except for assignments that essentially are janitorial in nature.

V. Other Considerations

A. Space and Equipment

52. Within twelve (12) months, the DOH and the AOC shall produce a written toint evaluation of the health care space and equipment in each of the Commonwealth's correctional institutions. The evaluation shall detail the type ot medical equipment (e.co, emergency, diagnostic and transport) available, the location or space and equipment in the institution, the size and adequacy ot clinical, administrative and storage space (noting the number ot examination rooms, offices, nursing stations, etc.), the condition and state of

20

repair of the areas and the equipment, and the availability of handwashing and toilet facilities.

53. Within two (2) yearst the AOC and the DOH shall jointly provide sufficient clinic space and non-emergency equipment in all facilities for the delivery of adequate health care in accordance with this plan.

54. Within six (6) months, all correctional medical facilities shall have telephone service in the medical units to facilitate medical transfers, the arrangement of consultations and diagnostic testing, and the coordination of the emergency medical responses.

55. Within six (6) months, each facility's medical unit shall have c~rrent editions of medical reference texts, which at a minimum include the following: Physician's Desk Reference, general medicine text, general surgery text, emergency medical text and, in institutions housing female prisoners, an obstetrical-gynecology text.

B. Pharmacy

56. Within twelve (12) months, pharmaceutical services in all correctional facilities shall be directed and supervised, according to written policies and procedures, by a systemwide Director of Pharmaceutical Services who shall report directly to the Administrative Director Of Correctional Health Services. Each regional intake facility shall have a pharmacy staffed by a chief pharmacist and at least one (1) additional pharmacist for every 750 inmates. The Chief Pharmacist at each regional intake facility (with the exception of Vega Alta) shall be designated as the Chief Pharmacy Area Supervisor for all correctional facilities in that region. The Chief Pharmacy Area Supervisor or his designee shall inspect and monitor the pharmaceutical services provided in each correctional facility in the region. A sufficient number of pharmacists and pharmacy assistants shall be hired according to the needs and size of each institution, but all facilities with more than 750 inmates will have at least one (1) pharmacist and one (1) pharmacy assistant. The number of pharmacists at each regional intake facility shall be adequate to provide pharmaceutical services in that facility and to supervise all pharmacy assistants in each region's correctional facilities. A written formulary of all medication used in AOC facilities shall be established by the Medlcal Director of Correctional Health Services and the Director of Pharmaceutical Services.

21

57. In order to $nsure that mlnimally adequate constitutional medical care is afforded to prisoners, pharmaceutical services in the Correctional Health Services system shall comply with all applicable Commonwealth and federal laws.

58. Beginning immediately, only pharmacists, pharmacy assistants under the direct supervision of a pharmacist, physicians, or nurses under direct physician supervision shall be permitted to dispense prescribed medications. The Institutional Medical Administrator shall implement appropriate procedures to ensure that this policy is followed. No correctional officer or inmate may be involved in the delivery or administration of any prescribed medication.

59. Within six (6) months, written documentation of each medication prescribed or the written prescription itself shall be maintained in a section for prescribed medication in the inmate's medical chart. Documentation of the medication administration (given, refused, out-to-court, no show, etc.), including administration of injectables such as insulin, shall be noted in the medical chart. If noted on a monthly medication sheet, the completed medical sheet shall be placed in the medical chart. No inmate shall be deprived Of a prescribed diet or of medication as a punitive or disciplinary measure.

60. Within three (3) months, a system shall be implemented by the pharmacy or nursing staff that notifies the health care providers of the impending expiration of a prescribed medication. At no~time will a prescription be renewed for more than three (3) months without a physician's reevaluation at sick call.

61. Beginning immediately, all routine medical supply and pharmaceutical orders to the central warehouse shall be filled and returned to the ordering facility within two (2) weeks. Emergency requests from the warehouse shall be filled on the next work day. Within three months, written procedures shall be in place to allow individual correctional facilities to procure from alternative sources (e.a., private pharmacies or local hospitals) all medications for which there is an emergency shortage and unusual medications or supplies not readily available from the central warehouse. Limited pharmaceutical supplies shall be maintained at each institution, and these supplies shall be inspected on a reqular basis.

22

C. tahoratory and Radiology Services

62. Laboratory and radiology services shall be provided pursuant to the provisions of thiR paragraph.

a. Within three (3) months, policies and procedures shall be established for obtaining needed laboratory diagnostic and radiological services for inmates in the AOc. The system shall provide for the timely completion of ordered tests and for timely return of test results to the health care provider. These policies and procedures shall ensure adequate provision of transportation.

b. Within twelve (12) months, each and every correctional facility must have fully implemented a system to provide laboratory services that includes daily pickup of specimens, a turnaround time of no more than 48 hours for routine laboratory tests, the capability of obtaining "stat" laboratory tests within four (4) hours, the development of a "panic" value protocol in which results falling outside established norms are immediately communicated to the facility's medical providers, and the prompt review and signing of all laboratory results by the facility's physician prior to their placement in the medical chart. Correctional health services may choose to establish on-site laboratories or to contract with private or public laboratories. If on-site laboratories are created, a written laboratory manual of policies and procedures shall be developed. In order to insure that minimally adequate constitutional medical care is afforded to prisoners, all on-site laboratories shall comply with the laws of the Commonwealth of Puerto Rico.

c. Pending the full implementation of the laboratory services system, Correctional Health Services must immediately establish an emergency plan to assure that adequate and timely laboratory services are Provided in all facilities.

d. Within six (6) months, every facility of the AOC shall have equipment and/or testing capability, together with written protocols for testing, as follows:

1. multi-test dipstix urinalysis;

2. finger stick blood glucose tglucose range

23

0-600);

3. peak-flow meter (hand held or other);

4. stool blood testing; and

5. in institutions housing female prisoners, a microscope, slides, slide covers, and normal saline and potassium hydroxide (KOH solution.

e. Within twelve tl2) months, on-site, non-contrast radiology services shall have been instituted at all regional intake facilities. All x-ray studies done on-site in a correctional facility shall be reviewed preliminarily and initialled by a physician prior to being sent out for interpretation by a radiologist. The turnaround time for the return of the radiologist's report shal} be no more than 72 hours. Within twelve (12) months, written policies outlining the procedures for obtaining contrast x-ray studies, ultrasound testing, and other special radiological studies shall be developed and implemented, and these policies shall be reviewed on an annual basis.

f. In order to insure that minimally adequate constitutional medical care is afforded to prisoners, radiological units in correctional facilities shall be constructed and regularly inspected in compliance with Commonwealth and federal laws. All radiological procedures shall be performed by l$censed radiology technicians or other trained medical personnel as permitted by the laws of Puerto Rico.

D. Medical Records

63. Within six (6) months, a registered Record Administrator shall be employed to supervise the medical record system for the entire Correctional Health Services system. This individual shall coordinate and develop all policies and procedures concerning medical records. Within one (1) year, each regional intake facility shall have at least one (1) registered record administrator or accredited record technician to coordinate and supervise all institution medical record clerks in the designated region. All facilities with 200 inmates or more shall have at least one full-time Medical Record Clerk. Each regional facility shall have one full-time medical record clerk

24

for each 500 inmates. Smaller facilities may delegate medical record duties to non-medical techniclans (institutional medical administrator, nursing staff, etc.); however, the work of these individuals shall be reviewed frequently by a registered record administrator or an accredited record technician.

64. As soon as possible but within one (1) year, the medical record system, the medical chart and all medical forms must be standardized throughout the Correctional Health Services system, and shall be maintained and used in accordance with the following provisions set forth below.

a. Each sentenced prisoner and pre-trial detainee shall have a permanent medical record initiated at intake. This record shall reflect the inmate's initial contacts with a physician, dentist or psychiatrist. Records developed during prior periods of incarceration shall be called up for inmates returning to the system.

b. The medical chart shall be filed and cross referenced using the inmate's AOC identification number, name, and date of birth.

c. The medical chart shall be organized in sections using clearly identified dividers. At a minimum, the various sections shall include the following:

1. medical, dental and psychiatric progress notes:

2. x-ray results;

3. laboratory results;

4. prescriptions (or copies/written documentation of prescriptions) and physician orders; and

5. consultations.

d. Each medical chart shall have a problem list and shall contain copies of all prescription medication and treatment orders.

e. The S.O.A.P. (Subjective/Objective/Assessment/ Plan) format shall be utilized by all health care providers.

f. All laboratory results, x-ray results and

25

consultations shall be reviewed and initialled by a physician prior to being filed in the medical chart .

g. The complete medical record, including results of intake medical screening, health assessments, tuberculosis, sexually transmitted disease testing, and prescriptions, shall accompany all inmates being transferred from one institution to anothur for housing. The medical record shall be transported in a sealed envelope or pouch as determined by the responsible health authority.

E. Hedical Diets

65. Within three months, special therapeutic diets as ordered by qualified medical and dental personnel shall be provided by the AOC. At a minimum, low sodium, low cholesterol/fat, prenatal, diabetic (varied caloric levels), dental soft, broken jaw, weight reduction (controlled calories) and other special diets shall be prepared separately or in combinations as prescribed by a physician. No less than every six (6) months, a registered dietician shall review the regular and therapeutic diets for nutritional adequacy.

F. Food Service Workers

66. Written policies and procedures, to be implemented within six months, shall require that all food service workers involved in the preparation or distribution of food are free from diarrhea, skin infections, and other illnesses that are transmissible by food or utensils. On a daily basis, all food service workers shall be monitored for health and cleanliness by the non-inmate coordinator of food services. All food service workers shall wear disposable gloveq when they are involved in any preparation or distribution of food that requires food to be touched.

G. Dental Care

67. Dental care shall be provided in accordance with the following provisions of this paragraph.

a. Within six (6) months, policies and procedures shall be established for obtaining emergency and non-urgent dental care by a dentist licensed in the Commonwealth of Puerto Rico. Within twelve (12) months, all inmates shall receive dental screening by trained medical or dental personnel at the time of or within seven days of admission,

26

and all sentenced inmates shall receive a dental examination by a licensed dentist within 30 days of sentencing.

b. Dental Care: At a minimum, the dental care provided to pr$soners shall include fillings, extractions, relief of pain and infection, minor repair and adjustment of dentures, basic hygiene and cleaning, pulpotomies and root canals. Full and partial dentures shall be provided to sentenced inmates. Written policy shall describe conditionr for which endodontic, periodontic, prosthetic and prophylactic services will be provided. Among factors to be considered before instituting a major or lengthy course of treatment are the potential effect on the prisoner's health and the expected length of the stay in the prison system. Written agreements shall be made with dentists and oral surgeons to provide necessary services that can not be provided by the dental staff in the correctional facilities.

c. Within six (6) months, a full-time licensed dentist shall be employed as Dental Director of Correctional Health Services to supervise all dental care provided in the correctional health system.

d. The Dental Director shall spend no less than twenty (20) hours per week (half-time) in the fulfillment of the administrative responsibiiities of this position. The Dental Director also may be assigned to provide primary dental care in one of the correctional institutions.

e. Within twelve (12) months, the Dental Director shall produce a written evaluation of the personnel, facilities, and equipment necessary to provide adequate dental care to all inmates in the AOC. This evaluation shall include an assessment of the adequacy of the current dental staffing, facilities, and equipment, and the evaluation shall be filed with the Court.

f. Within twelve (12) months following the filing of the evaluation required by subparagraph 67(e), suora, all deficiencies in dental services noted in that evaluation shall be corrected.

H. Prosthetic Devices

68. Within six (6) months, eyeglasses and other usual

27

prosthetic devices shall be provided to inmates who require them to function in the correctional setting. Policies and procedures shall be developed concerning the guidelines and system for obtaining prosthetic devices. The arrangement for payment of costs for prostheses shall be delineated in the written agreement between the AOC and the W H.

I. Hrv Infection

69. An intensive program encompassinq all aspects of HIV (Human Immunodeficiency Yirus) infection (education, prevention, screening, special housing and treatment) shall be expeditiously and aggressively established. In addition, training and educational programs for inmates, correctional staff, and medical employees shall be developed and implemented.

a. Beginning in three (3) months, all male inmates with Acquired Immune Deficiency Syndrom (AIDS) or Symptomatic Aids Related Complex (ARC) shall be transferred to facilities which have twenty-four (24) hour per day nurse staffing and increased access to primary, secondary, and tertiary care services. This transfer program is a temporary measure to expeditiously upgrade the care available to inmates with AIDS and symptomatic ARC. The transfers will allow Correctional Health Services to concentrate its services for this select group of inmates whose condition warrants enhanced monitoring and increased access to medical care.

b. With the development of enhanced health care services in other correctional facilities, inmates with AIDS, ARC, or advanced HIV infection shall be assigned to institutions housing individuals with other chronic illnesses, diseases, or conditions (E£~, paragraph 28, sucra). Individuals with significant debilitation (whether due to HIV infection or other illnesses) whose condition warrants extensive nursing care but not hospitalization shall be evaluated for admission to the special care unit currently situated in the Annex to the State Penitentiary, the infirmary in the State Penitentiary @@Hospital" or another suitably staffed and equipped facility. Referral for specialty consultation, hospitalization, or housing in a special care unit shall be expeditiously arranged as the patient's clinical condition dictates.

28

c. Under no circumstances in any institution are inmates to be segregated from other inmates solely because of their HIV infection.

d. Inmates with documented or suspected HIV infection shall be evaluated no less than monthly in ambulatory care clinic. Until fully stable, inmates with AIDS and symptomatic ARC shall be evaluated at least weekly in Zick call and monthly in rnternal Medicine Clinic.

e. Clinical, diagnostic and therapeutic guidelines concerning HIV infection and its complicated presentations shall be immediately developed and disseminated (and frequently updated) to all health providers in the Correctional Health Service. These guidelines shall minimally include the components set forth below.

1) All HIV Ab positive individuals shall be referred for counselling about AIDS and its prevention;

2) All HIV Ab positive individuals shall be seen at least monthly in sick call;

3) Asymptomatic HIV Ab positive individuals must have a CD4 Symphocyte Assessment done every six (61 months;

4) Chest x-rays must be performed at least annually on inmates who are known or strongly suspected to be HIV infected;

S) A PPD (T8 Test) of >Sm~ will be considered reactive in all HIV Ab positive patients;

6) Any further recommendations emanating from the Center for Disease Control will be lmplemented.

f. Within 90 days, defendants shall file, for the Court's review and approval following an opportunity for objections by plaintiffs, a protocol relating to the medical treatment of individuals with HIV infection and setting forth the therapeutic modalities to be used for treatment of these individuals. ~

g. Within 8iX (6) months, a comprehensive educational program shall be developed to instruct all inmates, correctional stat£, and correctional

29

health employees about HIV intection and its prevention. Within 8iX (6) months, at least four (4) health educators shall be employed and trained, and within twelve (12) months four (4) additional health educators shall be employed and trained. Overall the Correctional Health Services shall employ and train at least one (l) health educator for each 1,000 inmates $n the Administration of Corrections. The health educators will provide education in group and oneon-one sessions.

h. A system shall be established and promulgated for the voluntary HIV Ab testing of inmates. Pre-test and post-test counseling shall be provided.

i. Correctional Health Services shall educate prisoners concerning the use of preventive materials and measures needed to prevent the dissemination of HIV infection among inmates in the correctional facilities of Puerto Rico.

Vl. Quality Assurance

70. Within twelve assurance shall components, for system.

(12) months, a system of quality be established, with the following the entire correctional health care

a. Within six (6) months, a Quality Assurance Committee including appropriate health care representatives of the W H, DSCA and the AOC shall be formed and functioning. The Committee shall coordinate all quality assurance activity with respect to health services in the correctional system. Within six (6) months, a-director of the Division of Quality Assurance shall be appointed and shall coordinate, implement and evaluate quality assurance activities under the guidance of and in conjunction with the Quality Assurance on ; ittee .

b. Within twelve (12) months, each regional intake facility shall have a Regional Quality Assurance

~ Coordinator who shall assure that directives of the Quality Assurance Committee are carried out. Quality assurancs shall include at least monthly reviews of medical charts at each of the facilities. All results of quality assurance audits and review shall be forwarded to the central Quality Assurance Committee. At a minimum, the Quality Assurance Committee shall

30

review inmate mortalities, staff performance, adequacy of documentation with regard to medical records, utilization review, the care of select chronic and acute illnesses (AIDS, diabetes, etc.), specialty services and the specialty referral system, infirmary care, emergency care, and disaster drills.

VII. Health Education Division

71. A Public Health Education Division shall be established. The responsibilities of this Division shall include the coordination, design and implementation of a continuous education activities plan for the entire prison system. These activities will be programmed both for medical personnel and inmates. Activities will be coordinated and scheduled conveniently to insure the greatest participation. The HIV health educators shall be incorporated into the Health Education Division.

VITT Modification of Plan

72. The DOH, in coordination with the AOC, may submit to plaintiffs' counsel, through the Court Monitor, recommendations for variance from any provision of thiR Medical Care Plan if the proposed variance satisfies the intent of the provision for which variance is sought. If plaintiffs' counsel agree to the variance, the parties shall file a joint motion for modification to permit implementation of the variance. In the absence of agreement by the plaintiffs, any motion for modification by defendants shall be subject to the procedures and standards provided for by law. Likewise, plaintiffs' counsel may submit to defendants' counsel, through the Court Monitor, recommendations for modification of this Medical Care Plan if they believe that the modification is required to achieve the objectives of this plan. If defendants agree to the modification, the parties shall file a joint motion for

modification for the Court's consideration. In the absence of agreement by defendants, any motion for modification by plaintiffs shall be subject to the

procedures and standards provided for by law.

31

APPENDIX B

~N\bAL~ HEALTH PL~N

The Administration of Corrections

The Commonwealth of Puerto Rico

TABLE OF CONTENTS

Page Nwmher

I. OBJECTIVES OF THE MENTAL HEALTH CARE DELIVERY SYSTEM. .

II. LEVELS OF CARE.

A. DIAGNOSTIC AND RECEPTION SERVICES.

B. OUTPATIENT TREATMENT.

C. INTERMEDIATE TREATMENT.

D. ACUTE TREATMENT. .

III. INITIAL NEED ASSESSMEhx -- -n-ffiwra;x owars^s^~ A^-~

RECEPTION/SCREENING. ~. . . . . . . .

IV. IMPLEMENTATION OF THn ~...~ &s~A~& __,

V. USE OF PSYCHOTROPIC MEDICATION.

VI. TRAINING. .

VII. ACCESS TO M

VIII.QUALITY ASSURANCE.

IX. MENTAL HEALTH RECO

X. INVOLUNTARY TRANSFER A

XI. REPORTING REQUIREMENTS.

XII. MODIFICATION OF PLAN

I. OBJECTrVES 0F @r^s MENTAL EEALTH CARE DELIVERY SYSTEM

1. All inmates in the Administration of Corrections (^OC) shall be provided with mental health services that are adequate to maintain their basic mental health.

2. All mental health services shall be delivered by personnel responsible to the Assistant Secretary of Mental Health. All existing components of the current mental health

,i jsystem, including contract psychiatrists employed by the AOC,

\,- > WW

\,, b'

/shall be transferred to the jurisdiction of the Secretary of Health and combined into a coherent program for the delivery of mental health services under the direction of the Assistant Secretary of Mental Health. Provision of clinical services by the Unidad de Evaluacion y Asesoramiento ("UEAn) shall be replaced by mental health care providers as required by this plan, and the function of the UEA for the purposes of this Mental Health Plan shall be limited to making appropriate referrals to those providers. This provision does not limit other functions of the UEA pursuant to Law 21 of July 10, 1978.

3. In accordance with the timetable set forth in section

IV of this Mental Health Plan, Correctional Regional Mental Health Units ICRMHU) shall be established at no more than six

regional intake facilities, including Vega Alta and a-q9Sail-iSy for youthful offenders (age 22 and younger). Each CRMHU shall employ a mental health team, which shall fulfill the following functions:

a. reception screening; vv

b. evaluation and triage of referrals; >~

c. crisis lntervention and Psychlatric Intensive Care >, Unit (PICU) care;

d. intermediate care;

e. outpatient care;

f. case management;

g. training of correctional officers;

h. provision of information to the AOC and the Parole Board, as appropriate;

i. screening and treatment services in protective custody units;

j. close coordination with and consultation to the Hedical Department; and

k. close cooperation with and provision of mental health informatlon to the Classification Committee so as to promote the best interest of patients' rehabilitation and the prevention of illness.

4. Each CkMHU team shall consist of one or more full-time psychiatrists, including a Regional Chief Psychiatrist, Ph.D. clinical psychologists, graduate level psychologists, social workers mental health technicians and appropriate support

(e.a.,

personnel, including nurses, activities staff occupational/recreational therapists), medical record clerks and secretaries. Based on current mental health needs, and until final staffing levels are determined in accordance with the

assessment completed pursuant to of this Mental Health Plan, the

results of a sy-stem-wide need the provisions of section IV following full-time equivalent staff to patient ratios shall be considered the initial staffing target at each CRMHU: Out-Patient Staff

(1) Psychiatrists -- 1 to 100 patients; (2) Psychologists -- 1 to 50 patients: (3) Social Worker/Case Manager -- 1 to 75 patients;

2

(4) Mental Health Technicians -- 1 to 30 patients; (5) Nurses -- 1 to 100 patients X two shift~; (6) Stenographer/Secretary -- 1 to 3 clinicians; 17) Nursing Supervisor -- 1 to 5 nurses;

In addition to the out-patient staff that are required, additional staff will be employed to maintain the following intermediate care staff to patient ratios:

7

Intermediate Care Staff to Patient Ratios

(1) Ph.D. Psychologist -- 1 to 50; (2) Social Worker, Masters level -- 1 to 50; (3) Activities/Recreational Therapist -- 1 to 50;

No inmate shall be employed in the mental health delivery system except for assignments that essentially are janitorial in nature; the Department of Health (DOH), however, may submit a proposal for the Court's review and approval to allow inmates, after security clearance by the AOC, to be classitied and assigned to a supportive and rehabilitative role following proper screening and training and under careful supervision.

^ 5. At the time of the completion of the need assessment, 4pach region shall provide outpatient counseling services in all 2~ CRMHU's and in no more than two Institutional Mental Health Units

\ p ' (IMHU). Each regionapNMHU shall have a counseling unit, without ta f esychiatric capability, comprised of at least one ~ 1 g ~ or more mental health clinicians and sufficient

s ~ personnel>__~ncludin~

secretarie^r~and_5tanDgraphersr~to;

manage the mental health records system. At each IMHU, a Ph.Dt

psycholo Wst may serve-as administratiye director, ~ _

~ - -,

maintain an outpatient caseload. He shall be responsible to the

1 The number of mental health technicians required i~ determined more by the number of admissions to be screened than by active caseloads.

Chief Psychiatrist of the C^MHU for the region in which the IMHU is located. ThlZ paragraph shall not preclude the development of other levels of secondary care, for example an IMHU with some psychiatric capability, as determined by the need analysis and other factors.

To the extent feasible, a minimal counseling capability wlll be maintained at all other institutions through the services of one or more supervised, licensed psychologists or supervised psychological interns who shall assist the efforts Of AOC counselors in psycho-social rehabilitation of inmates by providing counselling services on an lndividual or group basis as needed and by providing consultative and triage services for the institutional medical personnel. These personnel shall be supervised by nearby IMHU chief psychologistsA or through any

9 _ ~_

other appropriate supervisory mechanism.

II. LEVELS OF CARE

A. DIAGNOSTIC AND RECEP5bION SERVICES.

6. All prisoners shall be admitted through an institution that has a CRMHU. At the time of admission or, at the latest within twenty-four (24) hours of admission, all prisoners shall be screened by health care staff for suicidal risk, any present use of psychotropic medication and gross mental illness. Any prisoner falling into one or more of these categories shall be referred for immediate mental health assessment.

7. Within seven (7) days of admission, all prisoners not referred for immediate mental health screening pursuant to paragraph 6, supra, shall receive a mental health Assessment by one or more qualified mental health~pr ctitissexa .to determine the need for treatment and the level of care required by the inmate for the purpose of his or her mental health classification. No prisoner shall be transferred from a CRMXU until he or she has received a mental health screen$ng and has been referred for treatment and/or classification.

8. Each CkMHU shall maintain a psychiatric Intensive Care

Prisoners in any institution requiring acute

Unit (PICU) psychiatric care or emergency treatment shall be referred immediately to the PICU for that region, where they shall be housed in the medical infirmary in single rooms dedicated to

mental health use. So long as one or more single rooms are available for PICU. additional small multiple-bed dormitories $wenty-four hour medical and nursing

(2-4 beds) are appropriate. coverage shall be available in each PICU for medical emergencies.

intensive psychiatric treatment, Diagnostic observation, therapeutic and recreational activities, both outdoors, and any examinations required for the involuntary hospitalization of a patient shall be provided by the CRMHU out-patient team. The AOC shall provide, upon adequate notification by DOH, appropriate security coverage to permit the recreation and other therapeutic activities described in this paragraph. Prisoners who have received treatment in a PICU shall be transferred to an outpatient case load or to an appropriate indoors and intermediate or acute care environment, depending on their clinical needs. Until the completion of the need assessment, each CRMHU shall develop the following number of infirmarY beds for PICU patient~: a minimum of 2 per 1,000 prisoners.

B. OUTPATIENT TREATHENT.

9. Each CRMHU and each IMHU Ahall provide outpatient counseling for prisoners whose mental health condition does not require a more intensive level of treatment. Outpatient treatment shall consist of a variety of treatment modalities, including crisis intervention, diagnostic evaluation and assessment, individual and group psychotherapy, and counseling.

10. Prisoners with behavioral or emotional instability or character disorders, but who (1) are without severe psychiatric illness, (2) do not require psychotropic medication, (3) have no significant history of mental illness or extended psychiatric hospitalization, and (4) are able to function in the general population without requiring frequent crisis intervention, shall be assigned to either a CRMHU or an IMHU for outpatient treatment.

11. Prisoners who meet the criteria for assignment to an IMHU pursuant to the provisions of paragraph 10, supra, but who also have a disabling psychiatric disorder, have a historY Of

recent or extensive hospitalization, or currently receive or are in need of psychotropic medication, shall be assigned to an institution with a CkMHU. Likewise, any patient requiring

emergency care, hospitalization or intermediate care, or whose needs otherwise cannot be met in an IMHU, shall be transferred to

the appropriate CRMHU for evaluation and treatment. No prisoner shall be transferred directly fron an IMHU to the ForensiC Hospital.

C. INTERMEDIATE TREATMENT.

12. Each CRMHU shall maintain a psycho-social unit (PSU)

that provides intermediate mental health treatment to chronic mentally ill prisoners who do not require hospitalization, but whose mental health condition requires separation from the general population of an institution. Each PSU shall provide long-term mental health rehabilitative treatment serviceZ, including psychological, social, educational, and vocational services, as well as transitional and convalescent care for patients returning from the Forensic Hospital. A prisoner requiring psychotropic medication shall be housed in a PSU onlt if he or she also requires intermediate care.

13. Until the need assessment is completed and appropriate numerical adjustments are made, each CRMHU shall establish the following number of intermediate care beds: ten intermediate care beds per 1,000 inmate population.

14. Until the completion of the comprehensive need assessment required by this Mental Health Plan, the long term mental health rehabilitative program at Guerrero shall be downsized to accommodate a maximum of 144 prisoners who meet criteria established by the Secretary of Health, and the excess population shall be transferred to other AOC facilities as guickly as defendants are able to effect transfers and provide each prisoner within the AOC at least 55 square feet of living and sleeping space. The number of spaces may be modified if a greater number of individuals need admission to Guerrero. The ultimate size of the population at Guerrero shall be established by the need assessment, and that population shall consist only of mentally ill prlsonerR who meet the criteria established by the Secretary of Health. A mental health treatment team and

7

sufficient administrative staff shall be established and maintained at Guerrero to meet the mental health treatment needs of the inmates assigned there.

15. The Administrator of Corrections and the Secretary of Health through the Assistant Secretary for Mental Health shall develop and sign a Hemorandum of Agreement that addresses the joint operation of all protective milieus, including Guerrero as well as PSU'^. At a minimum, the agreement shall address the following issues: admissions policy, inmate discipline, freedom

of internal movement by patients for medical or therapeutic activities, staffing and training, and the extent to which a

redefinition of the role and functinns of correctionr officers

will be necessary. Guerrero and all PSU's shall be staffed by specially trained Mental Health Correctionr Officers. Finally, more general features of the agreement shall encompass jointly developed policies and procedures in the areas of (1) transfer of patients, especially to the Forensic Hospital, (2) escort of patients within the institutions, and t3) security of patients and staff during mental health examinations.

D. ACUTE TREATMENT.

16. No later than July 1, 1993, defendants shall open a new or renovated Forensic Hospital that iR capable of meeting JCAH standards within one year of its opening. Evidence of the availability of adequate fundlnq for the required construction or

renovation shall be filed by defendantg no later than August 1,1 1990. The new or renovated facillity shall contain a maximum security hospital for the treatment of prisoners requiring acute care hospitalization, as well ag a separate facllity for the _~d

8

treatment of)forensic patients who are members of the Morales Feliciano class. The number of beds to be contained in the maximum security hospital shall be determined pursuant to the need assessment and subsequent experience with the acute care needs of the population.

17. Within one (1) year,2 construction plans and a staffing

plan for the new Forensic Hospital shall be developed and submitted to the Court. These plans also shall address the feasibility of establishing a small facility, closely associated

with the new Forensic Hospital, to provide extended care for patients who are too chronically ill and dysfunctional to function in a PSU or in the general population of a prison. In

addition, the function of the Therapeutic Community at Guerrero shall be reevaluated in these plans. /

18. The attorney employed by the Forensic Institute shall be responsible for reducing, to the greatest extent possible, use of the current Forensic Hospital for diagnostic evaluation of forensic commitments by local court~.

III. INITIAL NEED ASSESSMENT -- EMERGENCY STAFFING AND

RECEPTION/SCREENING

~ _ k

i ~-o_>*ssr 19. Within nine (9)

months, defendantr shall complete a

comprehensive assessment of the scope of need for psychiatric and psychological treatment of prisoners under the jurisdiction °f l-' the AOC. The final phase of the process, the actual conduct of the need assessment, shall be completed within a limited period 'od4> of no more than sixty (60) days. In order to accomplish the need

2 Unless otherwise specifically indicated, all time frames within which action must be taken pursuant to this Mental Health Plan 6hall commence on the date this plan is approved by the Court.

g assessment within nine (9) months, the following steps shall be taken within the time frames set forth below.

a. Within two (2) months, defendants shall employ a full-time Need Assessment Director and a full-time Assistant Need Assessment Director, who shall be responsible for designlng and implementing the need assessment. Within thirty t30) days of the appointment of these personnel, a Preliminary Need Assessment Plan and an Emergency Staffing Plan shall be filed vith the Court.

b. The Preliminary Need Assessment Plan shall describe the Need Assessment process to be followed. The plan\shall specify that the Need Assessment process will commenceo at all institutions designated as

regional intake centers and will be conducted

5 ~ subsequently at all other institutions. It also shall

provide that, @ to the me ~ of Need

Assessment teams to each regional lntake fac$1ity,

questionnaires will be mailed out to appropriate staff

at all correctional institutions, allowing sufficient

time for staff to answer these questionnaires

adequately prior to the xepltrbcAt of Need Assessment

teams to the institutions.

c. The Emergency Staffing Plan shall prov$de for the hiring or contracting of a gtaffing complement, adequate in 8ize and qualifications, \

(1) to develop the need assessment and

reception screening evaluative instruments

E 'I

10

tt..

(eR

and protocols within five (5) months of th

Court's approval of this Mental Health Pla

(2) to train and deploy need asses' teamq and reception staff withln sevJ

months after the Court' 8 approval

Mental Health Plan:

ent

(7)

of this

(3) to conduct the need assessment in a

SS period of no more

g beginning no later

than sixty (60)

days, than seven (7) months Court's approval Or this Mental Health Plan;

(4) to implenent the new reception screening procedures at all CRMHU's simultaneously with the commencement of the need assessment; and

(5) to ensure that those inmates already receiving mental health services at any institution are not deprived of needed

Assessment Plan and the Emergency

conduct of

J

(fo

services during the pendency or the need assessment.

d. Following the filing of the Preliminary Need

Staffing Plan, counsel shall have a period of fifteen (15) days to review and file commentq or objections to the plans. After the Court' 8 approval of these plans, the Need Assessment Director shall initiate the staff recruitment process in accordance with the Emergency Stafting Plan. The full staffinq complement shall be hired or otherwise obtalned ag soon thereafter as 11

,X,

possible, but no later_than_six (6) months from the

date of the Court'; approval of this Mental Health Plan.

(1) Professionals employed by the Need Assessment Director shall include personnel who will become part of the permanent mental health staff following the completion of the need assessment, contract personnel who will be used temporarily to provide extra support during the period the assessment is being made, and personnel temporarily reassigned from mental health.

(2) Efforts shall be mads to recruit staff from the UniverRity of Puerto Rico, the Puerto Rico Institute of Psychiatry, public mental health agencies, Veterans Administration hospitals and the private mental health community, as well as off-island professionals who may be available for a temporary period to assist in the conduct of the need assessment.

(3) Within 60 days following the completion of the need assessment, the WH shall prepare and submit to the Central Personnel Office (OCAP) a reimbursement schedule for mental health profe^<ionals and support staff whose Rervices are required to achieve the purposes and objectives of this

12

l

, .}

/.Mental Health Plan. The schedule, a copy of which shall be filed with the Court, shall take into consideration travel allowance, A

malpractice insurance, and continuing medical education. The reimbursement schedule shall

be at a level sufficient to recruit and

retain qualified professional ~taff.

e. All permanent and temporary staff employed

for the conduct of the need assessment shall receive intensive training, The training program ~ e

orientation to the prison system, including the mental health referral system, the Forensic Hospital, and the levels of care planned for the correctional mental

health system. CRMHU teams shall be organized and trained in the protocols and procedures to be used ln

the conduct of screening and diagnosis.

20. Within sixty (60) days after the Court's approval of the Preliminary Need Assessment Plan and the Emergency Staffing Plan, defendants shall file a Final Need Assessmen$t Plan, which

/ _ _ ~_ _

shall describe ii detail)the process and protocols to be followed

v in conducting the need assessment, the content of questionnaires,

E

to be sent to select staff ln advance of the_deployment of need

_l .,

assessment teams to the institutions, the content of instruments to be used in reception/intake screening, and a plan for implementing the new instruments concurrently with the commencement of the need assessment.

21. The Final Need Assessment Plan shall enRure that need assessment teams will ldentify and examine the following inmateS

13

~'

in order to determine the level of care needed:

a. those currently or formerly on psychiatric or psychological case loads;

b. those living in high risk areas such as maximum security, segregation, and admissions; and

c. randomly selected inmates from each housing

area.

All inmates who are examined will be invited to identify other

prisoners in their housing areas who appear to have emotional problems.

22. Within six (6) months of the Court'~ approval of this

Mental Health Plan , defendants shall submit a :raining curriculum, instructor roster, and schedule, which shall provide for the training of need assessment teams and reception teams/staff no later than seven (7) months from the Court's approval of this Mental Health Plan. The training program also shall provide for the training of all other CEMHU staff by no later than the completion of the need assessment.

23. During the conduct of the need assessment, the Need Assessment Director shall supervise the compilation of relevant

data and statistlss.

rv. IMPLEMENTATION OP THE MENTAL HEALTH SERVICES PLAN

24. Immediately upon the completion of the need assessment, each CRMHU shall be prepared to receive prisoners in the PSU's and, when appropriate, in the PICU's. Within six (6) months of the Court's approval of thls Mental Health Plan, defendants sha}l submit a provisional Mental Health Housing Plan adequatf to permlt appropriate placement of all prisoners ldentified as

14

requiring assignment to CRMHU's.

a. The housing plan shall $dentify specific housing units at each CRMHU that will be dedicated to housing mentally ill inmates according to the numbers set forth in Paragraphq 8 and 13, suDra. The identified space shall be provided at all CEMHU's upon the completion of the need assessment.

b. The housing plan shall identify the non-living areas in CRMHU's that will be dedicated for mental health purposes, to include at a minimum sufficient space for private and group counseling sessions, progran space, and staff offices. These areas shall be available for use upon the completion of the need assessment.

25. Transfers to CRnnu s snall commence upon completron or the need assessment, and the dedicated housing space shall be fully occupied by mental health inmate<, to the extent that such inmates are identified, within sixty (60) days of the completion of the need assessment.

@ Concurrently with the Mental Health Housing Plan, a Transportation Plan shalL be filed, which shall $dentify sufficient vehicles, drivers, and security gtaff to transport inmate~ to CRMHUfs, to transfer prisoners from CRMHU's to other appropriate institutions, and to maintain the ongoing, regular movement of prisoners who come into contact with the corrections mental health system.

27- Within sixty (60) days following the completion of the need assessment, defendantg shall tile a Final Mental Health

1S

Staffing Plan and a Final Mental Health Housinq Plan.

a ThQ Final Mental Health staffing Plan shall

specify any additional staff who may be needed to provide adequate treatment at CRMHU's and IMHU's for lnmates in each region of the system. The plan also

shall provide for the employment and assignment of a sufficient number of supervisory and support staff for the purpose of implementinq all provisions of this Mental Health Plan. In determining the appropriate treatment, supervisory, and support staffing levels, priority shall be given to meeting each and every objective and timetable set forth in this Plan. The plan shall include a strategy for meeting all staffing needs at the earliest possible time, but no later than twelve (12) months following the completion of the need assessment.

b. The Final Mental Health Housing Plan snall specify what additional living and non-living space is needed to meet the housing and program needs of inmates who, according to the outcome of the need assessment, are appropriate for transfer to institutions with a CRMHU or an IMHU. The Plan also shall address the adequacy of bed space in the PICU's and shall propose any needed adjustments to the number of beds being provided at that time. The Plan shall include a strategy for providing appropriate additional space that is needed for housing, prograns, counseling, and offlces at the earliest posgible tine, but no later

than twelve (12) months following the comple

need assessment. zg~p/ J 28. Within eiqhteen (18) months of

this Mental Health Plan,

I ~'

beSz \y

, .1 w

the <\

,he Court's approval of

intelligence,- edueaebonsE, and

VOCotiOnal testi~f, as well as- ~ stttgr shall be

tS~_~as~ C~ts,) implemented at each eFM§B>~for the purpose of permitting more

bt'\(,~.aWLt sophisticated mental health screening •e<tJtreatment and

sophistlcatea mental neas;n sUL %%s~s&|~ _ni g i~~_~_.,_ ~4,~J

Jut J/JG - fqbo wSe-w+~ Cl C7,) •/ ~ ~ r H S correctional programming. ~

29. Within eighteen (18) months of the Court's approval of this Mental Health Plan, defendants shall file with the Court a manual of policies and procedures governing the delivery of mental health services to all prisoners confined in correctional institutions of the Commonwealth of Puerto Rico. The procedures shall include written protocols for the delivery of all mental health services in the system. Each policy, procedure, and program shall be reviewed annually and be revised as necessary under the direction of the resPonsible mental health and corrections authorities.

V. USE OP PSYCHOTROPIC MEDICATION

30. Within nine (9) months of the Court's approval of this Mental Health Plan, a manual of policieq and procedures shall be developed to ensure that psychotropic medication is accounted for, that such medication is dispensed only by appropriate medical personnel, that a formulary ig established both centrally and at each institution with a C^MHU, and that appropriate professional caution is used with respect to the use of sedative hypnotics in the prison population. This manual shall be filed with the Court.

17

pfc ?O

VI. t-TRAINING

31. Within six (6) months of the Court's approval of this

.,

Mental Health Plan, defendants sball file a plan and timetable aor trainingwallscorrectional~officers-in-identlthingTprisoners~ with-*suicide-potential~ondzgross-mental-illness qnd in-making

referrals for mental-health treatment: The training program also

shall ~~address specialized training

t officers employed in PSU's and in

needs for correctional high-risk areas of the institution such as admissions, segregation units, protective custody units, and disciplinary units. Also, within six (6)

of this Mental Health Plan,

months of the Court's approval defendantA shall file a plan forkin-service~tratining rf-mental

ehealth-profess$onals~lmDIoved~~in all~institutionsXt

These plans shall be implemented within three months of their approval by the Court. VII. ACCESS TO KENTAL HEALTEI CARE 32. All prisoners at each institution shall have access to mental health care when the need for such care arises.

a. Upon admission to an institution, each prisoner shall receive orientation concerning the scope of the mental health system and the means by which he can gain access to that gystem. Written protocol shall guide admissions personnel in educating new admissionS about the mental health care system.

b. Correctional officers, who shall be trained

to identify specified mental heAlth problems, shall be

~ . _

required t

report any detected need or any request for

psychological evaluation or treatment to an appropriate

18

mental health professional.

c. All prisoners shall have direct, unimpeded access to mental health professionals through a system of intra-institutional or inter-institutional mail, to include strategically-placed locked boxes tor the placement Of written requests by inmates. At institutions employing mental health professionals, such correspondence shall be collected on a daily basis by health personnel only, and shall be responded to by an appropriate mental health professional according to the urgency of the problem. At other institutions, such mail shall be collected on a daily basis by medical personnel only, and shall be forwarded immediately to the Chief Psychiatrist of the appropriate CRMHU for prompt and appropriate response or referral.

d. At institutions employing mental :health professionals, appropriate mental health personnel shall conduct periodic tours of all housing units, including daily tours in high risk areas such as housing areas for new

admissions, segregation, and maximum security. Coordinating closely with correctional officers and counselors, a constant identified mental health professional shall make daily rounds in all segregation areag for the purpose of assessing and triaging cases of emotional disturbance. At institutions that do not employ mental health professionals, the duties set forth in this subparagraph shall be performed by medical personnel, who shall be responsible for making appropriate referrals to the Chief Psychiatrist of the appropriate CRMHU.

19

e. All prisoners admitted to a segregatiOn area of a prison or to a prison designated as a facility for punitive, administrative, protective or other segregation, must recelve a mental health screening examination within the first businesA day of their arrival. As a result of this evaluation, appropriately identified inmates must be treated either in the

segregation unit or facility or be removed to an appropriate level of mental health treatment as

clinically indicated.

VIII. QUALITY ASSURANCE

33. Within twelve (12) months of the Court's approval of

this Mental Health Plan, defendants shall file a quality assurance plan for the mental health system. The plan shall address, at a minimum, staff performance, institutional conditions, utilization review, peer review, adequacy of documentation, diagnosis, utilization of psychotropic medications, protection of patients' rights, and staff

The plan also shall contain a component rist management system based on critical incident reporting at the Forensic Hospital and at all institutions.

34. Withln six (6) months of the Court's approval of this

credentials. establishing a

Mental Health Plan, a Quality Assurance Coordinator shall be employed to develop the quality assurance plan and to staff and

permanently supervise the quality assurance program. Every six (6) months thereafter, the Quality Assurance coordinator shall submit a report to a Quality Assurance Committee, which •hall consist of appropriate mental health professionals representing

20

the DOH, DSCA, and the AOC. Each report shall describe the status of the quality assurance program and the findings of the past six months' period. The Quality Assurance Committee shall review the quality assurance reports and shall submit any required remedial plans to the DOH and the AOC within thirty t30) days following receipt of each bi-annual report.

IX. MENTAL HEALTH RECORDS

35. Beginning with the implementation of reception screening seven (7) months following the Court's approval of this Mental Health Plan, individual treatment plans shall be prepared for all prisoners who receive any level of mental health or substance abuse treatment. In addition, all requests for psychiatric consultation must be documented. All mental health records shall be maintained in a secure and confidential manner,

and access to such records shall be limited to mental health, medical, and DSCA staff, as appropriate. The mental health

records may also be reviewed, pursuant to proper regulations, by appropriately qualified staff of the AOC, to the extent that it

is necessary for the AOC to guarantee adequate provision of health care to inmates.

36. Within nine (9) months of the Courtts approval of this Mental Health Plan, written policies and procedures shall be filed regarding the communication of mental health informatlon to appropriate correctional or parole board staff.

37. Whenever a prisoner is transferred from one institution to another, hls or her mental health records shall accompanY the prisoner.

38. Within 8ix (6) months of the Court's approval of thls

21

Mental Health Plan, a certified Director of Mental Health Records shall be employed to supervise the mental health records system. This individual shall coordinate and develop all policies and procedures concerning mental health records. Within nine (g) months of the Court's approval of this Mental Health Plan, a certified Medical Record Technician and a certified Medical Record Clerk shall be employed at each CRMHU to assist the Director. The mental health secretary or stenographer employed pursuant to paragraph 5, supra, shall maintain mental health records at each IMHU under the supervision of the regional Mental Health Medical Record Technician. Physicians' orders and medication records, as well as the psychiatrist's progress noteR on medications and the patient's diagnosis, shall be recorded in the medical record. A separate mental health section shall be

maintained in the medical record of each inmate who receives mental health services. A file which is separate from the medical record must be maintained for each inmate who receives

mental health services containing material deemed confidential by written policy of the Assistant Secretary for Mental Health. This file must include at a minimum therapists notes, correspondence, and raw data from psychological test protocols.

X. INVOLUNTARY TRANSPER AND TREATHENT

39. Consent for all treatment and hospitalization shall be obtained from patients in accordance with contemporarY leqal requirements. Consent forms shall be read to an inmate, who voluntarily submits to treatment, before he signs the form~ Within BiX (6) months, appropriate forms and procedures shall be developed to obtain and record the patient's consent or to treat

22

a patient involuntarily pursuant to Commonwealth law. Transfers to the Forensic Hospital shall be preceded by a hearing

consistent with applicable law.

XI. REPORTING REQUIREMENTS

40. Commencing two (2) months following the Court's approval of this Mental Health Plan, defendants shall file with the Court every two months comprehensive reports detailing their progress toward compliance with paragraphs 19 through 23 of this plan. Commencing six (6) months following the Court's approval of this Mental Health Plan, defendants shall file with the Court semi-annual comprehensive reports detailing their progress toward compliance with each of the other paragraphs of this plan.

XII. MODIFICATION OF PLAN

41. The DOH may modify organizational and supervisory relationships required by this Plan when deemed necessary for reasons of administrative efficiency or effectiveness. The Court will be notified within ten business days of such action, describing the change and its rationale.

42. The DOH, in coordination with the AOC, may submit to plaintiffs' counsel, through the Court Monitor, recommendatlons for variance from any provision of this Mental Health Plan if the proposed variance satisfies the lntent of the provision for which variance is sought. If plaintiffs~ counsel agree to the variance, the parties shall file a joint motion for modification to permit implementation of the variance. In the absence of agreement by the plaintiffs, any motion for modification by defendants shall be subject to the procedures and standards provided for by law~ Likewise, plaintiffs' counsel may submit to defendants' counsel,

23

through the Court Monitor, recommendatio,ng for modification of this Mental Health Care Plan if plaintiffs' counsel believe that the modification is required to achieve the objectives of this plan. If defendants agree to the modification, the parties shall file a joint motion for modification for the Court's consideration. In the absence of agreement by defendants, any motion for modification by plaintiffs shall be subject to the rocedures and standards provided for by law.

24

CERTIFICATE OF SERVICE

The undersigned hereby certifies that a copy of the

foregoing Amended Sixty-Second Report of the Court Monitor -

Report Recommending Adoption of Revised Medical Plan and Mental

Health Plan has been mailed by ordinary United States mail this

1 3 - day of ) ~ ~_ > 1989 to:

Harvey Nachman

Nachman & Fernandez-Sein

Post Office Box 9949

Santurce, Puerto Rico 00908

Rafael Perez-Bachs

McConnell, Valdes, Kelley

Sifre, Griggs & Ruiz-Suria

GPO Box 4225

San Juan, Puerto Rico 00936

Harry Anduze Montano

.117 Eleanor Roosevelt Avenue

Suite 303

Hato Rey, Puerto Rico 00918

Pedro del Valle Ferrer

Federal Litigation Division

Department of Justice .

Box 192, Old San Juan Station

San Juan, Puerto Rico 00902

Carlos Ramos-Gonzalez

Inter American University Law

School .

Post Office Box 8897

Fernandez Juncos Station

Santurce, Puerto Rico 00910

CarloA Garcia Gutierrez

117 Eleanor Roosevelt Avenue

Suite 303

San Juan. Puerto Rico 00918

A. Manuel Martin

Ramirez & Ramirez

269 Ponce de Leon Avenue

Second Floor

Hato Rey, Puerto Rico 00918

Ivonne Diaz de Carreras

Midtown Building, Suite 206

421 Munoz Rivera Avenue

Hato Rey, Puerto Rico 00919

Nora Rodriguez Matias

Condominio "E1 Centro I"

Oficina 215

Hato Rey, Puerto Rico 00918

Louis A. Siegel

Office of the Court Monitor

Federal Court Building and

Old Post Office

Post Office Box 5918

San Juan, Puerto Rico 00902

Jose Fernandez Paoli

Centro de Seguros Building

Suite 407

701 Ponce de Leon Avenue

Miramar-Santurce, PR 00907

Oscar Gonzalez-Badillo

Banco de Ponce Building

Suite 2203

Hato Rey, Puerto Rico 00918

Vincent M. Nathan

Court Monitor