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