Report 2016-131 All Recommendation Responses

Report 2016-131: California Department of Corrections and Rehabilitation: It Must Increase Its Efforts to Prevent and Respond to Inmate Suicides (Release Date: August 2017)

Recommendation for Legislative Action

To provide additional accountability for Corrections' efforts to respond to and prevent inmate suicides and attempted suicides, the Legislature should require that Corrections report to it in April 2018 and annually thereafter on the following issues: 1) its progress toward meeting its goals related to the completion of risk evaluations in a sufficient manner; 2 its progress toward meeting its goals related to the completion of 72-hour treatment plans in a sufficient manner; 3) the status of its efforts to ensure that all mental health staff receive required training and mentoring related to suicide prevention and response; 4) the status of its efforts to fill vacancies in its mental health treatment programs, especially its efforts to hire and retain psychiatrists; 5) its progress in implementing the recommendations made by the special master's experts, the court-appointed suicide expert, and its own reviewers regarding inmate suicides and attempts and Corrections should include in its report to the Legislature the results of any audits it conducts as part of its planned audit process to measure the success of changes it implements as a result of these recommendations; 6) its progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides at the prisons.

Recommendation #2 To: Corrections and Rehabilitation, Department of

Corrections should immediately require mental health staff to score 100 percent on risk evaluation audits in order to pass. If a staff member does not pass, Corrections should require the prison to follow its current policies by reviewing additional risk evaluations to determine whether the staff member needs to undergo additional mentoring.

60-Day Agency Response

1. The California Correctional Health Care Services (CCHCS) Quality Management (QM) is developing an enterprise-wide tracking tool to track clinicians requiring Suicide Risk Evaluation (SRE) mentoring or re-mentoring to be beta tested the first week of September.

2. CDCR will be revising the SRE chart audit tool upon full implementation of the Electronic Health Record System (EHRS), as the current audit tool does not fully capture the scope of the risk assessment contained in the EHRS (now termed the Suicide Risk Assessment and Self Harm Evaluation or SRASHE). A workgroup will be established in late October 2017, with QM, the headquarters Suicide Prevention Unit, and selected institution Suicide Prevention and Response Focused Improvement Teams (SPRFIT), to develop the new audit criteria.

3. CDCR has reviewed the recommendation to increase the passing score to 100 percent, and has determined the current criteria is sufficient and appropriate.

  • Estimated Completion Date: December 2017
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #3 To: Corrections and Rehabilitation, Department of

To ensure that it identifies inmates who are at risk of attempting suicide and determines the treatments needed to prevent them from doing so, Corrections should immediately reevaluate and revise its goals for the percentage of risk evaluations that mental health staff must complete on time and for the percentage of risk evaluations that must pass its risk evaluation audits. It should set revised goals that better take into consideration the importance of mental health staff completing adequate risk evaluations in a timely matter. Corrections should require prisons that perform below its revised goals to develop improvement plans.

60-Day Agency Response

The Mental Health Program will work with the regional teams and institutions to establish corrective action plans if benchmarks are not met.

  • Estimated Completion Date: October 2017
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #4 To: Corrections and Rehabilitation, Department of

To improve the quality of its risk evaluations, by December 2017 Corrections should develop and incorporate into its electronic risk evaluation form prompts to aid mental health staff in completing adequate risk evaluations that meet all audit criteria.

60-Day Agency Response

The Statewide Mental Health Program (SMHP) is developing wording to be included in the various sections of the SRASHEs. Selected SPRFIT coordinators will be asked to review the proposed language changes. These changes will be incorporated by December 2017.

A copy of the SRASHE (screen shot) will be provided once complete.

  • Estimated Completion Date: December 2017
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #5 To: Corrections and Rehabilitation, Department of

To minimize the number of inmates who spend more than 24 hours in alternative housing, Corrections should use the audit process it is developing to monitor the amount of time inmates spend in alternative housing and annually reassess its need for additional crisis beds.

60-Day Agency Response

Monitoring is occurring to provide oversight regarding the amount of time inmates spend in alternative housing. Legislative approval has been granted to add 100 new Mental Health Crisis Beds.

See attached approval of crisis bed construction and copies of monitoring reports of alternative housing usage.

  • Completion Date: September 2017
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Fully Implemented

As we note in the audit report on page 30, the Legislature approved the construction of 100 new crisis beds. According to Corrections, its monitoring report allows it to see the percentage of inmates transferred out of alternative housing to a crisis bed within 24 hours Corrections-wide as well as by facility. Although this is not part of the audit process we describe in the report on page 53, Corrections stated headquarters reviews these reports on a monthly basis. While we consider this recommendation fully implemented, we encourage Corrections to continue to monitor and reassess the need for additional crisis beds if it continues to face challenges ensuring that inmates spend less than 24 hours in alternative housing before admission to a crisis bed.


Recommendation #6 To: Corrections and Rehabilitation, Department of

To ensure that prisons document the privileges, such as yard time, that inmates receive while in a crisis bed, Corrections should immediately require prisons to develop and formalize policies to record on their treatment plans the privileges inmates are allowed and receive while in a crisis bed.

60-Day Agency Response

Per the CDCR memorandum dated February 14, 2017, titled "Mental Health Crisis Bed Privileges Revision" privileges and out-of-cell activities are provided to all inmate-patients (IP) admitted to the Mental Health Crisis Bed's (MHCB). The Interdisciplinary Treatment Team (IDTT) shall review and update privileges at every IDTT and document restrictions within the treatment plan. When an IP receives or participates in a privilege or out-of-cell activity, custody staff shall notate the occurrence on the CDC Form 114-A, Inmate Segregation Record. The IP's 114-A will be discussed during each IDTT and documented within the treatment plan.

The Mental Health Compliance Team Lieutenants review the 114's during regional tours. This item will be included in the Continuous Quality Improvement Tool (CQIT) by January 2018. The Mental Health regional teams will be auditing if the IDTT reviews privileges and out-of-cell activities received.

By March 2018, institutions with MHCB's and regional teams will be provided training regarding the need to review the 114's in IDTT to ensure privileges are being granted consistent with the IDTT recommendations.

See attached CDCR memorandum dated February 14, 2017 titled "Mental Health Crisis Bed Privileges Revision." The CQIT additional audit item language and a copy of training materials will be provided once complete.

  • Estimated Completion Date: March 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #7 To: Corrections and Rehabilitation, Department of

To ensure that prison staff conduct required checks of inmates placed on suicide precaution in a timely manner, Corrections should implement its automated process to monitor suicide precaution checks in its electronic health record system by the time it is implemented systemwide in October 2017. Further, Corrections should train staff on how to plan for and conduct staggered suicide precaution checks.

60-Day Agency Response

EHRS will be modified to trigger staggered rounding and to allow determination of at what point the task was completed (real time). CQIT contains indicators to assess if rounding was staggered and if documentation occurred in real time. Regional mental health teams will audit to ensure entries are completed in real time by comparing task time and documentation time.

Suicide Watch and Suicide Precaution training will be provided to nursing staff statewide by December 31, 2017.

  • Estimated Completion Date: March 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #8 To: Corrections and Rehabilitation, Department of

To monitor prisons' compliance with its requirement that inmates in crisis beds receive daily progress notes, Corrections should implement monitoring of these notes electronically into its audit process by the time the electronic health record system is in use systemwide in October 2017. Corrections should require prisons that are out of compliance to develop and implement quality improvement plans, and it should follow up on the prisons' implementation of those plans.

60-Day Agency Response

Mental Health is currently developing an inpatient dashboard. For MHCB, an automated indicator will be added for daily mental health clinical contacts as measured by presence of a progress note.

A copy of indicator language and report will be provided once complete.

  • Estimated Completion Date: January 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #9 To: Corrections and Rehabilitation, Department of

To ensure that prison staff appropriately respond to attempted suicides, Corrections should implement its proposed changes to its emergency response policies regarding cut-down kits by December 2017 and should include in its policies a method for monitoring prisons' compliance.

60-Day Agency Response

The Division of Adult Institutions and Statewide Mental Health have drafted a memorandum titled "Response to Suicide Attempts by Hanging or Asphyxiation, Introduction of the Replacement Cut-Down Tool, and Standardization of the Cut-Down Kit." The memo along with a negotiation prep tool was submitted to the Office of Labor Relations on September 15, 2017, with the implementation date of December 1, 2017. Statewide Mental Health has already purchased the replacement cut-down tools and the CQIT already contains an audit question designed to monitor the prisons' compliance regarding the cut-down kits.

See attached memorandum.

  • Estimated Completion Date: December 2017
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #10 To: Corrections and Rehabilitation, Department of

To address the unique circumstances that may increase its female inmates' rates of suicide and suicide attempts, Corrections should Implement its planned same-sex domestic violence curriculum by December 2017.

60-Day Agency Response

1. The Statewide Mental Health Program is working on a contract to provide a same sex domestic violence program to MHSDS inmates. The vendor will provide a specialized curriculum and training for clinicians, who will lead the groups.

2. The Female Offenders Programs and Services held a Gender Responsive Workgroup meeting on August 30 and 31, 2017 to discuss specific needs of female offenders. Suicide prevention was among the topics discussed, and follow-up workgroups will be scheduled to further address the complex issues underlying self-harming behavior in female inmates.

3. The California Institute for Women (CIW) and the Central California Women's Facility (CCWF) are working with outside resources and community resource managers to bring in domestic violence prevention and awareness programs.

4. The California Department of Corrections and Rehabilitation has developed a partnership plan that includes daily huddles, executive leadership rounding, and quarterly round table meetings between custody and mental health staff. This plan will be implemented at CIW and CCWF in October 2017.

See attached domestic violence program summaries and Partnership narrative plan. A copy of the training curriculum will be provided once complete.

  • Estimated Completion Date: March 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #11 To: Corrections and Rehabilitation, Department of

To address the unique circumstances that may increase its female inmates' rates of suicide and suicide attempts, Corrections should continue to explore additional programs that could address the suicide risk factors for female inmates.

60-Day Agency Response

Continuation of Recommendation 10:

1. SMHP is working on a contract to provide a same sex domestic violence program to MHSDS inmates. The vendor will provide a specialized curriculum and training for clinicians, who will lead the groups.

2. The Female Offenders Programs and Services held a Gender Responsive Workgroup meeting on August 30 and 31, 2017 to discuss specific needs of female offenders. Suicide prevention was among the topics discussed, and follow-up workgroups will be scheduled to further address the complex issues underlying self-harming behavior in female inmates.

3. CIW and CCWF are working with outside resources and community resource managers to bring in domestic violence prevention and awareness programs.

4. CDCR has developed a partnership plan that includes daily huddles, executive leadership rounding, and quarterly round table meetings between custody and mental health staff. This plan will be implemented at CIW and CCWF in October 2017.

See attached domestic violence program summaries and Partnership narrative plan. A copy of the training curriculum will be provided once complete.

  • Estimated Completion Date: March 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #12 To: Corrections and Rehabilitation, Department of

To ensure that all prison staff receive required training related to suicide prevention and response, Corrections should immediately implement a process for identifying prisons where staff are not attending required trainings and for working with the prisons to solve the issues preventing attendance.

60-Day Agency Response

Custody: Currently during the CQIT reviews, Regional Lieutenants review training reports for custody at each institution to determine how many staff have received the required suicide prevention and response training. When an institution is not in compliance, this is reported to Headquarters (HQ) and corrective action is required. It is recommended this process continue. In addition, the Learning Management System (LMS) is being implemented in phases and the Division of Adult Institutions HQ will be included in the final phase at the end of 2017. LMS will allow HQ staff to run compliance training reports for each institution remotely and more efficiently determine compliance.

The In-Service Training department will run a negative report which captures staff who have not received required training. This will be sent to the Wardens, CEO's, Associate Directors and Regional Health Care Executives for review and follow up.

Mental Health: Mental Health will be working with LMS to include suicide prevention related clinical training tracking in the LMS system. Mental Health will create a training compliance report and will require corrective action plans for those institutions not in compliance.

Copies of negative reports and compliance reports will be provided once complete.

  • Estimated Completion Date: January 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #13 To: Corrections and Rehabilitation, Department of

To ensure that trainers and risk evaluation mentors at all prisons are able to train staff effectively, Corrections should immediately begin requiring prisons to report the percentage of their trainers and mentors who have received training on how to conduct training and mentoring. It should work with prisons to ensure that all trainers and mentors receive adequate training.

60-Day Agency Response

As noted in the previous recommendation, the Statewide Mental Health Program (SMHP) will be partnering with CCHCS to incorporate all suicide prevention related mental health training to track the training mentors and trainers have received. SMHP will issue a memorandum noting what training mentors must receive and will specify that no clinician shall provide mentoring unless this training has been received. The SMHP will monitor to ensure only those staff who have received appropriate training may serve as a mentor or provide suicide prevention-related training.

A copy of memorandum and report will be provided once complete.

  • Estimated Completion Date: January 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #14 To: Corrections and Rehabilitation, Department of

To maximize the value of its trainings related to suicide prevention and response, Corrections should ensure that starting in January 2018, its trainings include all content that the special master and its own policies require.

60-Day Agency Response

The SMHP and DAI will work with the Office of Training and Development to ensure that the annual Suicide Prevention and Crisis Intervention training and the Basic Correctional Officer Academy training include Dealing with Manipulative Inmates. Results of recent tours, audits and suicide case reviews will be incorporated. In addition, the Safety Planning webinar will be revised to include a segment on dealing with perceived manipulation.

The recommendation to include the Mental Health Assessment process for rules violation reports is not directly related to suicide risk reduction. Because the annual In-Service Training will be incorporating some additional items directly related to suicide prevention which must be covered in the allotted time, any additional information cannot be added without resulting in inappropriately shortening the suicide prevention related material.

Copies of revised training materials will be provided once complete.

  • Estimated Completion Date: January 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #15 To: Corrections and Rehabilitation, Department of

To ensure that it has enough staff to provide mental health services to all inmates who require care, Corrections should review and revise its mental health staffing model by August 2018.

60-Day Agency Response

The SMHP anticipates an order from the court regarding its proposed staffing plan submitted in February 2017.

  • Estimated Completion Date: To Be Determined
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #16 To: Corrections and Rehabilitation, Department of

To ensure that prisons comply with its policies related to suicide prevention and response, Corrections should continue to develop its audit process and implement it at all prisons by February 2018. The process should include, but not be limited to, audits of the quality of prisons' risk evaluations and treatment plans.

60-Day Agency Response

The Quality Management program continues to work with the Office of the Special Master in refining the CQIT and associated reports. The Chart Audit Tool, which evaluates SRASHE and treatment plans, is in use and will continue to be utilized.

  • Estimated Completion Date: To Be Determined
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #17 To: Corrections and Rehabilitation, Department of

To ensure that prisons can easily access Corrections' current policies related to mental health, Corrections should ensure that its program guide is current and complete as it works to incorporate the program guide into regulations. Corrections should immediately begin working with federal court monitors to draft regulations.

60-Day Agency Response

The SMHP and DAI continue to work on draft regulations.

  • Estimated Completion Date: December 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #18 To: Corrections and Rehabilitation, Department of

To ensure that suicide prevention teams meet quorum requirements, Corrections should, starting January 2018, work with prisons that consistently fail to achieve a quorum to resolve issues that may be preventing the teams from having all required members present at meetings.

60-Day Agency Response

This item refers to SPRFIT. SPRFIT enhancements address membership and quorum issues. Those should be issued by November 2017. SPRFIT audit and coding will also be updated.

A copy of revised SPRFIT requirements memorandum will be provided once complete.

  • Estimated Completion Date: January 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #19 To: Corrections and Rehabilitation, Department of

To eliminate confusion regarding suicide prevention team meeting attendance, Corrections should immediately update its program guide to clarify who is required to attend suicide prevention team meetings, which attendees may send designees, and the extent to which staff may fill multiple roles when meeting quorum requirements.

60-Day Agency Response

This item refers to SPRFIT. SPRFIT enhancements address membership and quorum issues. Those should be issued by November, 2017. SPRFIT audit and coding will also be updated.

A copy of the revised SPRFIT requirements memorandum will be provided once complete.

  • Estimated Completion Date: January 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #20 To: Corrections and Rehabilitation, Department of

To ensure that suicide prevention teams exercise leadership at prisons, Corrections should immediately require them to use available information about critical factors—such as the number and nature of inmate self-harm incidents and the quality and compliance with the policy of risk evaluations and treatment plans—to identify systemic issues related to suicide prevention. Corrections should require the suicide prevention teams to assess lessons they can learn, create plans to resolve current issues, and prevent foreseeable problems in the future.

60-Day Agency Response

This item refers to SPRFIT. SPRFIT enhancements address making qualitative improvements to SPRFIT functions. Those should be issued by November, 2017. SPRFIT audit and coding will also be updated.

A copy of the SPRFIT audit tool and results will be provided once complete.

  • Estimated Completion Date: January 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #21 To: Corrections and Rehabilitation, Department of

To provide the public and relevant stakeholders with accurate information on suicides and suicide attempts in its prisons, Corrections should immediately require prison staff to work with mental health staff to reconcile any discrepancies on suicides and suicide attempts before submitting numbers to the COMPSTAT unit.

60-Day Agency Response

Mental Health and DAI met with COMPSTAT to ensure that mental health data feeds COMPSTAT with respect to suicides and attempts. COMPSTAT and Mental Health are working on the report to allow for this feed. The process will be formalized in policy memorandum.

A copy of memorandum outlining process will be provided once complete.

  • Estimated Completion Date: November 2017
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #22 To: Corrections and Rehabilitation, Department of

To ensure that all its prisons provide inmates with effective mental health care, Corrections should continue to take a role in coordinating and disseminating best practices related to mental health treatment by conducting a best practices summit at least annually. The summits should focus on all aspects of suicide prevention and response, including programs that seek to improve inmate mental health and treatment of and response to suicide attempts. Corrections should document and disseminate this information among the prisons, assist prisons in implementing the best practices through training and communication when needed, and monitor and report publicly on the successes and challenges of adopted practices.

60-Day Agency Response

1. The next Suicide Prevention Summit is scheduled for 10/17-19, 2017. Minutes will be maintained and disseminated following the meeting.

2. Quarterly SPRFIT teleconferences continue to be held. Minutes will be kept and disseminated following the teleconferences.

3. Monthly suicide prevention videoconferences continue to be held. Statewide Mental Health is working to develop a system to record these videoconferences to distribute to all staff. Slides are disseminated prior to the videoconference.

4. The Chief of Mental Health, Statewide Nursing, and Warden's meetings continue to be held. Agendas, handouts, power point presentations, and/or talking points will be distributed to attendees.

Copies of agendas, Power Points, Talking Points, and minutes will be provided once complete.

  • Estimated Completion Date: Ongoing
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #23 To: Corrections and Rehabilitation, Department of

In an effort to prevent future inmate suicide attempts, Corrections should implement its plan to review attempts with the same level of scrutiny that it uses during its suicide reviews. Corrections should require each prison's suicide prevention team to identify for review at least one suicide attempt per year that occurred at its prison. To ensure that the reviews include critical and unbiased feedback, Corrections should either conduct these reviews itself or require the prisons to review each other. These reviews should start in September 2017 and follow the same timelines as the suicide reviews, with the timeline beginning once the team identifies a suicide attempt for review.

60-Day Agency Response

CDCR is exploring using a modified Root Cause Analysis process if it can be made applicable, supplemented with an additional mental health report that addresses requirements established by NCCHC and the American Association of Suicidology (the standards currently utilized on suicide case reviews). This requirement will be contained in the SPRFIT enhancements and will be audited.

A copy of the new audit item and results will be provided once complete.

  • Estimated Completion Date: July 2018
  • Response Date: October 2017

California State Auditor's Assessment of 60-Day Status: Pending


All Recommendations in 2016-131

Agency responses received are posted verbatim.