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.

Description of Legislative Action

As of August 17, 2022, the Legislature did not take action to address this specific recommendation.

California State Auditor's Assessment of Annual Follow-Up Status: No Action Taken

Description of Legislative Action

"As of August 17, 2021, the Legislature has not taken any recent action to address this recommendation." add the following paragraph: "SB 960 (Chapter 782, Statutes of 2018) requires Corrections to submit a report to the Legislature on or before October 1 of each year on its efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, describing Correction's progress in identifying and implementing initiatives designed to reduce risk factors associated with suicides among inmates. The report is required to be posted on Correction's website. This statute does not address the portion of the recommendation that the report include the status of Corrections' efforts to fill vacancies in its mental health treatment programs.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Description of Legislative Action

As of August 17, 2020, the Legislature has not taken any recent action to address this recommendation.

SB 960 (Chapter 782, Statutes of 2018) requires Corrections to submit a report to the Legislature on or before October 1 of each year on its efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, describing Correction's progress in identifying and implementing initiatives designed to reduce risk factors associated with suicides among inmates. The report is required to be posted on Correction's website. This statute does not address the portion of the recommendation that the report include the status of Corrections' efforts to fill vacancies in its mental health treatment programs.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

Description of Legislative Action

SB 960 (Chapter 782, Statutes of 2018) requires Corrections to submit a report to the Legislature on or before October 1 of each year on its efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, describing Correction's progress in identifying and implementing initiatives designed to reduce risk factors associated with suicides among inmates. The report is required to be posted on Correction's website. This statute does not address the portion of the recommendation that the report include the status of Corrections' efforts to fill vacancies in its mental health treatment programs.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

SB 960 does not address the portion of the recommendation that the report include the status of Corrections' efforts to fill vacancies in its mental health treatment programs.

Description of Legislative Action

Senate Bill 960 (Leyva) would require the California Department of Corrections and Rehabilitation (Corrections) to submit a report to the Legislature, on or before April 1 of each year, on its efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect Correction's efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the department's progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates. The bill would require the report to be posted on the department's website. The bill would also require Corrections to notify the contact person of an inmate within 24 hours by telephone, if a contact person is listed on record, in the event of the inmate's serious illness, serious injury, or death, which would include attempted suicide.

California State Auditor's Assessment of 1-Year Status: Pending

Legislation is pending in the Assembly.

Description of Legislative Action

Senate Bill 960 (Leyva) was introduced on January 31, 2018, and would require the Department of Corrections and Rehabilitation (Corrections) to submit a report to the Legislature on or before April 1 of each year, on its efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect Correction's efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the department's progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced

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.

Annual Follow-Up Agency Response From October 2023

The Department's response remains the same. No further action will be taken, and the Department considers this matter closed.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2022

The Department's response remains the same.

Previous Update

SRE Mentoring Update:

All institutional SPRFIT Coordinators maintain documentation and tracking related to the mentoring process for all clinical staff.

Chart Audit Revisions: SRE Mentoring:

Revised CAT audit questions have been completed and the field is now using the revisions as of April 1, 2020, which covers all documentation for 2020 Quarter 1 (1/1/2020-3/31/2020).

CDCR's position remains unchanged. We will not require 100 percent compliance for SRE mentoring. We are currently reviewing the SRE Mentoring policy and procedure to be more consistent with the current SRASHE form in EHRS. We will also be enhancing the oversight of the mentoring process to incorporate potential progressive discipline and/or referrals to the formal Peer Review Committee to consider action based upon clinical deficits of clinicians who repeatedly fail the mentoring process.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2021

The Department's response remains the same.

Previous Update

SRE Mentoring Update:

All institutional SPRFIT Coordinators maintain documentation and tracking related to the mentoring process for all clinical staff.

Chart Audit Revisions: SRE Mentoring:

Revised CAT audit questions have been completed and the field is now using the revisions as of April 1, 2020, which covers all documentation for 2020 Quarter 1 (1/1/2020-3/31/2020).

CDCR's position remains unchanged. We will not require 100 percent compliance for SRE mentoring. We are currently reviewing the SRE Mentoring policy and procedure to be more consistent with the current SRASHE form in EHRS. We will also be enhancing the oversight of the mentoring process to incorporate potential progressive discipline and/or referrals to the formal Peer Review Committee to consider action based upon clinical deficits of clinicians who repeatedly fail the mentoring process.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2020

SRE Mentoring Update:

All institutional SPRFIT Coordinators maintain documentation and tracking related to the mentoring process for all clinical staff.

Chart Audit Revisions: SRE Mentoring:

Revised CAT audit questions have been completed and the field is now using the revisions as of April 1, 2020, which covers all documentation for 2020 Quarter 1 (1/1/2020-3/31/2020).

Increase Passing Score on SRE chart audit tool:

CDCR's position remains unchanged. We will not require 100 percent compliance for SRE mentoring. We are currently reviewing the SRE Mentoring policy and procedure to be more consistent with the current SRASHE form in EHRS. We will also be enhancing the oversight of the mentoring process to incorporate potential progressive discipline and/or referrals to the formal Peer Review Committee to consider action based upon clinical deficits of clinicians who repeatedly fail the mentoring process.

Proof of Practice Item 2- Chart Updates Memorandum to be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Based on Corrections' response, they will not implement our recommendation as written.

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted through email, including proof of practice documentation.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

The tracking and Suicide Risk Evaluation chart audit tool was completed in January 2018. The production of the electronic tool was completed in March 2018.

California State Auditor's Assessment of 1-Year Status: Will Not Implement

Corrections maintains that it will allow clinicians to receive fail ratings in one of seven parts of a suicide risk evaluation and not receive re-mentoring. In our report on page 23 we stated that, because of the importance of each section of the risk evaluation, we believe requiring mental health staff to adequately complete all sections is essential for reducing the risk of inmate suicide.

6-Month Agency Response

1. The California Correctional Health Care Services (CCHCS) Quality Management (QM) has developed an enterprise-wide tracking tool to track clinicians requiring Suicide Risk Evaluation (SRE) mentoring or re-mentoring.

2. CDCR revised the items on the SRE chart audit tool as the previous audit tool did 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). The change to the audit tool is in production.

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

The tracking and SRE CAT audit items tool was completed in January 2018. The production of the electronic tool will be completed in March 2018.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

1-Year Agency Response

The Chart Audit Tool (CAT) implementation resumed post-EHRS implementation. The first quarterly review was completed in April 2018 for the first quarter of 2018. SPRFIT reviews the quarterly CAT results and will develop CAPs as needed. This is an ongoing quarterly process.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

CDCR believes current benchmarks are sufficient and appropriate. However, the Mental Health Program will work with the regional teams and institutions to establish corrective action plans if benchmarks are not met. Timeliness of SREs is now reviewed in SPRFIT.

The new Chart Audit Tool items have been completed and the electronic tool is in production. Chart Audit Tool implementation has resumed post-EHRS implementation. The first quarterly review will be complete in April 2018 for the first quarter of 2018. SPRFIT will be reviewing the chart audit tool at the time.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

1-Year Agency Response

The Statewide Mental Health Program, in conjunction with selected SPRFIT coordinators, developed wording that was included in various sections of the SRASHEs. Small modifications to the language have also been completed based on feedback from additional mental health staff in the institutions.

Pleas see attached SRASHE screenshot examples.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

The Statewide Mental Health Program (SMHP), in conjunction with selected SPRFIT coordinators, developed wording that was included in various sections of the SRASHEs. However, small modifications to that language are being made based on feedback from additional mental health staff in the institutions.

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

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

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.

1-Year Agency Response

The Mental Health Compliance Team Lieutenants review the 114s during regional tours. This item is included in the Continuous Quality Improvement Tool.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

The "114s" that Corrections refers to in its response are "Inmate Segregation Records." While Corrections did not address the recommendation as written, the actions it is taking to monitor and ensure compliance with its existing policies regarding inmate privileges would be sufficient to address the issue we discuss in the report; however, additional audit work would be required to determine whether Corrections' monitoring is effective over time. Nevertheless, we will report this recommendation as fully implemented.

6-Month 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 is included in the Continuous Quality Improvement Tool (CQIT). The Mental Health regional teams will be auditing 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.

The CDCR memorandum dated February 14, 207 titled "Mental Health Crisis Bed Privileges Revision" was provided with the 60-day response. The CQIT additional audit item language and a copy of training materials will be provided once complete.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

1-Year Agency Response

EHRS modification to trigger tasking of Mental Health observation orders was completed in February 2018. This will trigger staggered rounding and allow determination of at what point the task was completed (real time) Training via Webinar was completed mid-February 2018 with full implementation at the end of February 2018. 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.

CNA training on conducting suicide watch and suicide precaution was offered to all nursing staff statewide and was completed in December 2017.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

EHRS modification to trigger tasking of MH observation orders has been developed. This will trigger staggered rounding and allow determination of at what point the task was completed (real time). Training via Webinar will begin in mid-February with a full implementation date by the end of February 2018. 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.

CNA training on conducting suicide watch and suicide precaution was offered to all nursing staff and was completed in December 2017.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email, including proof of practice documentation.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

1-Year Agency Response

The completion of daily Primary Clinician contact is currently measured and Mental Health is examining the most accurate way to measure the progress note completion. A copy of indicator language and report will be provided once complete.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month 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.

It is currently possible to determine if a mental health contact occurred in EHRS. A report to determine if a corresponding progress note was completed is in process.

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

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

1-Year Agency Response

The memorandum titled "Response to Suicide Attempts by Hanging or Asphyxiation, Introduction of the Replacement Cut-Down Tool, and Standardization of the Cut-Down Kit" was distributed to all institutions in January 2018. Institutions implemented the updates within the 60-day time frame and the replacement cut-down tools have been distributed.

The CQIT contains an audit question designed to monitor the prisons' compliance regarding the cut-down kits.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

DAI and the Statewide Mental Health Program 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. The replacement cut-down tools have been distributed. The CQIT contains an audit question designed to monitor the prisons' compliance regarding the cut-down kits.

The memo was distributed January 2018. Institutions have 60 days to implement.

See attached documentation.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

1-Year Agency Response

The Female Offenders Programs and Services held a Gender Responsive Strategies Workgroup meeting on the following dates: August 30 and 31, 2017, December 14, 2017, March 28, 2018 and June 19, 2018 where specific needs of female offenders were discussed. Suicide prevention was among the topics discussed.

CDCR developed a Partnership Plan that includes daily huddles, executive leadership rounding, and quarterly round table meetings between custody and mental health staff. The Partnership Plan implemented in December 2017 and is ongoing at CIW and CCWF.

Further, the Plan was incorporated into CIW's and CCWF's local operating procedures.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

1. SMHP is working on a contract to provide a same sex domestic violence program to MHSDS inmates. 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.

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

3. CDCR developed a partnership plan that includes daily huddles, executive leadership rounding, and quarterly round table meetings between custody and mental health staff. This plan was implemented at CIW and CCWF in December 2017.

The Partnership plan has been implemented and is ongoing at CIW and CCWF. The SMHP contract estimated completion date by May 2018.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email, including proof of practice documentation.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

1-Year Agency Response

CIW, CCWF and FWF are working with outside resources and community resource managers to bring in domestic violence prevention and awareness programs. SMHP is working on a contract to provide a same sex domestic violence program to MHSDS inmates.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

1. SMHP is working on a contract to provide a same sex domestic violence program to MHSDS inmates. 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.

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

3. CDCR developed a partnership plan that includes daily huddles, executive leadership rounding, and quarterly round table meetings between custody and mental health staff. This plan was implemented at CIW and CCWF in December 2017.

The Partnership plan has been implemented and is ongoing at CIW and CCWF. The SMHP contract estimated completion by May 2018.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email, including proof of practice documentation.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

1-Year Agency Response

Mental Health now has the ability to run training compliance reports through the Learning Management System portal. As the Suicide Prevention In Service Training is an annual training, compliance will be run September 1 of every year with results sent to the Chief Executive Officer and Chief of Mental Health of each institution, indicating which staff still need to be trained for that calendar year. Compliance will again be reported in January for the previous calendar year.

Mental Health created a training compliance report based on information institutions submit and began reviewing compliance and requiring corrective action plans for those institutions not in compliance in January 2018.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month 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 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 DAI HQ was included January 22, 2018. LMS will allow HQ staff to run compliance training reports for each institution remotely and more efficiently determine compliance.

Mental Health will be working with LMS to include suicide prevention related clinical training tracking in the LMS system in late spring.

Mental Health created a training compliance report based on information institutions submit and began reviewing compliance and requiring corrective action plans for those institutions not in compliance in January 2018.

Compliance rates for health care staff attendance at annual Suicide Prevention In-Service-Training is collected by the SPRFIT coordinators at each institution via the IST office until LMS is available to HQ Mental Health Program staff.

Copies of reports will be provided once complete.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

Annual Follow-Up Agency Response From October 2020

The training codes for both Initial and Advanced SRE Mentoring courses allow CDCR to track compliance for all clinicians who have completed the required training. CDCR is in the process of developing an automated tracking system to identify clinicians who have been assigned to be mentors and when they received the training. Currently, CDCR is able to monitor this manually.

Proof of Practice - Item 13 - Initial and Advanced SRE Mentoring Chart to be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We asked Corrections to provide evidence that it is tracking individuals trained as mentors and the percent of clinicians trained by mentors who received training through Corrections' approved process. Corrections stated that tracking is currently a manual process and expects to complete collecting information in February 2020. Until it provides documentation demonstrating adequate tracking of this information, we will report the status of this recommendation as partially implemented.

1-Year Agency Response

The SMHP tracks which individuals have been trained as mentors by the SMHP. The SMHP will require the institutions to verify that only trained mentors are providing mentoring. 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 maintain tracking of the percent of clinicians at each institution who were trained by mentors who received training through the approved process. A copy of the memorandum and report will be provided once complete.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

As noted above, SMHP will be partnering with CCHCS to incorporate all suicide prevention related mental health training to track the training mentors and trainers have received. In the meantime, the SMHP will require the institutions to verify that only trained mentors are providing mentoring. SMHP will issue a memorandum by February 28, 2018, 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 the memorandum and report will be provided once complete.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

Annual Follow-Up Agency Response From October 2020

CDCR finalized the curriculum for the 2-Hour IST Suicide Prevention course. It has been fully vetted and approved for use in the institutions. As of January 1, 2020, all institutional IST departments were instructed to utilize the new curriculum.

Proof of Practice - Item 14 - IST Suicide Prevention v4.0 - Lesson Revision to be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, updates will be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

The Department will ensure that the annual Suicide Prevention Annual In-Service Training and the Basic Correctional Officer Academy training includes Dealing with Manipulative Inmates. Results of recent tours, audits and suicide case reviews have been incorporated. The Statewide Mental Health Program met with the Office of the Special Master Suicide Prevention Expert the week of February 12, 2018 to review the training and additional recommendations, which have been added to the training. Changes were made in 2017 and implemented in January of 2018. Copies of revised training materials will be provided once complete.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The SMHP and DAI will work with the Office of Training and Development to ensure that the annual Suicide Prevention Annual In-Service Training and the Basic Correctional Officer Academy training include Dealing with Manipulative Inmates. Results of recent tours, audits and suicide case reviews have been incorporated. The Statewide Mental Health Program will be meeting with the Office of the Special Master Suicide Prevention Expert the week of 2/12/18 to review the training and additional recommendations.

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.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

Annual Follow-Up Agency Response From October 2021

Modifications to the staffing plan were filed with the Coleman court on December 11, 2020, and the court filed an order approving it on January 26, 2021.

Supporting documentation will be submitted as directed.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2020

As of September 2020, the staffing plan remains an open issue to be resolved by the parties to the Coleman case or the court itself, and is subject to potential litigation.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

1-Year Agency Response

The SMHP received an order from the court regarding its proposed staffing plan in February 2017. Staffing is being reviewed.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The SMHP received an order from the court regarding its proposed staffing plan in February 2017. Staffing is being reviewed.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

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

Annual Follow-Up Agency Response From October 2023

The Continuous Quality Improvement Tool (CQIT) and the indicators and measures continue to undergo data validation with CDCR, the plaintiffs, and the Office of the Special Master as part of an ongoing effort to resume CQIT audits. In the interim, the current iteration of the Suicide Prevention CQI Onsite Audit is being utilized by the Statewide Suicide Prevention Coordinators to conduct regular site reviews of prisons with mental health programs. These reviews produce recommendations and formal corrective actions for all deficiencies noted. This guidebook is updated regularly as key indicators complete the Court-mandated data remediation process.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2022

The Quality Management program worked 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.

Per direction from the Office of the Special Master, CDCR will implement CQIT in 10 institutions beginning July 2018.

Update: The CQIT and the indicators and measures continue to undergo data validation with CDCR, the plaintiffs, and the Office of the Special Master as part of an ongoing effort to resume CQIT audits.

Occurring in a parallel process is the review of the Suicide Prevention CQIT on-site guidebook. The measures have been established, and methodology and questions have been developed for all suicide prevention-related indicators. Work continues to finalize language and seek feedback from the parties, after which time CDCR will begin implementing the guidebook for on-site monitoring of institutional suicide prevention practices.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2021

The ongoing use of the CQIT is a matter of active discussion amongst the Coleman parties, and the parties are working to determine when the CQIT audits will resume.

The Suicide Prevention CQIT is being designed to be separate from CQIT and will be able to run independently from the full CQIT. This tool is being tested at 4 institutions currently and will be refined based upon feedback from those using the tool. Target completion for this tool is early 2022.

Outside of the CQIT process, CDCR has hired a Senior Psychologist-Specialist for each region to participate in regular site visits to audit the suicide prevention practices of each institution. Any deficiencies identified during these site visits result in Corrective Action Plans. A sample of 4 Regional SPRFIT Reports are attached as proof of practice for auditing this item.

Supporting documentation will be provided as directed.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2020

Chart Audit Tool Update:

All required revisions to the Chart Audit Tool audits have been completed and approved by the parties in the Coleman case. The audits of SRASHEs resumed on April 1, 2020, for SRASHEs completed in the first quarter of 2020.

Continuous Quality Improvement Tool:

All CQIT audits were completed in 2018 and 2019. Ongoing use of the CQIT is a matter of active discussion amongst the Coleman parties, and no additional audits are currently scheduled at any CDCR institutions.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

The Quality Management program worked 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.

Per direction from the Office of the Special Master, CDCR will implement CQIT in 10 institutions beginning July 2018. The CQIT Audit of California State Prison, Los Angeles County was completed the week of July 16, 2018. Audits of the remaining nine institutions will be completed through October 2018.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month 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.

Per direction from the Office of the Special Master, CDCR will implement CQIT in 10 institutions beginning March 2018.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

Annual Follow-Up Agency Response From October 2021

CDCR has submitted a revised 2021 version of the Mental Health Services Delivery System (MHSDS) Program Guide to the Coleman court, which codifies all subsequent changes to the 2018 Program Guide.

Supporting documentation will be submitted as directed.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2020

Suicide Prevention and Response regulations continue to be reviewed and require coordination across multiple class actions. The Office of the Special Master in Coleman has also requested that these regulations be placed on hold for further discussions.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

CDCR continues to work on draft regulations.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The SMHP and the Division of Adult Institutions continue to work on draft regulations.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The SMHP and DAI continue to work on draft regulations.

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.

Annual Follow-Up Agency Response From October 2021

Senior Psychologist-Specialists have been assigned to each region to provide oversight to institutions with suicide prevention efforts. These specialists attend SPRFIT Committee meetings, and if quorums are not met, Corrective Action Plans are implemented. These Specialists have been conducting site visits since the first quarter of 2021.

Supporting documentation will be submitted as directed.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From October 2020

The self-monitoring guide continues to be under development/approval. We are currently auditing all institutional Local Operating Procedures related to this item to ensure they are in compliance with required members. We will be coordinating the audits of the SPRFIT Committee minutes for compliance.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, updates will be submitted via email, including supporting documentation.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We asked Corrections to provide an audit tool they stated would help monitor compliance with prevention team requirements. Corrections stated that the tool has been developed but revisions are pending, and did not provide an estimated date for the tool's completion.

1-Year Agency Response

This item refers to SPRFIT. SPRFIT enhancements address membership and quorum issues. SPRFIT audit and coding will also be updated. Corrective action plans will be developed for institutions who consistently do not establish quorums.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

Corrections stated that it is developing an audit tool to verify that suicide prevention teams are meeting quorum and that Corrections will require a corrective action plan for teams that do not meet quorum for two consecutive meetings.

6-Month Agency Response

This item refers to SPRFIT. SPRFIT enhancements address membership and quorum issues. SPRFIT audit and coding will also be updated. CAPS will be developed for institutions who consistently do not establish quorums.

A copy of revised SPRFIT requirements memorandum will be provided.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

6-Month Agency Response

This item refers to SPRFIT. SPRFIT enhancements address membership and quorum issues.

See revised SPRFIT requirements memorandum.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

Corrections updated its policy regarding membership on suicide prevention teams. The policy discusses the staff that must attend, who may designate others to attend, and who may play multiple roles for the purposes of determining whether the meeting has achieved a quorum.

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.

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.

6-Month Agency Response

This item refers to SPRFIT. SPRFIT enhancements address making qualitative improvements to SPRFIT functions.

California State Auditor's Assessment of 6-Month Status: Fully Implemented

In February 2018, Corrections released a detailed policy memo clarifying the requirements and responsibilities of its suicide prevention teams, which are teams that Corrections refers to as SPRFIT. That memo outlines a number of activities that address our recommendation, including accurately tracking self-harm incidents, monitoring compliance and review quality of five-day follow-ups and risk assessments, conducting root cause analysis of suicide attempts, and developing performance improvement plans.

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.

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.

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, updates will be submitted via email, including supporting documentation.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Corrections provided a policy memo dated October 2019 that clarifies how Corrections will count and record incidents of suicide and suicide attempts. The memo addresses our recommendation; however, additional audit work would be necessary to ensure implementation of the new procedures.

1-Year Agency Response

CDCR will ensure that mental health data feeds into COMPSTAT with respect to suicides and attempts. COMPSTAT and Mental Health have developed a report to allow for this feed.

CDCR has set up a data conduit for de-identified suicide and suicide attempt data to be sent on a monthly basis to COMPSTAT from the healthcare data warehouse.

The process will be formalized in policy memoranda. A copy of memorandum outlining process will be provided once complete.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month 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 memoranda.

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

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

1-Year Agency Response

1. A Suicide Prevention Summit was held 10/17-19, 2017. The next Summit is scheduled for 9/18-20, 2018. 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. 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.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

1. A Suicide Prevention Summit was held for 10/17-19, 2017. The next Summit is scheduled for September, 2018. 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. 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.

California State Auditor's Assessment of 6-Month Status: Pending

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.

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.

1-Year Agency Response

CDCR uses an aggregate Root Cause Analysis (RCA) process, 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). These RCA's are to be performed every six months. This requirement is contained in the SPRFIT enhancements. Training was held in January 2018.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

CDCR will use an aggregate Root Cause Analysis process, 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 is contained in the SPRFIT enhancements. Training was held in January 2018.

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

California State Auditor's Assessment of 6-Month Status: Pending

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.

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

All Recommendations in 2016-131

Agency responses received are posted verbatim.