By Mark Gutglueck
Even as questions were emerging about the psychological abuse of prisoners within San Bernardino County’s jails, the San Bernardino County Board of Supervisors last month increased by $14.2 million the contract the Liberty Healthcare Corporation will receive for providing mental health services in the county’s detention facilities.
The increase was made despite recurrent reports of inadequate care being provided to county inmates with mental issues, evaluations that conform with the interests of the county’s jailors rather than the inmates in need of psychological or psychiatric care and suggestions of kickbacks to county sheriff’s personnel and county officials in exchange for sustaining what has now become for Liberty a highly lucrative contractual arrangement.
San Bernardino County and its sheriff’s department originally contracted with Liberty Healthcare while Orange County-based psychiatrist Thomas C. Lester M.D., who was then doing business as Liberty Healthcare of California, Inc., held the professional license under which those psychiatric services were provided. Lester, however, has ended his relationship with Liberty Healthcare for reasons that have not been made publicly clear. His successor at Liberty is not a psychiatrist but rather a licensed clinical social worker.
It now appears that an eight figure revenue stream into the county for the pass-through of psychiatric evaluation services to jurisdictions throughout the state has blinded county officials to how indigenous county inmates in the sheriff’s jail system are having their psychiatric needs neglected or are the victims of both physical and psychological abuse by their jailers that is being ignored by the mental health professionals Liberty employs. In some cases it is apparent that the mental health professionals employed by Liberty have allowed their function to be compromised such that they have allowed their authority to dispense psychoactive drugs to become a tool in the panoply of methods used by deputies working the jails to perpetuate the abuse of the inmates.
The matter is exacerbated by the consideration that the county’s soon-to-be-departing director of behavioral health has failed to exercise any oversight of the mental health treatment of San Bernardino County citizens housed in the sheriff’s jails and detention facilities.
When Lester and Liberty first obtained what was a relatively modest contract with the County of San Bernardino in 2010 under the auspices of an experimental “pilot program,” competitive bids were bypassed. Subsequently, that contract was renewed without any competitive bidding, and the pilot program has now become an institution at the West Valley Detention Center in Rancho Cucamonga.
While the first contract Lester’s company landed with the county for the three-year period between July 1, 2010 to June 30, 2013 specified a not-to-exceed $499,977 annual cost, not including the cost of medication, in April of 2015, when that no-bid contract was renewed for the period from June 1, 2015 to May 31, 2016, it had zoomed to more than nine times the original cost, $4,756,536.
Last month, Liberty came in for an even more substantial windfall.
On August 23, the San Bernardino County Board of Supervisors voted unanimously to approve an amended contract with Liberty “for comprehensive mental health and programming services in the county’s correctional facilities.”
According to a joint staff report to the board of supervisors dated August 23, 2016 from sheriff John McMahon and CaSonya Thomas, the director of the county’s behavioral health department, the $4.75 million annual contract with Liberty approved last year had been jettisoned in January, in favor of a newly configured one that did not run concurrent with the standard governmental fiscal year running from July to June but rather from the middle of the second week of January 2016 through the middle of the second week of January 2017. That contract imposed a substantial – $1.75 million annual – reduction. But less than eight months into that arrangement, they recommended that the contract be upped.
“On January 12, 2016, the board of supervisors approved Contract No. 16-08 with Liberty Healthcare Corporation to provide comprehensive correctional mental health and programming services to supplement and enhance related services being provided by the department of behavioral health,” the McMahon/Thomas report states. “The initial contract term was January 12, 2016 through January 11, 2017, and included two one-year options to extend the term for a maximum three-year period. In an ongoing effort between the sheriff and department of behavioral health to ensure the quality and effectiveness of mental health services being provided to the county’s inmates, the departments mutually recommend that Liberty assume a greater responsibility for correctional mental health care while inmates are in custody. The department of behavioral health will continue to provide transitional care services for inmates upon release.”
The contract amount was increased by $14,161,308, from $3,047,314 to $17,208,622, and was altered from a one-year contract term to a three-year term, for a new total contract period of January 12, 2016 to January 11, 2019. Thus, the annual value of the contract will jump from $3,047,314 to $5,736,207.33.
According to the report, the number of Liberty staff will increase at the jails. While there will be no change with regard to the single chief psychiatrist in place at the jails and the two mental health registered nurses employed therein, the number of psychiatrists will increase from 4.75 working full-time to 6.75 working full-time; the number of licensed clinical supervisors will jump from one to two; the seven master’s level clinicians will increase to 12; an office assistant will be hired; and the sheriff’s department will hire a supervising correctional nurse to augment the function. Overall, the number of mental health professionals has now seen an increase from 13 to 25.75.
There is a lack of clarity as to what Liberty’s employees’ function actually is and whether the team members are in the county’s jails to facilitate the fulfillment of the Hippocratic Oath – the commitment by doctors and medical professionals to do no harm and help their patients – or whether they are to assist the sheriff’s department and the district attorney’s office in carrying out their missions, which are to obtain convictions against those who have been apprehended and charged criminally.
County and sheriff’s department officials have acknowledged that a major portion of the work carried out by Lester and his employees consists of mental competency restoration services for inmates. A percentage of individuals arrested and incarcerated and slated for trial move into an area of legal limbo after a court determines they are incompetent to stand trial. Once a trial court makes such a determination with regard to a defendant and orders the defendant committed to a state mental hospital for care and treatment to restore competence in order to be processed through the justice system, the state mental hospital has 90 days to make a written report to the court concerning the defendant’s progress toward recovery of mental competence.
But because of chronic shortages of beds within California State Hospitals which have created lengthy waiting lists of inmates in county jails, including those in San Bernardino County, who are in need of mental competency restoration services, the state of California created economic incentives to promote the mental competency restoration concept. This has led to some questionable actions by governmental entities and psychiatric professionals in the scramble for the money. As part of an effort to clear the county’s jails of this backlog of inmates awaiting admission to the state mental hospital system, the county in 2010 hit upon the idea of bringing in a psychiatrist who would provide to those inmates in the county jail the same services those inmates would receive in a state mental hospital. It was at that point that Lester and Liberty entered the picture. In May of 2010, the California Department of Mental Health contracted with Liberty (State Agreement No. 09-79156-000) to establish a pilot program to provide restoration of mental competency services in a county jail. On June 22, 2010, the board of supervisors approved a revenue agreement with Liberty to allow West Valley Detention Center to be used as a site for a state pilot program to provide restoration of mental competency services to county inmates. The San Bernardino County Sheriff’s department allocated 20 beds in a sheltered housing unit for use by Liberty and assigned a deputy to provide security for Liberty’s staff.
San Bernardino County likewise has a financial interest in the program. By utilizing a psychiatrist to provide mental competency restoration services to inmates deemed to be mentally incompetent within the jail setting as opposed to transferring them to a state mental hospital, the county stood to obtain reimbursements from the state. San Bernardino upped the stakes, agreeing to accept inmates from other jurisdictions – all 57 of the state’s other counties – who would be evaluated by Lester and his staff with an eye toward certifying those people to be ready to go to trial. In Fiscal 2015-16 alone, San Bernardino was angling to obtain a reimbursement of $10,857,697.44 from the state for that use of its detention center space.
With this emphasis on monetizing Lester and Liberty’s services, an arrangement that was delivering cold cash into the county’s coffers and Lester and Liberty’s bank accounts, concern arose that the legitimate psychological care of inmates was being overlooked.
This is because, in addition to providing the mental competency restoration treatment, Liberty is also contracted to tend to the psychological needs of the general inmate population. Many see a potential or actual conflict of interest between those two functions. While the mental competency restoration treatment of inmates transplanted into San Bernardino County jails and detention facilities represents an influx of income to the county, the provision of psychiatric care to the county’s general inmate population does not. In such an environment, when there is a shortage of psychiatric care assets they end up being apportioned overwhelmingly away from San Bernardino County citizens.
Moreover, reports have reached the Sentinel of the abuse of jail inmates, including what might be defined as mental and emotional abuse – intended to “psychologically break” the inmates, at least some of whom maintain they are innocent of the crimes they are charged with and form the basis of their incarceration.
In one case, that of Kristen Arthur, after Judge Charles Umeda ordered that she be granted a session with a jail psychiatrist, her jailors refused for more than six hours to bring her out of solitary confinement so she could be seen by Dr. Patricia Kirkish, a psychiatrist who had travelled from her office in Pasadena to West Valley Detention Center to evaluate Arthur and her condition. After the interminable wait and no indication that access to Arthur would be granted, Kirkish departed without seeing her.
In this way, it appears the psychological health of certain inmates is not being tended to. This is most likely to occur, the Sentinel is informed, when sheriff’s department or jailhouse personnel have a particular animus toward the inmate in question or the inmate has been the victim of physical or psychological abuse by sheriff’s deputies which may have triggered behavioral issues with the inmate. Given the power relationship that exists between the sheriff’s department, its administrators and personnel vis-à-vis Liberty and its mental health professionals, taken together with the lucrative nature of Liberty’s contract, the willingness of Liberty’s employees to stand up for the inmates it is their responsibility to treat has been compromised.
More troubling still is the sheriff’s department’s use of psychoactive drugs to render the inmate population within the jail system manageable, and Liberty’s acquiescence in this practice. Jailors dole out a host of psychoactive drugs to inmates, including sedatives, tranquilizers or anti-psychotic agents.
The inmates commonly refer to these drugs as Skittles, because of their coloration and visual similarity to the fruit-flavored candy produced by the William Wrigley, Jr. Candy Company. Not all of the inmates are amenable to being administered these drugs, which leave those taking them in a zombie-like or near catatonic state.
One former inmate at West Valley Detention facility told the Sentinel of his experience.
“I had been jailed after getting two driving under the influence tickets within a relatively short time,” he said. “I had been playing the fool and after my incarceration I arrived at the conclusion that I was going to get my life together. I was going to get sober and remain so. I resolved that I would use the time I was going to be in jail to get started on that. One day, something like two months after I had been in continuous custody, I awoke from a bad dream, cursing, and another inmate, who thought I was cursing at him, tried to get violent with me. Fortunately, cooler heads prevailed and no actual fight took place. Shortly after that, I was called out to talk to a psychiatrist and later that evening I was given Thorazine. That evening, a deputy, who was with a medical officer, called my name. The medical distributor, a woman, tried to hand me the medication. I declined it. At that point, the deputy told me in a loud enough projection of his voice to be overheard by all 47 inmates in the dormitory that if I did not take the Thorazine, privileges for all of us – phone access, day room, yard access, and television – would be revoked indefinitely. At that point, I would say ten or fifteen of the inmates made threats of violence toward me. Several of the others were mocking me, saying, ‘Take your skittles.’ So, I did.”
The former inmate told the Sentinel that he reluctantly complied with taking the Thorazine for roughly the next two weeks.
He said the drug left “me basically in a tongue-tied, slobbering, invalid state.”
As his date for release approached, he was advised by another inmate that he would be taken off the Thorazine “cold turkey,” which would very likely leave him incapable of maintaining sobriety. At that point, he declined taking any more Thorazine. He said a deputy, “tried the same scare tactic of revoking the entire dormitory’s privileges if I stuck with” his refusal. “I turned to the rest of the tank and told them, ‘If anyone has a problem, step down right now and we will go toe-to-toe.’ The deputy, who recognized at that point he would have a major problem on his hands, moved on without forcing me to take the medication.”
Later that evening, he was called out for a phone interview with a psychologist, who, he said “asked me why I was refusing to take my meds. When I told her the entire story, she looked into the situation and got back to me about a week later, saying she had looked into my psychiatric case file and she found no notes in there warranting any medication at all.”
The Sentinel approached Dr. Lester. He was unwilling to make any statements about whether he and Liberty had facilitated the sheriff’s department’s use of psychoactive drugs to control inmates or what standards or protocols are in place with regard to determining if inmates should be medicated. Nor was he willing to discuss whether he considered Liberty’s dual contracts for restoration of competency and psychiatric care to be in conflict with one another. Nor would he discuss if there was a strict separation of functions involving different Liberty personnel to supply the evaluations and other personnel to provide the inmate psychiatric care to ward off any such conflicts.
“I don’t know how they are doing things there now,” he said. “I haven’t been there in nine months. Liberty needs to address these things you are asking about, or the sheriff’s department, or both of them.”
Lester did not explain why he was no longer working for Liberty or with the San Bernardino County Sheriff’s Department.
“You should talk to Kevin Rice,” he said. “He’s in charge of what Liberty is doing at West Valley now.”
When the Sentinel contacted Rice, he did not dispute that the sheriff’s department was utilizing tranquilizers or anti-psychotic drugs to render the jail population manageable, but said, “Medication cannot be provided to an inmate without a doctor’s order. Under no circumstances would drugs be provided without a doctor’s assessment. That is standard anywhere. You can’t give medications to anyone without a doctor’s order.”
Asked whether he perceived some order of conflict in Liberty providing both the restoration of competency services and psychiatric care to the inmates in the same detention facilities and if there was some separation of duties that would ward off such a conflict, Rice said, “I can’t answer specifically how the services are provided.”
He gave a somewhat ambiguous response when asked if the county department of behavioral health exercised some oversight over the provision of psychological and psychiatric services provided to inmates in the county’s jail system. “The sheriff’s department has always been in charge of mental health programs in the jails,” he said. The Sentinel reposed the question, asking if the department of behavioral health monitored the delivery of the services. “Ultimately, mental health services is the responsibility of and under the authority of the sheriff’s department,” Rice said.
Rice, a licensed clinical social worker, shied away from explaining how he was able to replace Lester, a licensed psychiatrist, in overseeing Liberty’s psychiatric care and restoration of competency operations at West Valley.
“Those decisions are made at a higher level, way beyond me,” he said. “You need to speak to someone who is part of those decisions.”
When the Sentinel asked whether the sheriff’s department passes along to the department of behavioral health the records and authorizations relating to the dispensing of sedatives, tranquilizers and anti-psychotics to jail inmates, Rice moved to shut the interview down. “There’s not a whole lot I can answer,” he said. “I don’t have the authority to speak on behalf of the sheriff’s department regardless of which direction it is going. It is not appropriate for me to say anything. You should speak with Terry Fillman, the sheriff’s department’s medical services administrator.”
The Sentinel was unable to obtain a substantive response from Fillman. When reached by phone at his office at West Valley Detention Center he declined to explain on what basis the deputies working the jails could prevent an inmate from being interviewed by a psychiatrist after a judge had ordered that such a session with a psychiatrist take place. He refused to entertain any further questions, lawyering up in the process. He said the Sentinel should provide the questions it has in writing to sheriff’s department spokeswoman Jody Miller.
“She’ll give you that information once she is authorized to do so by county counsel,” Fillman said.
The office of county counsel is the county’s stable of in-house attorneys.
In attempting to reach CaSonya Thomas, the director of the county’s behavioral services department, the Sentinel was diverted to both the county’s main spokesman, David Wert, and the department of behavioral services’ public information officer, Aimara Freeman.
Freeman asked for questions to Thomas to be submitted in writing. Accordingly, the Sentinel inquired as to:
• Whether Thomas sees a potential or actual conflict between Liberty’s competency restoration and psychiatric care functions;
• If Thomas was sensitive to the consideration that the mercenary motive of running psychiatric evaluations of inmates originating from outside the county and the revenue the county receives from the state for providing that service may have compromised the psychiatric care provided to the inmates in the county’s jails;
• If Thomas was aware of the sheriff’s department using sedatives, tranquilizers and anti-psychotics to render elements of the jail population more manageable;
• If Thomas considered the practice of using sedatives, tranquilizers and anti-psychotics to render elements of the jail population more manageable appropriate;
• What sort of records are kept of medications issued to the county’s jail inmates;
• What the protocol for determining whether a jail inmate should receive sedatives, tranquilizers and anti-psychotics is;
• Whether there are medical or psychiatric authorizations made by licensed medical or psychiatric professionals for the dispensing of sedatives, tranquilizers and anti-psychotics to jail inmates;
• If the sheriff’s department passes along to the department of behavioral health the records and authorizations relating to the dispensing of sedatives, tranquilizers and anti-psychotics to jail inmates;
• If the department of behavioral health had any participation in creating the protocol for determining whether a jail inmate should receive sedatives, tranquilizer and anti-psychotics;
• How many inmates in the county’s jails at present are receiving sedatives, tranquilizers or anti-psychotics; and
• If Thomas has monitored Liberty’s function with regard to the services it is providing in the jail system.
Freeman was unwilling to provide substantive answers to any of the questions. She offered a curt, two sentence reply. “The department of behavioral health has no authority over the provision of jail mental health services or the contract with Liberty,” she said. “Please direct your questions to the sheriff’s department.”
The Sentinel followed up with a single question, inquiring how it was that Freeman had co-authored the report to the board of supervisors relating to its August 23 vote for increasing Liberty’s contract scope at the jails if she had no authority over mental health services at the jail. Freeman did not respond.
The Sentinel redirected the written questions provided to Freeman to sheriff’s department spokeswoman Jody Miller, who on Wednesday said she would respond if the questions were provided in that form. By press time, Miller had not responded in writing or verbally to any of those questions.
Wert told the Sentinel, “The department of behavioral health is recognized nationally for the extraordinarily high level of care it provides to its clients in San Bernardino County. However, to ensure client privacy, the department does not discuss the specific care it provides. Additionally, the department has no role in the management of the county’s jails.”
The Sentinel has learned that Thomas is not a licensed psychiatrist or psychologist, despite her status as the head of the county’s behavioral services division. Rather, she is an administrator, with a master’s degree in business administration. She does possess a certificate in health care compliance.
The board of supervisors has voted to remove Thomas as the director of the behavioral services division and “kick her upstairs” to become the county’s human services director in mid-October.
By Mark Gutglueck