The Public Eye

California for-profit company faces allegations of inadequate inmate care


On a Saturday morning in 2010, Clearlake police showed up at the home of 38-year-old Jimmy Ray Hatfield after he barricaded himself in his bedroom and told his parents he had a bomb.

Hatfield was mentally ill and thought someone was going to kill him, his parents told police. After a lengthy standoff, he was brought to a hospital, given an antipsychotic and a sedative and transported to the Lake County jail, records show.

The jail nurse received paperwork from the hospital detailing his psychotic state, but said she did not review it because that was the job of another nurse. That nurse wasn’t scheduled to work for another day and a half.

By then, Hatfield was found unresponsive in his cell, hanging from a bed sheet.

The company responsible for the jail’s health care, California Forensic Medical Group, was accused by Hatfield’s family of negligence in his death and settled the case for an undisclosed amount. It has faced allegations that it failed to provide proper care in dozens of U.S. District Court cases over the last decade.

CFMG is the state’s largest for-profit correctional health care company, delivering medical service in 27 counties, including El Dorado, Placer and Yolo. The company also provides jail mental health service in 20 counties.

The company started in 1984 with a contract to provide care in Monterey County and has consistently grown by taking over inmate health care in small and medium-size counties. Bigger counties, including Sacramento, tend to provide their own correctional health care.

Since the state started sentencing lower level offenders to county jails instead of state prisons in 2011, attorneys who successfully sued the state over inmate health care are now suing counties. That realignment has prompted more counties to rely on private companies such as CFMG to oversee jail health care to control costs and reduce liability.

At least three county grand juries have criticized the company’s role in inmate deaths. Some investigations have been spurred by a spike in deaths – four people in Sonoma County in an 11-month period ending in 2007 and four people in nine months in Santa Cruz County after CFMG took over health care in 2012.

Sonoma County officials are promising yet another investigation following the death of four inmates in less than a month last year.

A common thread in the reports and court complaints: CFMG allegedly provides insufficient mental health and detoxification services, two of the most persistent needs in jails.

In a 10-year period ending in May 2014, 92 people died of suicide or a drug overdose while in the custody of a jail served by CFMG, according to a Sacramento Bee analysis of a state Department of Justice database. CFMG’s population-adjusted rate for such deaths is about 50 percent higher than in other county jails. Most of the people who died in such cases were not yet convicted of a crime, according to the state database, as is the case for most jail fatalities.

“There have been needless deaths under the watch, care and authority of this organization,” said Monterey County Public Defender James Egar.

The company has settled six lawsuits in five years but has not admitted any wrongdoing, said CFMG Chief Executive Officer Kip Hallman, who declined to provide the amounts of the settlements. He said that the company has faced litigation because it works in the highly scrutinized field of correctional health, and that legal challenges are not reflective of the quality of CFMG’s work. Hallman and others at CFMG declined to discuss the lawsuits.

Elaine Hustedt, chief operating officer and a company co-founder, said, “We’re proud of what we do. Are we perfect? No, but nobody is.”

Staffing vs. profit

Michael Bien, a Bay Area attorney suing the company in Monterey County along with Egar and the American Civil Liberties Union, said CFMG puts inmates at risk.

“The profit motive is inconsistent with constitutional levels of care,” he said. “The less medical and mental health products provided by CFMG, the more profit is consumed by CFMG.”

Bien said he hasn’t found anything improper about the company’s Monterey County contract, but he said the agreement creates an incentive to limit costs because the county pays CFMG a set amount, regardless of how many doctor visits or prescriptions are needed.

CFMG’s agreements in Yolo and Placer counties are similar, with the company agreeing to be “financially responsible for the medical costs of all persons” in Placer County’s jails for $3.7 million a year, and agreeing to provide services in Yolo County for $3.3 million a year. Robin Faille, a recently retired captain of the Yolo County Sheriff’s Office, said the agreement has allowed the county to keep medical costs relatively flat in recent years even as it took responsibility for more lower level offenders.

If the jail population exceeds a certain level or a single medical expense exceeds $16,500, at least some of CFMG’s contracts call for counties to increase reimbursements to the company.

Hallman said CFMG doctors and nurses make medical decisions based on the circumstances of each case and not because of financial considerations.

However, in a 2002 lawsuit over the suicide of a young man in the Yolo County jail, company co-founder Dr. Taylor Fithian conceded that he had written a letter to one of his Yolo employees expressing concern that inmates were making “too many emergency room visits, hospitalizations and orthopedic visits,” according to Fithian’s deposition in the case. The lawsuit was settled for more than $800,000, almost all of which was paid by CFMG, according to the Associated Press.

In the case against Monterey County and CFMG over improper medical and mental health care in the jail, a central issue has been staffing. The parties selected independent experts to review mental health and medical care.

Richard Hayward, a Bay Area psychologist, found that “the mental health service suffers from understaffing.” Dr. Michael Puisis, author of a textbook on correctional health, found that medical staff was not “performing at an adequate level” and “staffing issues are a major contributor to deficiencies.”

CFMG and Monterey County declined to comment on the case, although CFMG attorneys have denied the allegations against the company.

When the reviews were completed in 2013, the company had 2.65 employees per 100 inmates in the Salinas jail. Monterey County recently approved an additional $3 million annually for health care workers and sick inmate transportation. The sheriff says the money was needed because inmates are staying in jail longer under realignment and require care for chronic conditions such as diabetes.

CFMG has had similar staffing ratios in the capital region. In Yolo County, the company had 3.59 employees per 100 inmates in 2013. In Placer County, it was 2.79 employees per 100 inmates. The industry has no specific standard for staffing ratios “but the number of staff must be sufficient to ensure that there are no unreasonable delays in patients receiving necessary care,” according to the National Commission on Correctional Health Care.

In Yolo, Placer and other counties, CFMG relies on part-time doctors and psychiatrists, compared to larger counties that have those professionals on site full time. In Yolo and Placer counties, CFMG must have a doctor in the jails a minimum of 10 hours a week, and psychiatrists have to be on site eight or nine hours a week. Nurses and social workers provide the rest of the services.

The counties can choose to have professionals on site more at an additional cost.

Dr. William Douglas said he served as company medical director in Glenn and Colusa counties by working one day a week. Hallman said Douglas was terminated in 2013 for reasons unrelated to medical care. According to court records, prior to working for CFMG, Douglas was fired from separate jobs by the California Department of Corrections and Rehabilitation and Sacramento County for withholding treatment from inmates. He disputes those claims.

Placer and Yolo county officials said they were not aware of CFMG’s problems. Told that CMFG had about the same staffing ratio in Placer County as the one found insufficient in Monterey County, Maureen Bauman, Placer’s behavioral health director, said her county has never had a significant problem with CFMG service in its 16-year relationship with the company. Faille, of the Yolo County Sheriff’s Office, which has contracted with CFMG for 24 years, gave a similar assessment.

Suicides questioned

According to state Department of Justice records, 72 people committed suicide in the last decade while in a jail served by CFMG.

In recent years, the company’s suicide prevention efforts have been challenged in the federal lawsuits in Monterey and Lake counties, as well as in a third case in Ventura County.

In his examination of the Monterey County jail, Dr. Pablo Stewart, an expert hired by plaintiffs in the case, reviewed three suicides since 2010. “In each case, problems with the jail’s mental health and suicide prevention programs appear to have contributed to the suicides,” he wrote. He pointed to inmates who were not given medicine or psychiatric consultation prior to their deaths.

In Ventura County, inmate Daniel Hernandez had a history of mental illness severe enough that he was once ruled incompetent to stand trial. According to testimony cited by a U.S. District Court judge, a CFMG psychiatrist and other employees were aware of his condition and were responsible for “Hernandez receiving no treatment for his mental health condition in the three months prior to his suicide and grossly insufficient monitoring, and thereby contributed to his death.” Hernandez committed suicide in 2009 and the case was settled for $775,000, court records state.

In a written proposal made to Fresno County officials in 2013, the company said it trains employees to identify suicide risks and prevent suicide. Nurses ask questions about mental conditions when inmates are booked, and those at risk for suicide are seen by psychiatrists and watched by CFMG and county custody staff.

But questions remain about whether the company dedicates enough resources to suicide reduction. About 20 percent of the inmates in CFMG jails were identified as having mental health needs in 2013. In Placer and Yolo counties, that is an average of 115 inmates each at any time. Yet the company is contracted to have a psychiatrist on site no more than nine hours a week, an average of less than five minutes of in-person psychiatric care each week.

Bauman, mental health director in Placer County, said inmates receive enough mental health care because a nurse with a psychology background and a clinical social worker also treat them. In Yolo County, two marriage and family therapists supplement the work of the psychiatrist.

Yolo County Capt. Larry Cecchettini said certification of the company’s work in the jail by the San Francisco-based Institute for Medical Quality shows that inmates receive proper care. The institute performs independent and voluntary reviews of correctional health services. Six of CFMG’s 27 adult jails have received the certification, while two have lost it in recent years.

In Yolo, Placer and other counties, the company also provides psychiatric care through telemedicine, psychiatrists who talk with inmates via video conferencing from CFMG headquarters in Monterey. The program lessens “the wait time for appointments that would otherwise not be able to be seen until the following week,” according to CFMG.

In a lawsuit filed in November, attorneys blame CFMG cost-cutting in general and telepsychiatry in particular for the May 2014 suicide of ​37-year-old truck driver​ ​James Ellis Smith​ ​in the Lake County jail. Smith had a history of mental illness and made requests for psychiatric help during his four months in jail, but he was seen only three times by a psychiatrist on a video monitor.

That was “a wholly inadequate process for mental health care, with no purpose other than to save CFMG money by not having to bring a psychiatrist to the jail,” according to the complaint filed by attorneys representing Smith’s family.

CEO Hallman generally defended the use of telepsychiatry. “Telepsychiatry is a very effective way to deliver services,” he said. “The state of Texas provides all of its psychiatric services through telepsychiatry. In some rural areas, it’s the only way to get a psychiatrist.”

In a 2008 study in the journal Behaviorial Sciences and the Law, professors at East Carolina University found that telepsychiatry had the potential to improve access to mental health care in prisons and jails, particularly in rural areas. However, more research is needed on the effectiveness of the practice, the authors concluded.

Detox criticized

Alcohol and drug abuse are among the most pressing health problems in jails. They’re also a top cause of deaths in CFMG jails.

Twenty-one people died from alcohol or drug overdose in its jails in the last 10 years, second only to hanging and strangulation, according to the state database.

A related problem, drug and alcohol withdrawal, can contribute to fatalities. Longtime alcohol abusers can die from alcohol withdrawal, and people addicted to heroin and similar drugs can experience withdrawal symptoms that, combined with other chronic conditions, can result in death, according to the National Commission on Correctional Health Care.

Grand juries in Sonoma, Ventura and Santa Cruz counties have criticized CFMG for how it handles inmate detoxification. In a 2008 report titled “Death by Incarceration,” a Sonoma County grand jury found indications that “drug and alcohol withdrawal played key roles in three ... deaths” and the company’s procedures failed to detect people at risk for alcohol withdrawal.

As a result, CFMG hired a national expert to craft a new method to identify and treat alcohol withdrawal, a process now used at all of its facilities, Chief Operating Officer Hustedt said.

Yet a Ventura County grand jury in 2013 cited failures in CFMG’s alcohol detoxification process as a reason for the death of a 53-year-old woman and recommended the county consider another medical provider. CFMG disputed the findings, pointing to evidence from the county’s medical examiner that the woman died from complications related to chronic alcoholism. The county stayed with CFMG.

In a May 2014 report, a Santa Cruz County grand jury examined five deaths, four of which happened after CFMG took over medical care in September 2012. The death spike led inmate activists to take to the streets of Santa Cruz, demanding an investigation.

Two of the four deaths on the company’s watch involved drug or alcohol detoxification, according to the grand jury report. One man told jail staff that he was detoxifying from heroin and methadone when he was booked at 10:45 p.m. in November 2012, but CFMG did not start treating him for withdrawal until 9:30 a.m. the following day. He died from withdrawal-related symptoms that evening, according to the report.

In its reply, CFMG disputed the claim that insufficient treatment played a role in either inmate’s death. Santa Cruz County also disputed the claims and said it would not implement the jury’s recommendation to improve detox services, saying that was up to the company, which uses “medically approved detoxification protocols.”

“It was all very frustrating,” said Nell Griscom, the grand jury’s forewoman.

Call The Bee’s Brad Branan, (916) 321-1065. Follow him on Twitter @BradB_at_SacBee.