ATTACHMENT 1

JEFFREY L. METZNER, M.D., P.C.
3300 EAST FIRST AVENUE
SUITE 590
DENVER, COLORADO 80206
_____
TELEPHONE (303) 355-6842
FACSIMILE (303) 322-2155
TAX ID #84-0848664

October 31, 2007
National Prison Project
Attn: Eric Balaban
915 15th St, NW
7th Floor
Washington, DC 20005-2112
Re: Carty v. DeJongh, No. 94-78
Dear Mr. Balaban:
I have completed my assessment of mental health services offered to inmates at
the Criminal Justice Complex (CJC), St. Thomas, United States Virgin Islands
(USVI), and to five persons adjudged not guilty by reason of insanity (NGRI) who
are now housed at the Golden Grove Adult Correctional Facility (ACF), St. Croix,
USVI.
I site visited the CJC and ACF during August 6, 7, 8, 2007. I had previously made
similar site visits during 1994, 2005 and 2006. In addition to reviewing my May
2006 site visit report, I reviewed the following documents as part of this
assessment:
1. The Settlement Agreement,
2. Findings of Fact and Conclusions of Law (February 2007),
3. documents produced by Defendants in responses to the February 2007
court order, as well as documents included in Appendix III to this
report
4. various CJC logbooks, and
5. the classification, medical and mental health records of 19 inmates.
During the morning of August 6, 2007 I interviewed Leighman Lu, M.D., Lisa
LaPlace, R.N. and correctional officers in Clusters 1, 2, 3, 4, 5, & 6. I also

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interviewed Agnes George (Warden–CJC) and Jennifer Charles, MSW (mental
health coordinator at ACF).
At CJC, I briefly interviewed in two group settings seven male mental health
caseload inmates housed in Cluster 3. I also interviewed the five persons at ACF
found NGRI.
Appendix I provides a summary of these interviews and my review of selected
healthcare records.
Introduction
The CJC is located on the third floor of a building in the Alexander Farrelly
Justice Complex. The first two floors are occupied by the Virgin Islands Police
Department. The jail has a rated capacity of 97 prisoners, which is the total
number of fixed beds, and the Agreement caps the population at this total. At any
one time, about 80% of the prisoners at the CJC are pre-trial detainees. Sentenced
inmates, with few exceptions, who typically have less than a year remaining on
their sentences, are transferred to the CJC Annex, which also houses a limited
number of federal and/or immigration detainees.
The prisoners (also referred to as inmates in this report) are housed in seven
housing clusters. The capacity of these clusters ranges from 10-20 prisoners.
Three of the clusters have special designations: Cluster 7 houses female prisoners.
Cluster 6 houses new admissions and prisoners in administrative or disciplinary
segregation, although all clusters can also house segregation prisoners. Cluster 3
houses mentally ill prisoners, and some protective custody inmates, who cannot
safely be housed with the general population. All of the cells are double-bunked.
There are no single cells at the jail (although there are inmates who have been
single bunked due to safety reasons, including one inmate in Cluster 3 who has
been singled bunked for over two years), and no cells are specifically designated
for mental health observation or suicide watch.
There have been no significant changes relevant to the statistics concerning the
average daily census, monthly admissions and percentage of inmates on the mental
health caseload since my April 2005 visit. The average daily population remains
about 89 inmates. The average monthly admissions over the past year have been
102 inmates. See Appendix III, Ex. T.

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The CJC Annex opened shortly after my May 2006 site visit. The facility has an
80-bed capacity, but the average daily population at the Annex since it opened has
been 18 inmates. There are occasional federal detainees at the Annex. There is
currently one registered nurse (Odulia Anderson) who works at the facility 20
hours per week (five days per week). Galen Hall, M.D. provides physician
services up to 10 hours per week.
The Bureau of Correction (BOC) has not developed policies and procedures to
assess, identify, and exclude mentally ill inmates from the CJC Annex. Instead,
Lisa LaPlace, RN, the Territorial Nursing Coordinator and CJC head nurse, acts as
an informal gatekeeper. Ms. LaPlace was aware of four inmates with mental
illnesses being transferred to the CJC Annex during different weekend days, which
was brought to her attention on the first Monday following their transfer.
Inmates who cannot be treated at the CJC theoretically can be transferred to the
Roy L. Schneider (RLS) Hospital in St. Thomas, which is about a mile from the
jail. The hospital has a small behavioral treatment unit (BTU) for acutely mentally
ill persons. However, there have been no such transfers for treatment purposes for
at least the past 18 months, due to obstacles to transfers rather than a lack of
clinical need for transfers.
Agnes George remains the CJC’s warden. Rosaldo Horsford (ACF warden) is no
longer the acting head of the BOC. He was recently replaced by Alvin York, who
was the BOC’s acting director in 1996-97. Vincent Frazier was confirmed as
Attorney General in mid-2007, and John DeJongh was sworn in as Governor in
early 2007.
Recommendations: As per my May 2006 report, policies and procedures need to
be developed that describe the screening process to be used to identify and exclude
mentally ill inmates from the Annex. In addition, these policies and procedures
need to describe the process to be implemented to identify and transfer inmates
who were appropriately admitted to the Annex but later demonstrate symptoms of
a mental illness. These policies and procedures would be a subset of the previously
recommended mental health system policies and procedures (see my May 2006
report) that would address the subject areas summarized in Appendix II. Of note,
the BOC still has not developed relevant mental health policies and procedures
related in large part to leadership and staffing issues that will be further described
later in this report.

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In addition, Ms. LaPlace needs a full-time head nurse at CJC in order to allow her
to relinquish these duties so she can assume her role as Territorial Nurse
Coordinator, which would facilitate implementation of the above recommended
policies and procedures.
The next section of this report will provide my updated findings based on this site
visit.
Staffing
Physician staffing
The jail’s physician remains Garfield Less, M.D. and the psychiatrist is Leighman
Lu, M.D. Both are contracted to provide 10 hours of service weekly. Galen Hall,
M.D. provides physician coverage when Dr. Less is unavailable. Dr Less has
announced his intention to retire by the end of the year. There is no designated
psychiatrist to cover on site for Dr. Lu during his absences from the jail. There
appears to be limited psychiatric coverage during his absences via the local
psychiatric hospital by telephone for inmates known to the covering psychiatrist.
Nursing staff
During April 2005 Ms. LaPlace was hired as the Territorial Nursing Coordinator.
There is still no approved job description for the coordinator position. Ms.
LaPlace submitted for approval a draft job description to the BOC’s personnel
department during April 2007. See Appendix III, Ex. D (2007Progress Report) at
Ex. B. She has not heard back from personnel about her draft description.
In addition to Ms. LaPlace, there is a full time LPN at CJC (Ms. Smith) and two
part-time LPNs (each working 10 hours per week). Ms. Smith, who was hired last
year, has duties that include scheduling appointments, assisting Dr. Less with
examinations, and distributing medications. She cannot under her license assess
prisoners for sick call. One of the part time LPNs has announced her plan to retire
at the end of October 2007.
The head nurse position at CJC remains vacant, but is functionally filled by Ms.
LaPlace. As a result, Ms. LaPlace has little time available to fulfill her duties as
Territorial Nursing Coordinator. Ms LaPlace thought that the head nurse position
had been transferred to ACF (and another one not yet created/approved for CJC),
and, therefore, had not been actively recruiting to fill this position. Ms. LaPlace

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did tell me that she had identified candidates to replace her over the past year, but
that these candidates took other positions because the CJC head nurse position was
not an approved vacancy she was authorized to fill.
Warden George, however, indicated that a head nurse position was still open at
CJC, but vacant due to recruitment difficulties.
Mental health staffing
Beverly Latimer, M.S. was the jail’s mental health specialist, and had contracted
for 10 hours of service weekly. Ms. Latimer resigned in June 2006. Ms. LaPlace
had identified a candidate (Ms. Mann) to replace her around April 2007, but the
BOC has not approved the hire to date.
Both Dr. Less and Dr. Lu are on-call 24 hours per day.
During March 22, 2006, the Court ordered the Defendants to submit a staffing
plan for the CJC and the Annex. To date, the BOC has not produced a
comprehensive staffing plan, noting hours, vacancies and Notice of Personnel
Action (NOPA) status. Ms. LaPlace did create a list of vacant health care
positions for the CJC and Annex in May 2007. See Appendix III, Ex. C, memo
dated May 7, 2007. That list does not include filled positions, does not list the
hours of service for the vacant positions, and does not indicate whether the
positions have NOPAs and budget control numbers.
Ms. LaPlace provided the following information about the current (and requested)
staffing at the CJC and Annex:
Annex
Physician (10 hrs-filled)
RN (20 hrs-filled)
RN (10 hrs-status unknown)
LPN (10 hrs-status unknown)
Social worker (10 hrs-status unknown)
Ms. LaPlace identified candidates for the unfilled positions at the Annex and
submitted applications to the Department of Justice’s department of personnel
about four months ago. Ms. LaPlace was unclear whether these positions have

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been created. She also said she was confused about the process for creating these
positions as well as the NOPA process.
CJC
Physician (10 hrs-filled)
Psychiatrist (10 hrs - filled)
Head nurse (FTE position-vacant)
Mental health specialist (10 hrs, created but vacant)
NP/PA (FTE position requested but not created)
RN (20 hrs- position requested but not created)
LPN (FTE-filled)
2 LPNs (10 hrs each-filled)
Social worker (10 hrs, filled but not functional—essentially vacant for the past 7
years)
Psychologist (10 hrs, position requested but not created)
Ms. LaPlace drafted a job description for the Medical Director position at the
request of Richard Schrader, Jr. and Eliza Joshua (Department of Justice personnel
department). See Appendix III, Ex. D. She consulted with colleagues at the RLS
Hospital for models. Ms. LaPlace did not know if her draft job description was
approved.
On June 19, 2007, the personnel department sent to Ms. LaPlace, at her request, a
memorandum listing all BOC heath care vacancies that have existing NOPAs and
budget control numbers. See Appendix III, Ex. F. However, the vacancy list did
not include positions for which a NOPA is pending, or positions with a NOPA but
no budget control number. Also, the memo does not list vacancies by facility
(e.g., CJC, ACF, Annex, Forensic Facility). Therefore, it is very difficult to know
what this document means in terms of staffing for the CJC.
The next section of this report will be organized by general subject headings
relevant to mental health services at the CJC and the forensic facility at Anna’s
Hope, St. Croix, USVI. I have noted below the applicable provisions and the
Court’s remedial orders. An “SA” denotes the Settlement Agreement headings,
and the headings from the remedial orders are denoted by “Order”. This section
will use my April 2005 report as a template.
MEDICAL LEADERSHIP AND POLICIES & PROCEDURES
The Settlement Agreement requires the BOC to hire a Health Care Coordinator
who will oversee the health care system at the CJC and Annex. [SA ¶¶ IV.A.1.,

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IV.M.4.] The coordinator is required to conduct bi-weekly meetings with CJC
health care staff. The coordinator also is responsible for producing and
implementing a complete set of medical policies and procedures that are consistent
with National Commission on Correctional Health Care (NCCHC) Guidelines. On
March 22, 2006, the Court also ordered the Defendants to hold monthly
management team meetings with BOC leadership where health care is a
permanent agenda item. [Mar. 22, 2006 Order ¶4]. The Court also ordered the
Government to provide a laptop computer to Mr. LaPlace so she could carry out
her duties as a territorial nursing coordinator. [Mar. 22, 2006 Order ¶8].
I previously reported that during November 2005 Dr. Olaf Hendricks resigned
from his positions as the BOC’s medical director and as the lone treating
psychiatrist at ACF. I was told last year that a NOPA was in process to replace
Dr. Hendricks, although it was unclear when the NOPA process would be
completed.
Last year, Ms. LaPlace had proposed that Dr. Less’ hours be doubled to 20 hours
per week in order to have him serve as an interim medical director. This proposal
included changing Dr. Hendricks’ NOPA to create two separate NOPA’s—one
NOPA for a medical director position and one NOPA for a psychiatrist’s position
at ACF. The BOC never determined the number of hours for each of these
proposed positions, nor had it decided whether it would split Dr. Hendricks’
NOPA.
The medical director’s position remains vacant, and Dr. Less has told the BOC he
is not interested in being interim director. The NOPAs were reportedly never
processed by the Department of Justice’s personnel department.
In fact, as of May 2007, the BOC did not have a budget control number for the
position, although there is a budget control number for a health services
administrator. See Appendix III, Ex. F, June 19, 2007 memorandum to Ms.
LaPlace from Eliza Joshua. This position is funded at an annual salary of $60,000.
However, the approved job description of the health services administrator
position is apparently lacking. In other words, there appear to be major obstacles
to filling the vacant medical director's position originating from the department of
personnel
In May 2007, Ms. LaPlace proposed that the BOC sign a contract with Charles
Braslow, M.D., who is now in private practice in St. Croix, to “assist the BOC in
developing and implementing Medical Policies and Procedures, the Organizational

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Chart, Continuous Quality Improvement Program and Infection Control Program.”
See Appendix III, Ex. D at Ex. A. Dr. Braslow would be responsible for recruiting
and interviewing candidates for the Medical Director of Health Services for BOC.
Dr. Braslow told Ms. LaPlace he also was willing to negotiate memoranda of
understanding (MOUs) with outside agencies and vendors to obtain lower-cost
medications, medical services, and supplies. Ms. LaPlace suggested a one-year
contract for Dr. Braslow. Ms. LaPlace has not received a response from the BOC
to her proposal. Since making the proposal last May, she has not spoken with Dr.
Braslow to determine if he remains interested.
Dr. Lu, as in the past, said that he did not consider himself to be in charge of
mental health services at the jail.
The BOC has also produced a health care organizational chart. See Appendix III,
Ex. D at Ex. C. Essentially all the key positions (medical director, mental health
director, and territorial nursing coordinator) are vacant. Despite her title as
Territorial Nursing Coordinator, Ms. LaPlace continues to work full-time as the
head nurse at the CJC. She reported being unable to hire her replacement because
the BOC transferred the head nurse position to ACF. It was her understanding that
the BOC must either create a new head nurse position and/or complete a new
NOPA before hiring a new head nurse at CJC.
Warden George told me, however, that there is a vacant head nurse position at the
CJC, and that it had not been filled because of recruitment difficulties. If Warden
George is correct, then Ms. LaPlace has been unable to hire her replacement
because she does not know there is a vacant position. Again, the BOC must
establish reliable communications between custodial management, its office of
personnel, and health care staff. This cannot be done without strong health care
leadership.
The mental health director position is vacant. Jennifer Charles, MSW was
recently hired as a mental health coordinator for ACF. I briefly interviewed Ms.
Charles, who returned to work at ACF on June 20, 2007 after a prolonged stress
leave that began during 2006. Ms. Charles stated that there is a written job
description for her position, although it was not relevant to her actual job. I
reviewed the mental health coordinator job description, approved on July 25,
2006, which appears to be more consistent with a director job description than a
coordinator description. It was clear that Ms. Charles does not perceive her job to
be the BOC director of mental health. Her job is appropriately restricted to
coordinating mental health services for inmates at ACF, given her qualifications.

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In my May 2006 Report, I found that Ms. LaPlace had taken part in two meetings
with BOC leadership, although minutes were not kept, and that there were no
regularly scheduled meetings regarding health care services. I recommended that
management team meetings be held at least monthly, and minutes should be
distributed to all attendees. As I understand it, my recommendation is now courtordered. Carty v. DeJongh, Civil No. 94-78, Order (D.V.I. Nov. 20, 2006) ¶1.
Ms. LaPlace has met with Attorney General Frazier once since he took office, in
April 2007. One month later, Attorney General Frazier appointed Ms. LaPlace to
head the Medical Assessment Team (MAT). See Appendix III, Ex. D at Ex. I.
The MAT was charged with providing the Attorney General with a report on the
condition and needs of the medical care units, including an inventory of needed
supplies and equipment to bring the facilities “up to constitutional standards;” and
a recommended staffing list. In addition to Ms. LaPlace, Attorney General Frazier
appointed Dr. Park (ACF physician) Dr. Less, RN Qualey (ACF), LPN Moise
(ACF-Detention) Dwayne Benjamin (prison compliance coordinator), and Jennifer
Charles (mental health coordinator) to the MAT.
The MAT completed its report on June 10, 2007. Ms. LaPlace told me that she
had not spoken with the Attorney General since the MAT gave him the report, and
she knows of no actions that have been taken as a result of the report. The MAT
has not scheduled any more meetings until it hears back from the Attorney
General.
Monthly management meetings between healthcare and CJC administrative
custodial staff have not been scheduled although informal brief meetings occur.
However, such informal meetings have not been very productive as evidenced by
findings summarized in this report. In August 2006, Ms. LaPlace asked thenDirector Horsford to arrange monthly meetings between health care and custodial
staff regarding operations at the Annex. See Appendix III , Ex. H, November 6,
2006 Memorandum from Lisa LaPlace Knight, R.N. to Director Horsford. Ms.
LaPlace was prompted to ask for these meetings after a series of snafus plagued
the opening of the health care office at the facility. 1 There have been no such
meetings to date.
1

The Annex began accepting prisoners in May 2006. Three months later, Ms. LaPlace described
the conditions in the health care office as follows, “Ms. Anderson hired part-time 20 hours week
RN . . . . Awaiting access to Medical office. Equipment arrived but not set up. Then when set up
not as requested by Territorial Coordinator. Privacy compensated. No garbage can, no privacy
screen, no water source, fire hydra[nt] hung where inmate may use as a weapon, exam table

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On August 8, 2007, I spoke with Warden George. She acknowledged that she
does not meet formally with either Dr. Lu or Ms. LaPlace about mental health
issues at the jail. Information obtained from Ms. George concerning the mental
health services at the CJC was, at times, inconsistent with my findings. For
example, she described Dr. Lu as being involved in the decision process to place
inmates on, or remove them from, suicide watch. Dr. Lu was generally not
involved with such decisions. Warden George also said that either Dr. Lu or Ms.
LaPlace was involved in the decision to admit and discharge prisoners from
Cluster 3. However, Ms. LaPlace and Dr. Lu described little, if any involvement,
in such decisions. Other examples can be found in this report.
Ms. LaPlace described significant problems in communicating with the
Department of Justice's personnel department as well as the Department of
Justice's financial section. The department has failed to provide Ms. LaPlace with
requested job descriptions, and has not answered her requests for updates on the
status of personnel decisions. For example, Ms. Josiah failed to show up at a
scheduled meeting she had with Ms. LaPlace to discuss the status of health care
positions and vacancies. See Appendix III, Ex. C, June 10, 2007 Medical
Assessment Team Rpt. at 2. Because of her poor working relationship with the
personnel department, Ms. LaPlace was very unclear how the hiring process
worked and what positions have been created and/or are ready to be filled.
In my May 2006 Report, I also recommended that the BOC develop a budget
specific to mental health services. I understand my recommendation is now courtordered. Carty v. DeJongh, Civil No. 94-78, Order (D.V.I. Nov. 20, 2006)) ¶1.
In February 2007, Acting Director Horsford asked Ms. LaPlace to develop a
budget for BOC health services. On February 8, 2007, she spoke with BOC
Director Horsford’s secretary, and proposed estimated costs for one year. See
Appendix III, Ex. C, Feb. 14, 2007 memorandum from Lisa LaPlace-Knight. Ms.
LaPlace does not know if the BOC has developed a health care budget, and has
had no further conversations with either the BOC Director or the Attorney General
about developing a budget.
missing part and torn fabric to cover. Build-in cabinet not where requested and no consultation
with Territorial Coordinator as to reason for the need to change from requested placement.
Improved communication between Health Services and Security Staff would be recommended.
Suggest monthly meetings to develop policies for Annex. It is not clear as to what type of client
will be housed at [the Annex] and the procedure to have patients seen at CJC by Dr. Less.” See
Ex. H.

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According to a newspaper article, on June 29, 2007, Attorney General Frazier
appeared at a hearing before the Virgin Islands Senate Finance Committee on the
proposed budget for the Department of Justice. The proposed budget had a single
line item for $5,201,970 to cover “professional services, inpatient and outpatient
services, repairs, and travel.” See Appendix III, Ex. J. The Government failed to
provide the budget documents it submitted to the legislature by the time of my site
visit, as requested by class counsel
A laptop computer has been provided to Ms. LaPlace.
Mental health policies and procedures have not been completed, let alone
implemented. This is primarily related to the absence of a medical director, a
director of mental health, and a shortage of mental health staff positions. Ms.
LaPlace told me that there has been no work done on the draft policies I reviewed
in May 2006 because the BOC has not hired a medical director to replace Dr.
Hendricks.
Assessment: My assessment from my April 2005 report remains essentially
unchanged. A reliable mental health system is based on a set of appropriate
policies and procedures, which guides staff in delivering services. Policies and
procedures will not be successfully developed and implemented without strong
leadership. The BOC has not had a medical director for close to two years, and
there are no concrete plans to hire Dr. Hendricks’ replacement. It is clear that no
one is in charge of mental health services in the BOC, and the Bureau has not
established a clear health care management structure. The absence of established
mental health care leadership and healthcare policies for the BOC have resulted in
serious deficiencies in the mental health services at the CJC. Many inmates with
serious mental illness have received inadequate mental health treatment.
As I stated in my May 2006 report, Defendants cannot devise a reasonable quality
improvement (QI) program until a complete set of health care policies is
developed. CJC currently conducts no QI activities, and there is little, if any,
oversight of mental health services.
There is a very problematic working relationship between health care staff and
several key offices in the Bureau of Correction, including the personnel and
finance departments. Ms. LaPlace’s requests for the authority and/or assistance to
hire staff for key health care positions have often gone unanswered by the BOC.
As a result, key health care positions remain vacant, with no concrete action by the

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Bureau to fill them. If Warden George is correct, Ms. LaPlace has not been told
that there is a vacant head nurse position available for her to hire her replacement.
Also, the BOC continues to operate without a specified health care budget, even
though it provides services to over a 1000 prisoners in the territory.
Recommendations: The infrastructure of the mental health system is lacking and
basically unchanged from my May 2006 findings. By infrastructure I include the
following elements:
1. Key administrative staff and medical leadership as per the submitted
organizational chart.
2. Mental health policies and procedures as previously recommended and
currently court ordered. They should include those areas summarized in
Appendix II.
3. A reasonable working relationship between custody and healthcare
management staffs.
4. A hiring process that is able to create and fill needed mental health care
positions in a timely manner.
5. Timely access to adequate assessment and programming space for mental
health purposes.
6. A discrete and adequate healthcare budget, which includes mental health
services.
There needs to be a designated director of mental health services with a budget
specific to mental health services. Although there are a variety of acceptable
administrative structures for correctional healthcare services, having the mental
health services closely integrated with medical services would be the most costeffective, and would be my recommendation. It remains my recommendation that
the Territorial Nurse Coordinator position include significant healthcare
administrative responsibilities over both medical and mental health services.
Unfortunately, the current organizational chart is not consistent with this
recommendation. See Appendix III, Ex. D at Ex. C.
Although I think that hiring Dr. Braslow would potentially have been very helpful
in the development of a healthcare system within CJC, I am very pessimistic how
much Dr. Braslow could have accomplished without controlling an adequate
healthcare budget, and receiving direct and ongoing support from the Attorney
General and the Governor, while also having the independence and power to build
a health care system from the ground up. Even if his proposed contract had been
approved, Dr. Braslow would not have acted as an interim medical director. He

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would not have had the power to hire, fire, or discipline personnel. He would not
have supervised the physicians or health care staff, and he would not have
provided any direct services.
Based on site visits at CJC since 2005 and experience with similar class action
litigation in many other states, it is my opinion that more drastic intervention is
necessary to implement the desperately needed changes and remedy the significant
mental health system problems that have been summarized in each of my site visit
reports. Despite numerous contempt findings and specific court orders instructing
the Government what steps it must take to bring its health care system up to
constitutional standards, the mental health care system in the BOC is very
deficient. As a result, seriously mentally ill prisoners have needlessly suffered.
Most striking is that fact that Jonathan Ramos and prisoners adjudged NGRI
continue to languish in BOC facilities, despite court orders entered over two years
ago requiring that they be hospitalized. Absent more action by the Court, I can see
no realistic prospects for the kind of systemic improvements in the BOC’s health
care system that are long overdue.
MENTAL HEALTH STAFFING & TREATMENT
Intake Screening
Screening Form
Defendants have been ordered to implement a revised intake evaluation form. All
officers responsible for administering the form are required to receive training by
health care staff in use of the form and all officers are required to receive training
in identifying prisoners exhibiting signs of mental illness, suicide ideation, or
potential for self-harm behavior. [SA ¶IV.G.1., Jan. 18, 2001 Order ¶ 5].
Ms. LaPlace revised the intake screening form in November 2006 consistent with
my prior recommendations, and the new form began to be used in December 2006.
However, my review of medical records indicated that the form was not
consistently completed. See Appendix I. Ms. LaPlace said that no formal training
has been provided to the correctional officers on this screening form, but she has
periodically trained correctional officers in the intake area about using this form.
However, correctional officers in the intake area are not permanently assigned
there, which makes training an ongoing issue.

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The jail has not implemented a computerized management information system
(MIS), which means that it remains very difficult to assess a variety of issues
relevant to the mental health screening process due to data gathering problems. All
intake screening forms are still completed by hand. I had recommended that the
jail develop an MIS in my previous two reports.
Screening Process
My assessment of the CJC’s screening process remains unchanged from my April
2005 report. The current mental health screening process remains flawed. The
only mental health screening provided to all inmates involving a health care
clinician occurs during the physician's intake history and physical examination.
Unfortunately, this examination does not include an adequate mental status
examination.
Most of the active health care records have been combined although Dr. Lu has
continued to have a small number of patients who have separate medical and
mental health charts (see Appendix I).
Ms. Latimer, the jail’s mental health specialist, no longer works at the CJC. She
has not been replaced. Therefore, the jail has lost the capacity even for the
limited intake mental health assessments she did perform at the time of my last
visit.
In May 2007, Ms. LaPlace submitted a “Mental Health Services Proposed Plan”
which includes proposed changes to intake procedures for mental health
assessment. See Appendix III, Ex. C. Under the proposed plan, a deputy would
continue to complete the revised screening form. Any positive answers to mental
health screening questions would trigger an assessment within 12-24 hours. All
inmates without positive mental health indicators upon intake would receive a
mental health screening within 14 days. The plan does not specify who will
perform these evaluations, but does recommend the hiring of two psychologists
and two social workers to serve on the team. Furthermore, “a request for Mental
Health Services form may be filled out at any time and given to the Mental Health
RN,” a position which does not exist. The plan proposes that the team train a
specified RN to function as the “triage person” for mental health services. The
plan also specifies that all mental health caseload inmates “involved in any
altercation will receive an assessment to evaluate if the psychiatrist needs to adjust
medications.”

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Ms. LaPlace told me that she had not received a response from either the BOC or
from the Attorney General’s office regarding the proposal. This proposed
screening process has not been implemented, in part because the jail does not have
adequate staff. As a result of problems with the screening process, there are still
seriously mentally ill prisoners who were not identified at intake as needing
mental health services.
Psychiatric Services
The Agreement requires the BOC to retain mental health staff to establish a mental
health referral system, and to provide evaluations and follow-up care to prisoners
in need of mental health services. [SA ¶¶IV.V.2-3.]
I interviewed Leighman Lu, M.D. during the morning of August 6, 2007. Dr. Lu
reported averaging five days per week of coverage at the CJC, which he said
generally involve 8-10 hours per week. The contractual rate of $80 per hour that
he is paid has not changed since my May 2006 site visit. He indicated that he is
likely to retire at the end of September 2007 if the pay issue has not been resolved.
However, he reported being open to remaining in his role at CJC if his contract
was increased to the equivalent Department of Health per diem rate of $214 per
hour.
Ms. Laplace proposed raising Dr. Lu’s salary to $200 in her Mental Health
Services Proposed Plan. Appendix III, Ex. C. Ms. LaPlace told me that she had
submitted the plan to the BOC and Attorney General’s Office, but had not
received a response to it.
The BOC would have significant problems recruiting a replacement psychiatrist
for Dr. Lu should he leave. Dr. Lu told me that there are currently a total of four
psychiatrists on the Island, one of whom does not have license to practice
medicine in the Virgin Islands.
It appears that Dr. Lu is working significantly less than the number of hours he is
contracted to work at the jail. My review of the Main Control CJC logbook
indicated that for selected weeks in July 2006, August 2006, and January 2007,
Dr. Lu’s actual time at the CJC was averaging around 4 hours per week. This is
similar to the findings I made regarding Dr. Lu’s actual hours of direct services in
my May 2006 Report.

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In April 2005, I found that mental health services were limited to initial
assessments, psychopharmacological management, and some discharge planning.
There did not appear to be any meaningful psychosocial interventions or
psychotherapy available to inmates with serious mental illnesses. I found no
evidence of discharge planning documented in the mental health records.
There has been no change in the nature of the direct treatment services provided
by Dr. Lu since my April 2005 site visit.
In early 2006, Dr. Lu informed the territorial court the he would no longer perform
court-ordered forensic evaluations. However, Dr. Lu resumed performing court
ordered forensic evaluations shortly after my May 2006 site visit. It is unclear to
me how much of his time at the CJC involves these assessments; however, court
ordered forensic evaluations often involved multiple interviews in order to obtain
the needed minimum database for them.
Dr. Lu reported very little involvement in the decision whether to admit and/or
discharge inmates from Cluster 3. This was confirmed by my review of medical
records. See Appendix I. However, correctional officers told me that all such
decisions were made by Dr. Lu.
Mental health referrals from Ms. LaPlace and custody staff generated a significant
proportion of Dr. Lu's daily schedule. There was not a systematic way of
scheduling patients to be seen by Dr. Lu.
Dr. Lu indicated that he infrequently uses atypical antipsychotic medication
because the high costs of these medications are raised with him when he
prescribes them. He stated that laboratory studies relevant to drug screening have
become problematic because they are not available.
Dr Lu said that the combining of the medical and mental health records of active
mental health patients had decreased his access to medical records in a timely
fashion due to the absence of medical records staff. Dr. Lu stated that it was
common for him to see patients without the medical record. During the past three
to four months he has not been documenting his meetings with patients when the
medical record is not available, which has caused obvious documentation issues.
Dr. Lu made it very clear that he is not in charge of the mental health program at
CJC. He has had some contact with Jennifer Charles, MSW in the context of
temporary transfers of inmates from ACF for psychiatric consultation. However,

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he does not know information relevant to her job description or her
responsibilities.
Dr. Lu estimated that the mental health caseload during 2006 averaged 18 to 20
inmates. He thought the mental health caseload during 2007 averaged about 14
inmates at any given time. On August 6, 2007 there were 11 inmates on the
mental health caseload.
Dr Lu said he rarely went to Cluster 3.
Dr. Lu reported that he did not receive information relevant to inmates being
discharged, which meant that he was unable to provide adequate discharge
services for mental health caseload inmates.
Dr. Lu said that he is not involved with the decision whether or not to transfer an
inmate to the CJC Annex. In addition, he does not provide any treatment to
inmates at the CJC Annex.
As I have previously reported, there still is not a process in place that triggers a
mental health assessment for inmates with serious mental illnesses after they are
involved in disciplinary infractions. In my review of records and incident reports, I
continued to document assaults that involved inmates with serious mental
illnesses. See Appendix I. Ms. LaPlace estimated that she receives information
from custody staff concerning approximately 20% of such incidents. Dr. Lu
reported not being notified as a matter of course about such incidents, which was
confirmed by my review of records.
As a result, inmates with serious mental illnesses may be punished, instead of
receiving appropriate treatment, for behaviors that directly relate to their mental
illness. In addition, staff and other inmates are at risk of being injured due to
behaviors related to inadequately treated mental illnesses of various inmates.
Warden George said that either Ms. LaPlace or Dr. Lu would be notified every
time a mental health caseload prisoner was involved in a disciplinary or violent
incident at the jail. This was inconsistent with my own record review.
Warden George also said that deputies record in incident reports all violent or
unusual behavior by mentally ill prisoners, and that the shift supervisors review all
daily logs and incident reports to ensure that deputies do prepare appropriate
reports. Again, I reviewed a number of logs documenting mentally ill prisoners

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exhibiting violent or unusual behavior, but there was no corresponding incident
report, and these prisoners were not referred to Dr. Lu for an assessment.
As I have previously reported, there are significant problems related to the mental
health assessment process and with provision of timely psychiatric follow-up care.
In addition, needed psychosocial interventions for inmates with serious mental
illnesses are essentially not available at the CJC. These problems are primarily
related to lack of policies and procedures, inadequate mental health staffing
allocations, and physical plant limitations (see “Mental Health Housing” section
later in this report).
I reiterate my finding from last year that it is also likely that more than 10 hours
per week of direct psychiatric services are required, based on the average monthly
admission numbers and the average mental health caseload figures. The jail will
also need additional services once the Annex is fully re-opened, and the total
prisoner population on St. Thomas doubles.
Mental Health Specialist
Under the Agreement, the jail also must hire a master’s level mental health
specialist to conduct initial mental health evaluations, develop treatment plans,
ensure follow-up, and provide individual and group counseling. [SA ¶¶ IV.A.2.,
V.; Dec. 10, 2002 Order ¶ 2]. In December 2002, the Court ordered the
Defendants to conduct a study on the feasibility of using the rooftop recreation
area for group therapy, and to increase the hours of the mental health specialist to
provide expanded substance abuse and counseling services.
The mental health specialist, Ms. Latimer, no longer works at the CJC, and the jail
has not hired her replacement. In October 2006, Ms. LaPlace identified a
candidate for the position, but that candidate has not been hired.
Except for the medication management services provided by Dr. Lu and the
attempted discharge planning efforts by Ms. LaPlace, there are no other mental
health services that CJC offers to inmates. There are not any meaningful
psychosocial interventions or psychotherapy available to inmates with serious
mental illnesses.
I reviewed the healthcare records of 14 inmates who are or
were receiving mental health services at CJC. Refer to Appendix I which
documents my assessments, which are also summarized in the next section entitled
“Assessment.”

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Ms. LaPlace described an expanded mental health program in the Mental Health
Services Proposed Plan. See Appendix III, Ex. C. It states that Dr. Lu has
contacted two local psychologists, and Ms. LaPlace has contacted two local social
workers, all with an interest in working part-time on the mental health team “to
develop a new approach to Mental Health Care within BOC.” The psychologists
each requested a fee of $180 an hour, and the proposal calls for them to each work
five hours a week, during which time they will evaluate and test individuals and
offer individual counseling services. The social workers “will see clients that
require referrals to substance abuse, outpatient mental health services, and family
contacts.” Ms. LaPlace proposed that this team would train a registered nurse to
perform mental health triage. The entire team would meet bi-weekly “and as
needed” to develop plans of care and to evaluate progress or changes in
conditions. Some of the meetings would include the classification officer “to
coordinate the inmates housed in the designated Mental Health Area.”
Ms. LaPlace has not received a response from the BOC to her proposal. None of
the new positions listed in her plan have a finalized NOPA, and none of the
positions has been filled. In October 2006, Ms. LaPlace did identify a candidate
(Bentley Thomas) who was willing to return to the CJC to fill the social worker
position at a higher rate of pay. See Appendix III, Ex. C, Oct. 12, 2006
memorandum from Lisa LaPlace-Knight, RN. That candidate was not hired by the
BOC, and Ms. LaPlace has not heard from the personnel department about her
request to hire him.
Assessment: There is no change in my current findings as compared to my 2006
site visit. Dr. Lu’s work is still limited mostly to medication management, and he
is still contracted to provide 10 hours of mental health services although he
provides less than 10 hours per week of direct treatment services to CJC inmates.
Dr. Lu estimated that there were generally 13-14 inmates being prescribed
psychotropic medications at CJC at any given time during the past year. Review of
records indicated that many of his contacts with mental health caseload prisoners
occurred in the nurse’s office during pill pass.
My review of medical records revealed the following significant problems in the
mental health service delivery system at CJC:
1. The current mental health screening process is flawed due to the nature of
the healthcare screening process and lack of mental health training for
correctional officers.

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2. The absence of a sufficient number of health care staff creates significant
problems with the mental health assessment process. A timely and
comprehensive initial mental health assessment is usually not present in the
healthcare records.
3. There are significant problems related to the provision of timely psychiatric
services.
4. Needed psychosocial interventions for inmates with serious mental illnesses
are not available at the CJC.
5. Group counseling is not available for inmates with serious mental illnesses.
6. Treatment plans are not developed. This is most likely related to the lack of
available psychosocial interventions due to inadequate programming spaces
and inadequate mental health staff.
7. There is inadequate access to psychiatric hospitalization for inmates in need
of such a level of care.
8. I again found that there was not a process in place that triggered a mental
health assessment for inmates with serious mental illnesses after they are
involved in disciplinary infractions.
9. Communication between correctional staff and healthcare staff is
problematic, especially regarding behavioral problems being exhibited by
inmates with serious mental illnesses. This communication issues often
results in missed opportunities to re-assess an inmate’s clinical condition
and make appropriate medication adjustments and/or provide needed
counseling. Mental health staff is also not involved in the disciplinary
process for mentally ill inmates.
10. There is inadequate clinical intervention for prisoners who are noncompliant with their medication orders.
11. Mental health records are still not yet fully integrated with the medical
record.
12. There is inadequate discharge planning.
As a result of these problems, seriously mentally ill prisoners continue needlessly
to suffer at the CJC
MEDICAL CHARTS
The Agreement requires the jail to adopt standardized charting practices so that
prisoners’ medical records are complete and usable. [SA ¶IV.N.1-4.]. On March
22, 2006, the Court ordered the Defendants to hire a medical records clerk to
maintain health care files at the jail. [Mar. 22, 2006 Order ¶5].

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During my April 2006 site visit, I noted significant problems with the current
health care record system that were caused by jail’s maintaining multiple health
care records for the same inmate, and by not having medical records staff to
organize and maintain the files. It was extremely difficult to document and assess
a specific inmate’s course of treatment with the disorganized records system. This
had current and future treatment implications. Specifically, it is much more
difficult to determine the adequacy of treatment when clear documentation
relevant to an inmate's treatment program is lacking or difficult to obtain.
Since my 2006 site visit, the Defendants have hired a civilian, Latoya Horsford, on
a temporary basis to assist health care and classification staff to file and maintain
records at CJC. As of June 2007, 75% of records had been integrated. She has
been providing these services for four hours per week for the past several months.
MENTAL HEALTH HOUSING
The Agreement requires the jail to set aside a housing area for prisoners requiring
mental observation, who are on suicide watch, or who need to be secluded or
restrained. [SA ¶IV.V.4-5.]
Nothing with regard to mental health housing has changed since my May 2006
report. Cluster 3 remains the designated mental health unit. Deputies assigned to
the cluster have not received specialized training or any in-service training on
mental health issues.
I interviewed the correctional officer who was staffing Clusters 3 & 4 during the
first day of this site visit, who indicated that the usual staffing pattern around-theclock was one correctional officer for both of these units. He indicated that the
assignment of the correctional officer to these clusters, like all other clusters, was
based on a rotating schedule. He stated that inmates in Cluster 3 were supposed to
be observed by the correctional officer every 15 minutes, which was not possible
due to the officer’s other job responsibilities in staffing both of these clusters. He
thought that such inmates were generally observed about every 30 minutes. This
correctional officer indicated that inmates placed on suicide watch were supposed
to be seen every 15 minutes, which was difficult to accomplish for similar reasons.
The assigned officer has duties that require him to leave the control office, leaving
the Cluster 3 prisoners periodically unsupervised and unobserved. I reviewed the
record of one seriously mentally ill prisoner who was able to open his cell door
after lockdown while the Cluster 3 & 4 officer was out of the control office. See

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Appendix I, Inmate 10. This prisoner was very agitated on the night he freed
himself from his cell, and posed a risk to himself and other prisoners.
The Cluster 3 correctional officer thought that the decision to admit and/or
discharge inmates from Cluster 3 was made by Dr. Lu, which turned out to be
inaccurate. These decisions are made by custody staff with little or no input from
Dr. Lu.
The Cluster 3 correctional officer estimated that three inmates per month are
placed in in-cell restraints for mental health purposes. The decision to use
restraints was made by a supervisor. The correctional officer reported that, at
times, Dr. Lu was notified by the custody staff that restraints had been used.
Inmates in this cluster have periodically been triple bunked. For example, as of
June 23, 2007, one cell in the cluster had held three prisoners for at least two
weeks. The Cluster 3 deputy also acknowledged that mentally ill prisoners have
been triple-celled in Cluster 3.
When prisoners are triple-celled in Cluster 3, one mentally ill prisoner must sleep
on the cell floor. This poses substantial security risks, particularly given that the
cluster is manned by a single deputy who is responsible for both Clusters 3 & 4.
As summarized in my record reviews, mentally ill prisoners housed in Cluster 3
have been involved in multiple violent altercations with both deputies and fellow
prisoners.
The overcrowding in Cluster 3 has been exacerbated in recent months because the
cluster has also been used as a protective custody unit. In the past year, a
protective custody prisoner (N. Parker) was single-celled in Cluster 3 for several
months, even though he was not on Dr. Lu’s roster, and did not receive mental
health treatment. As a result of his being single-celled, and of Jonathan Ramos
being single-celled, the Cluster only had 8 beds available for mental health
caseload prisoners.
We also smelled marijuana smoke prior to entering the custody station for Clusters
3 & 4. We observed the cells in Cluster 3, which had just been cleaned. Despite
the cleaning, the smell from several of the cells related to hygienic issues was
obvious. Review of the daily custody sheet had indicated that the cell conditions
in Cluster 3 were very poor at times.

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I interviewed all the inmates in Cluster 3 in two separate small group settings
within the law library, which was problematic. The supervisor did not allow us to
use the day room within Cluster 3, as I had on my previous site visit, due to
reported security concerns.
Inmates in group 1 (see key to Appendix I) all demonstrated obvious symptoms of
a serious mental disorder, which included agitation, responding to internal stimuli,
gross thought disorder and withdrawn behaviors. Inmate 10 was periodically
agitated and Inmate 6 was very withdrawn. Inmate 21 was disorganized in his
speech.
Inmates in group 2 were generally very reluctant to discuss issues related to
mental illness problems. Inmate 22 denied having any mental health problems but
complained about behaviors demonstrated by his cellmate. He acknowledged
receiving psychotropic medications. Inmate 2, who appeared disorganized, was
unwilling to state his name and was withdrawn throughout the interview. Inmate
23 was withdrawn throughout the interview. Inmate 11 appeared disorganized and
was very sparse in his speech.
Inmates from both groups acknowledged access to the dayroom during most of the
day except during lockdowns. They also stated they had access to the outdoor
recreational area about one hour per day. Information provided by the inmates
relevant to access to Dr. Lu was variable.
Several inmates reported having had periods of time when they were restrained
although the information provided by them relevant to these episodes was rather
vague.
Inmate 10 reported lack of access to phone calls to his mother related to financial
issues. He reported that he wanted to talk to his mother in order to arrange for a
custodian in order to be bailed out.
Assessment: My opinion regarding this housing unit remains unchanged from my
prior site visits. Cluster 3 does appear, based on inmate interviews, to provide a
safer environment for inmates with serious mental disorders. Cluster 3 does not
provide enhanced mental health programming or even adequate mental health
programming. The CJC is not equipped to house and treat the most seriously
mentally ill prisoners who are in Cluster 3. Some of these prisoners require inpatient psychiatric hospitalization.

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The lack of psychosocial interventions has contributed to CJC inmates with
serious mental disorders (often associated with active psychotic features) either
clinically deteriorating or not improving. Problems persist as a result, which
include periodic assaults among these mentally ill inmates as documented in my
review of records section. See Appendix I. The absence of adequate psychosocial
services can also lead to longer stays in the jail for seriously ill prisoners who have
ongoing problems being restored to and maintaining competency to proceed in
their criminal cases.
The need for chronic care programs (often known as a residential treatment unit,
intermediate care unit, supportive living unit, special needs unit, psychiatric
services unit, or protective environment) for the seriously mentally ill in a
correctional setting is now widely recognized. Inmates appropriate for these units
generally have had significant difficulty functioning in a general population
environment due to symptoms related to their serious mental disorders.
Recommendations: Corrections and mental health staff need to develop a
working relationship regarding the operation of this unit, where there is regular
and open communication between staff about the condition of the prisoners
housed there, which would help decrease, but not eliminate, the resulting harm to
many of these inmates with serious mental disorders who are receiving inadequate
psychiatric treatment. To this end, the jail should institute treatment team meetings
between Dr. Lu, Ms. LaPlace, Warden George, and correctional personnel to
discuss the operation of the cluster, and mentally ill prisoners who have exhibited
behavioral/psychological changes. The goal of the treatment team is to come up
with interventions that may help the inmates clinically improve.
Correctional staff monitoring of cluster 3 prisoners is significantly compromised
due to custody staffing patterns in this unit, which at times requires lockdown
status due to the custody staffing shortage. This unit should be staffed by
adequate numbers of specially trained correctional officers, who are assigned to
this unit on at least a six-month basis in contrast to the current practice of staffing
this unit with different officers on a very frequent basis.
Establishment of a psychosocial rehabilitation model for inmates in need of such a
level of care should be a priority at the CJC, which will require additional mental
health staff and adequate programming space.
Dr. Lu should be involved with the decision to admit or discharge prisoners into
Cluster 3.

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Seclusion, Restraint & Suicide Precautions
In April 2005, I reported that Dr. Lu did not initiate mental health observation or
suicide precaution measures. Rather, most orders for suicide watch or close
observation came from the correctional supervisors. There were no specially
designated cells for prisoners on suicide watch. I was also told that some
prisoners are moved for suicide watch. These prisoners are usually transferred to
Cluster 6. I toured that cluster. The inside of the cells were not directly
observable by correctional staff assigned there. There were also no specially
designated cells for secluding or restraining mentally ill prisoners.
There has been no change in suicide precautions or the use of restraints/seclusion
since my previous site visits.
Ms. George said that all prisoners who were placed on suicide watch were referred
to Dr. Lu for an assessment, that Dr. Lu generally made the determination whether
to initiate and discontinue suicide precautions, and that the only time that prisoners
would be put on suicide watch absent an order from Dr. Lu was when Dr. Lu was
not on-site. This was inconsistent with Dr. Lu’s description of his role in suicide
prevention practices.
Dr. Lu reported minimal involvement in the decision leading to inmates being
placed on or taken off suicide watch precautions. Dr. Lu thought that all such
inmates would be placed in Cluster 3. However, correctional officers indicated
that the suicide watch precautions could be initiated anywhere in the CJC,
although inmates on such watch were frequently housed in either Cluster 6 (the
intake unit) or Cluster 3.
There are no specially designated cells for prisoners on suicide watch. I spoke
with several deputies assigned to general population clusters, who told me that
suicide precautions could be initiated in any general population housing cluster.
As during prior site visits, I was also told that some prisoners are moved for
suicide watch. These prisoners are usually transferred to Cluster 6, where deputies
cannot directly observe prisoners inside their cells. Deputies generally receive an
order to initiate suicide watch from the shift supervisor. The deputies record their
checks of these prisoners in the cluster logbook.
During the morning of August 6, 2007 I visited Cluster 1, where inmates reported
that the dayroom phones and television were not functioning. There were two
correctional officers for Clusters 1 & 2, with one of the officers sleeping and/or

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very drowsy and rather incoherent during our attempted interview with him. The
other correctional officer in the office, who had been working in the system for 18
years, reported not having ever received training relevant to mental health issues
or use of emergency equipment or suicide attempts (e.g., cutdown tools, Ambu
bags). Such equipment was not available to the correctional officers.
The alert correctional officer in Cluster 1 indicated that inmates were placed on
suicide precautions by the Warden, who conveyed the information to the
supervisor, who then conveyed the information to the line staff. Inmates placed on
suicide watch were reportedly observed every 30 minutes by correctional staff.
There were no special cells used for suicide watch precautions. The correctional
officer indicated that generally suicide watch precautions occurred in Clusters 3 &
6.
I also visited Clusters 5 & 6 during the morning of August 6, 2007. The
correctional officer reported that they were currently about four inmates on 15
minute watch related to the nature of their crime in contrast to suicide precautions.
This information, which appeared to be accurate, was not consistent with
information obtained from the correctional officer from Clusters 1 & 2. This
correctional officer confirmed that inmates could be placed on suicide watch in
any of the housing units within CJC.
Cluster 5 had much better, although still limited, observation of the cells from the
correctional officers’ perspective in contrast to Cluster 6.
The correctional officer in Cluster 5 & 6, who had been working at CJC for eight
years, confirmed that he had not received any training relevant to mental health or
training relevant to cardiopulmonary resuscitation (CPR). Cutdown tools and
Ambu bags were not present in the control office. The first aid kits within the unit
were inadequately stocked.
Cut down tools were not available in any of the housing units nor were mouth
guards/ambu bags which could be used for CPR.
Dr. Lu appeared to have very little knowledge regarding the use of restraints for
mental health purposes at CJC and aid he was not involved in the decision either
to put someone in restraints or remove them from restraints.
I reiterate my assessment of suicide precautions from my last report. The lack of
specially designated cells for secluding or restraining prisoners, or for prisoners

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who are on suicide watch, is very problematic, especially from the perspective of
developing an adequate suicide prevention program. Dr. Lu’s lack of involvement
with suicide precautions and the use of restraints is also a matter of concern and
likely reflect both the lack of adequate communication with the custody staff
concerning issues relevant to suicide prevention and the use of restraints, as well
as inadequate mental health staffing allocations at the CJC.
Ms. LaPlace has contacted Dr. Tom Tyne, a psychologist on St. Thomas, to
perform a series of in-service workshops for corrections staff on mental health
issues, including suicide prevention. Ms. LaPlace submitted her proposal to
Attorney General Frazier, and asked for budget authority to complete a contract
with him, but has not heard back from Mr. Frazier. As of August 8, 2007, no inservice classes had been offered for many years (according to information
obtained from correctional officers).
The CJC does not maintain statistics on suicide attempts or self-harm incidents.
The only way to determine how many prisoners have been placed on suicide
watch is to review all incident reports, cluster logs, and medical records.
Assessment: The suicide prevention program at CJC is not adequate. Mental
health staff is infrequently involved in the suicide precautions process (e.g.,
initiation, assessment, or termination of suicide precautions). The cells used for
suicide watch are very problematic from a physical plant perspective. They are not
retrofitted for suicide prevention purposes and significant visibility issues exist.
Fifteen minute checks are very difficult to perform due to custody staffing issues.
Since it is very common for healthcare staff to not be notified about inmates being
placed on suicide precautions, and given staffing allocation shortages, such
inmates may not receive timely mental health interventions.
Recommendation: I again recommend that correctional officers receive at least
annual training relevant to suicide prevention policies, procedures, and practices.
Cut down tools and mouth guards/ambu bags should be available in all of the
housing units for CPR purposes. Separate training also needs to be provided
concerning CPR.
ACUTE REFERRALS & HOSPITALIZATION
Under the Agreement, Defendants must transfer all prisoners in need of
emergency mental health intervention or hospitalization to either the Roy L.

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Schneider Hospital or a community mental health center (CMC). [SA ¶¶IV.V.2-3,
6.
In April 2005, I found that inmates in need of inpatient psychiatric hospitalization
rarely were transferred to the Roy L. Schneider Hospital due to significant access
problems. I recommended that the BOC and RLS Hospital develop a
memorandum of understanding (MOU) regarding admissions to the BTU. On
March 22, 2006, the Court ordered the Defendants to produce this memorandum in
thirty (30) days. [Mar 22, 2006 Order ¶12].
Essentially, there have been no changes since my 2005 site visit. An MOU still
does not exist between CJC and the Roy L. Schneider Hospital. It was very clear
that access to psychiatric treatment for inmates with chronic psychiatric symptoms
was very poor. Staff could only remember one prisoner being transferred to the
BTU at the Roy L. Schneider Hospital, but his transfer was court-ordered.
Recommendations: CJC should develop an MOU with a hospital that provides
inpatient psychiatric care that describes the procedure for admitting and
discharging CJC inmates that should include the criteria for admission and
discharge.
Review of medical records of inmates assessed to be mentally ill revealed the need
for an inpatient psychiatric setting for various inmates incarcerated at CJC within
the past several years. See Appendix I.
FORENSIC FACILITY
The July 19, 2004 Order required Defendants to submit a progress report
documenting their efforts to construct, staff and open a forensic facility in the
territory that could safely house and treat chronically and acutely mental ill
prisoners. [July 19, 2004 Order ¶2] The September 8, 2004 Order required
Defendants to complete construction of the forensic unit by November 30, 2004.
[Sept. 8, 2004 Order]
During my 2006 site visit, I spoke with BOC Director Rosaldo Horsford regarding
the BOC’s efforts since my April 2005 tour to construct and open the forensic
facility. This facility had not yet been opened. Mr. Horsford indicated that
construction issues currently focus on a sewage line and the electrical system. No
other construction had occurred except for the pouring of a concrete floor for a
conference room. The BOC did submit a supplemental budget request for 34

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correctional officers and healthcare staff positions during the fall 2005. Mr.
Horsford believed that the budget request had been approved. He did not know of
any recruitment efforts by the BOC to hire staff for the facility.
As of May 2006, there had apparently been some discussions with the Department
of Health about contracting out the mental health services for this forensic unit,
although Director Horsford described these discussions as very preliminary in
nature and inconclusive. The BOC did not implement my recommendation last
year that it consult with an expert experienced with architectural/treatment issues
for a forensic facility. I again provided the BOC with a referral to Joel Dvoskin,
Ph.D.
It appears that the BOC has made little progress in the past year to open the
forensic facility, given the limited information I have received.
As of November 2006, Defendants had made no effort to complete a contract with
the Department of Health to operate the forensic facility. See Appendix III, Ex. I,
Defendants’ Responses to Plaintiffs’ First Set of Interrogatories, response to
Interrogatory 18. They had not hired any personnel for the facility, had not hired a
construction firm, nor contacted any consultant to assist them in constructing and
opening the facility. Nor had they developed a staffing plan, construction time
line, construction budget, or operational budget for the facility.
According to a newspaper report, Attorney General Frazier on June 28, 2007 told
the Virgin Islands Senate Finance Committee that he had offered the job of facility
director to a psychologist, and that his goal was to complete the facility by the end
of the year.
During my site visit, I asked to speak with BOC staff person who could describe to
me the Government’s efforts over the past year to construct, staff, and open the
forensic facility. No one spoke with me about the facility during my tour.
Recommendations: I reiterate my previous recommendations that the BOC
strongly consider executing a contract with the Department of Health to operate
this facility. Under a contract, the BOC along with the Department of Health
should then develop a staffing plan for the facility. The facility’s medical
leadership should be hired well in advance of the unit’s opening, so that they can
develop policies and procedures and hire key staff. The BOC should also develop
a budget and a timeline for the construction project, and hire either a construction
firm with experience building forensic facilities, or a consultant to help oversee

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the project. It is my understanding that these recommendations are now court
ordered. See Carty v. DeJongh, Civil No. 94-78, Order (D.V.I. Nov. 20, 2006).

QUALITY IMPROVEMENT PROGRAM
A quality improvement (QI) program is the process by which BOC leadership can
measure staff performance in delivering mental health services. It involves a
multidisciplinary quality improvement committee of health care providers who
meet regularly with correctional administrators to design QI monitoring activities
and to review the results.
As reported after my 2005 and 2006 site visits, Defendants did not conduct any QI
activities, and there is no meaningful oversight of mental health services at the
CJC, and the lack of a comprehensive QI program contributed to the continuation
of an inadequate mental health system.
There has been no change since my tour last year. The CJC still has no MIS, nor
the equipment needed to install a MIS, which is needed to facilitate the QI process.
There is currently no QI program at the jail.
MEDICATIONS
The jail still does not have a formulary. Last year, Darby, the medications vendor,
was bought by Henry Schein, Inc. On October 12, 2006, Ms. LaPlace wrote to
Attorney General Kerry Drue asking for authority to pursue a new medication
vendor. The BOC had been experiencing difficulties with the current vendor in
obtaining medications in a timely manner. Ms. LaPlace was particularly interested
in soliciting a proposal from Doctor’s Choice, which has local pharmacies in the
territory. Ms. LaPlace has not received a response to her request. Now, Ms.
LaPlace purchases from local pharmacies medications that she cannot obtain from
Schein.
The CJC’s medical office also does not have a working fax machine, so staff
cannot fax medication orders to the vendor or to local pharmacies.
In general, discharge medications are provided on a planned basis only to
sentenced inmates. Ms. LaPlace discussed the need for a medical social worker to
better coordinate discharge planning.

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NGRI Inmates
As of late 2004, the BOC transferred four prisoners from the CJC to Golden Grove
after they were deemed not guilty by reason of insanity (NGRI). The four
prisoners are Inmates 15, 16, 17 & 18 (see Key to Appendix I). Following a July
19, 2004 hearing, the Court ordered the Government to transfer all of the NGRI
patients to an appropriate forensic unit by August 19, 2004. [July 21, 2004 Order ¶
1]. These prisoners were transferred to the forensic unit at the Juan Luis Hospital
in St. Croix in 2005, and were moved back to ACF seven weeks later. On March
22, 2006, the Court entered the following order:
Defendants shall move the four prisoners adjudged not guilty by reason of
insanity, who have been previously identified in this case, to the psychiatric
unit at the Juan Luis Hospital or the Roy L. Schneider Hospital or to both
hospitals, as the case might be, until such time as the Defendants complete
retrofitting and staffing an appropriate forensic unit at the Golden Grove
Correctional Facility.
[Mar. 22, 2006 Order ¶10].
As summarized in my May 2006 report, the four NGRI patients were receiving
grossly inadequate mental health treatment at that time. They received
psychotropic medications that were last ordered during April 2005 without any
further monitoring of these medications by a physician.
I had noted that each patient had been hospitalized at the Juan Luis Hospital (JLH)
for about 7 weeks until their discharge in April 2005, with clinical improvements
being documented. The four NGRI patients were discharged because JLH staff
was concerned that the hospital’s accreditation would be jeopardized if they
remained housed there.
In May 2006, I also toured the "temporary" forensic unit under renovation at ACF,
which was clearly not yet completed.
During my 2006 site visit I learned that no psychiatrist has been on staff at ACF
since Dr. Hendricks’ resignation five months earlier, and that there was no current
mental health staff providing services at the prison. Ms. LaPlace did describe a
staffing plan for the prison, but it was my opinion that it was unlikely to be
implemented in the near future given the unwieldy and time-consuming NOPA

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process, and the lack of medical leadership in the BOC. As result, the four patients
would continue to languish untreated in the jail.
I had recommended that these patients be immediately assessed “by a psychiatrist
relevant to their current psychotropic medications as well as ongoing monitoring.”
I also recommended that they be transferred to an appropriate mental health
treatment setting.
During my August 7, 2007 site visit to ACF, Jennifer Charles, MSW reported that
the psychiatrist position there had remained vacant until very recently when
arrangements were made to have Dr. Hendricks provide limited psychiatric care to
inmates at ACF, including the current five NGRI inmates. It was not clear to me
the number of hours of coverage that are provided by Dr. Hendricks. Despite Dr.
Hendricks’ contract, as per the June 2007 medical assessment team report, the
healthcare staffing situation at ACF is “at a critical level.”
Unfortunately, I learned during my August 7, 2007 site visit that these four NGRI
patients, along with one additional NGRI patient (Inmate 19 – see key to
Appendix I), remain housed in general population units at ACF. I briefly
interviewed Inmates 15, 16, & 18 in a group setting. See Appendix I. None of
these inmates were able to clearly state the reason they were currently
incarcerated. All of these inmates reported receiving medications. They provided
inaccurate information regarding the frequency of being seen by a psychiatrist.
These inmates reported generally not being locked down in their cells. None of
them were receiving any form of ongoing mental health counseling, although they
had recently been informed by Ms. Charles that she would be starting some group
therapies for them.
I interviewed Inmate 17 individually. He also reported receiving psychotropic
medications. The information obtained from him was similar to the information
obtained from the other inmates.
I reviewed the healthcare records of these inmates. Appendix I summarizes my
findings.
These inmates, who all experienced significant symptoms of serious mental
illness, were receiving inadequate psychiatric treatment that was also dangerous
due to lack of adequate monitoring related to both their clinical conditions and
prescriptions of psychotropic medications.

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It was my understanding from Warden George and Defendants’ Responses to
Plaintiffs’ First Set of Interrogatories at 9 (response to Interrogatory 20) that the
Government had not contacted any psychiatric facilities about these men since
March 2006, when Warden George called six “maximum security forensic
hospitals” about accepting them.
I spoke briefly to Warden George about her past attempts to transfer the NGRI
inmates to an appropriate forensic facility. Because there are clinical issues
surrounding such potential transfers that are clearly not within Warden George’s
expertise, it is not surprising that these transfer attempts have been unsuccessful. It
is my recommendation that the responsibility for arranging such transfers should
be the responsibility of a Department of Health’s mental health clinician and
coordinated with the BOC.
Recommendations: These inmates need immediate assessment by a psychiatrist
relevant to their current psychotropic medications as well as ongoing monitoring.
They should also be transferred to an appropriate mental health treatment setting.
2007 Summary
There is very little change from my 2006 assessment. Significant problems
continue to exist relevant to the CJC mental health system, although there were
some positive finding present.
As during 2006, positive findings included the following:
1. Lisa LaPlace, R.N., who provides the glue for the very fragile healthcare
system at CJC, has filled the position of Territorial Nursing Coordinator.
However, due to staffing vacancies and allocation issues, she remains
functionally as the head nurse at CJC and is unable to devote much time in
the role of Territorial Nursing Coordinator.
2. Cluster 3 does appear to provide a better environment for inmates with
serious mental illnesses as compared to the other clusters. However,
Cluster 3 is not designed or staffed to provide adequate psychiatric care to
inmates with serious mental illnesses.
Negative findings included the following:
1. The BOC medical director position is vacant.
2. Essentially all of the key leadership positions in the current healthcare

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organizational chart are vacant.
3. There is not an established budget for the healthcare services.
4. The continued lack of relevant mental health policies and procedures and
established healthcare leadership has contributed to an inadequate mental
health system at the CJC. This problem is directly related to the three
previously listed problems.
5. The current mental health screening process remains flawed due to the
content of the medical screening intake form, nature of the healthcare
screening process, and lack of training for correctional officers relevant to
mental health issues.
6. There are significant problems related to the mental health assessment
process due primarily to lack of adequate numbers of mental health staff
and lack of relevant policies and procedures.
7. Treatment plans were absent.
8. There are significant problems related to the provision of timely psychiatric
services.
9. Needed psychosocial interventions for inmates with serious mental illnesses
are rarely available at the CJC.
10. Group counseling was not available for inmates with serious mental
illnesses.
11. Despite providing a better environment for inmates with serious mental
illnesses, as compared to the other clusters, Cluster 3 does not provide
enhanced mental health programming, or even adequate mental health
programming.
12. The lack of specially designated cells for secluding or restraining prisoners,
or for prisoners who are on suicide watch, is very problematic, especially
from the perspective of developing an adequate suicide prevention
program.
13. Inmates in need of inpatient psychiatric hospitalization are not transferred
to the Roy L. Schneider Hospital due to significant access problems.
14. There appears to have been little, if any, progress concerning construction
of a forensic facility since my May 2006 site visit.
15. An ineffective discharge planning process for mentally ill inmates
continues to exist at CJC.
16. The five NGRI inmates at ACF are receiving grossly inadequate mental
health treatment. The lack of any psychotropic medication monitoring by a
physician is a very dangerous practice.
For ease of reading, the following is a listing of the Recommendations sections of
this report. These recommendations are modified versions of recommendations I

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made in my May 2006 Report that have not been implemented:
Recommendations: As per my May 2006 report, policies and procedures need to
be developed that describe the screening process to be used to identify and exclude
mentally ill inmates from the Annex. In addition, these policies and procedures
need to describe the process to be implemented to identify and transfer inmates
who were appropriately admitted to the Annex but later demonstrate symptoms of
a mental illness. These policies and procedures would be a subset of the previously
recommended mental health system policies and procedures (see my May 2006
report) that would address the subject areas summarized in Appendix II. Of note,
the BOC still has not developed relevant mental health policies and procedures
related in large part to leadership and staffing issues that will be further described
later in this report.
In addition, Ms. LaPlace needs a full-time head nurse at CJC in order to allow her
to relinquish these duties so she can assume her role as territorial nurse
coordinator, which would facilitate implementation of the above recommended
policies and procedures.
Recommendations: The infrastructure of the mental health system is lacking and
basically unchanged from my May 2006 findings. By infrastructure I include the
following elements:
1. Key administrative staff and medical leadership as per the submitted
organizational chart.
2. Mental health policies and procedures as previously recommended and
currently court ordered. They should include those areas summarized in
Appendix II.
3. A reasonable working relationship between custody and healthcare
management staffs.
4. A hiring process that is able to create and fill needed mental health care
positions in a timely manner.
5. Timely access to adequate assessment and programming space for
mental health purposes.
6. A discrete and adequate healthcare budget which includes mental health
services.
Recommendations: Corrections and mental health staff need to develop a
working relationship regarding the operation of this unit, where there is regular
and open communication between staff about the condition of the prisoners

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housed there, which would help decrease, but not eliminate, the resulting harm to
many of these inmates with serious mental disorders who are receiving inadequate
psychiatric treatment. To this end, the jail should institute treatment team meetings
between Dr. Lu, Ms. LaPlace, Warden George, and correctional personnel to
discuss the operation of the cluster, and mentally ill prisoners who have exhibited
behavioral/psychological changes. The goal of the treatment team is to come up
with interventions that may help the inmates clinically improve.
Correctional staff monitoring of cluster 3 prisoners is significantly compromised
due to custody staffing patterns in this unit, which at times requires lockdown
status due to the custody staffing shortage. This unit should be staffed by
adequate numbers of specially trained correctional officers, who are assigned to
this unit on at least a six-month basis in contrast to the current practice of staffing
this unit with different officers on a very frequent basis.
Establishment of a psychosocial rehabilitation model for inmates in need of such a
level of care should be a priority at the CJC, which will require additional mental
health staff and adequate programming space.
Dr. Lu should be involved with the decision to admit or discharge prisoners into
cluster 3.
Recommendation: I again recommend that correctional officers receive at least
annual training relevant to suicide prevention policies, procedures, and practices.
Cut down tools and mouth guards/ambu bags should be available in all of the
housing units for CPR purposes. Separate training also needs to be provided
concerning CPR.
Recommendations: CJC should develop an MOU with a hospital that provides
inpatient psychiatric care that describes the procedure for admitting and
discharging CJC inmates that should include the criteria for admission and
discharge.
Recommendations: I reiterate my previous recommendations that the BOC
strongly consider executing a contract with the Department of Health to operate
this facility. Under a contract, the BOC along with the Department of Health
should then develop a staffing plan for the facility. The facility’s medical
leadership should be hired well in advance of the unit’s opening, so that they can
develop policies and procedures and hire key staff. The BOC should also develop
a budget and a timeline for the construction project, and hire either a construction

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firm with experience building forensic facilities, or a consultant to help oversee
the project. It is my understanding of these recommendations are now court
ordered (see Carty v. DeJongh), Civil No. 94-78, Order (D.V.I. Nov. 20, 2006).
Recommendations: D5 NGRI inmates at a cf. need immediate assessment by a
psychiatrist relevant to the current psychotropic medications as well as ongoing
monitoring. They should also be transferred to an appropriate mental health
treatment setting.
Recommendations from prior reports that have not changed and are yet to be
implemented:
Recommendations: A management information system should be developed,
which should include data points relevant to the intake screening process, in
addition to other important data elements such as mental health caseload inmate
names, diagnoses, medications, scheduled appointment dates, etc. . . .
Recommendations: The BOC should strongly consider increasing Dr. Lu’s fee
structure rate to bring it more in line with his rate with the Department of Health.
I was told that there are only three psychiatrists who provide services on St.
Thomas, and therefore there is a strong chance that the BOC would be unable to
find a replacement should Dr. Lu decide to terminate his contract. Along with
increasing the rate structure, the BOC should periodically review Dr. Lu’s hours to
ensure that he is providing a level of services that is consistent with his contract.
Recommendations: As I recommended last year, Dr. Lu should be involved with
the decision to admit or discharge prisoners into Cluster 3. Corrections and mental
health staff need to develop a working relationship over the operation of this unit,
where there is regular and open communication between staff about the condition
of the prisoners housed there. To this end, the jail should institute treatment team
meetings between Dr. Lu., Ms. Latimer, the warden, and correctional personnel to
discuss the operation of the cluster, and mentally ill prisoners who have exhibited
behavioral/psychological changes. The goal of the treatment team is to come up
with interventions that may help the inmates clinically improve.

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Recommendations: Correctional officers should receive at least annual training
relevant to suicide prevention policies, procedures, and practices. Cut down tools
and mouth guards/ambu bags should be available in all of the housing units for
CPR purposes.
Recommendations: CJC should develop an MOU with a hospital that provides
inpatient psychiatric care that describes the procedure for admitting and
discharging CJC inmates that should include the criteria for admission and
discharge.
Recommendations: The BOC has made little progress in the past year to open the
forensic facility. I reiterate my April 2005 recommendation that the Bureau
strongly consider executing a contract with the Department of Health to operate
this facility. Under a contract, the BOC along with the Department of Health
should then develop a staffing plan for the facility. The facility’s medical
leadership should be hired well in advance of the unit’s opening, so that they can
develop policies and procedures and hire key staff. The BOC must also develop a
budget and a timeline for the construction project, and hire either a construction
firm with experience building forensic facilities, or a consultant to help oversee
the project.
Recommendations: The NGRI inmates need immediate assessment by a
psychiatrist relevant to their current psychotropic medications as well as ongoing
monitoring. They should also be transferred to an appropriate mental health
treatment setting.
Please contact me if I can answer any further questions.
Sincerely,

Jeffrey L. Metzner, M.D.
Clinical Professor of Psychiatry
University of Colorado School of Medicine