2-00/070.00 Custody Compliance and Sustainability Bureau

The Custody Compliance and Sustainability Bureau (CCSB) is responsible to oversee, monitor, and assess the Department’s jail suicide prevention program in coordination with Correctional Health Services (CHS). The CCSB captain or designee reports to the Assistant Sheriff for Custody Operations through the chain of command. The CCSB captain is responsible to ensure CCSB personnel:

• Conduct assessments at each facility to ensure compliance with the provisions of various court actions and adherence to policies and procedures

• Liaise with the Access to Care Lieutenant (ATC) at each facility

• Facilitate the timely and thorough administrative review of suicides and serious suicide attempts in custody facilities, court lockups, and Sheriff’s station jails

• Complete reports as required by various court actions

• Oversee the Jail Mental Evaluation Teams (JMET)

• Monitor facilities’ annual suicide hazard inspections

INMATE DEATH REVIEWS AND SERIOUS SELF-INJURIOUS BEHAVIOR/SUICIDAL INMATE REVIEWS

Personnel from CCSB are responsible for reviewing and tracking all in-custody inmate deaths, including suicides.  Personnel from CCSB will promptly notify the County Office of Inspector General (OIG) of all apparent or suspected suicides occurring at the jails. Refer to CDM sections 4-10/050.00, “Inmate Deaths - Reporting and Review Process,” and 4-10/060.00, “Critical Incident Review Committee - Suicidal Inmates.”

The CCSB shall attend meetings with the following committees:

• Suicide Prevention Advisory Committee - meets twice per year to analyze recent patterns, if any, of attempted suicides. This includes, but is not limited to: time of day, housing, methods, profile, and/or any significant characteristics
• Critical Incident Review Committee - Suicidal Inmates (CIRC-SI) - meets monthly to discuss and identify possible issues from each serious suicide attempt and serious self-injurious behavior incident
• Joint Quality Improvement Committee (JQIC) - meets monthly to review and further examine the possible issues identified during CIRC-SI meetings. Both CIRC-SI and JQIC meetings work to identify any causal factors or patterns in jail suicides.  Refer to CDM section 4-10/060.00, “Critical Incident Review Committee - Suicidal Inmates”

Custody Support Services Bureau (CSSB) shall conduct an annual inspection of every Custody Services Division facility regarding suicide prevention. Refer to CDM section 5-01/050.00, “Handling of Suicidal Inmates.”

QUALITY IMPROVEMENT AND CORRECTIVE ACTION

Personnel from CCSB will conduct follow up assessments upon the completion of corrective action plans (CAPs) to verify that any identified deficiencies have been addressed. CCSB will participate in meetings with CHS to develop, implement, and track CAPs addressing recommendations of the quality improvement program.

The CCSB will be responsible to analyze staffing, prisoner classification, and mental health service delivery issues as they relate to suicides and serious suicide attempts to identify the need for corrective action where appropriate; and recommend remedial measures, to address the deficiencies and ensure implementation.

The CCSB will identify patterns and trends of suicides and serious suicide attempts, keeping centralized records and inputting data into a unit database for statistical analysis, trends, and corrective action, if necessary.

The CCSB will oversee corrective actions to mitigate suicide risks at both the location of occurrence and throughout the jails by providing, or obtaining where appropriate, technical assistance to other administrative units within custody operations when such assistance is needed to address suicide-risk issues.

Deficiencies identified as a result of an inspection or review of an incident will be documented and forwarded to the concerned facility or unit. The concerned facility or unit will be responsible to prepare and submit a CAP to CCSB within the time allotted by CCSB, depending upon the urgency or complexity of an issue. The concerned facility or unit will be responsible to identify the required corrective action(s), personnel tasked with addressing the deficiency, as well as a projected completion date(s) for addressing the deficiencies.

CAPs generated as a result of deficiencies identified during inspections, throughout the inmate death review process, and CAPs developed at CIRC meetings are maintained by CCSB.

If the deficiency has not sufficiently been addressed, either in whole or in part, CCSB will follow up with the concerned units through the completion of the corrective action.  Upon being notified that a CAP item has been completed, CCSB will collect supporting documentation and update the CAP as complete.