govinfo:USCOURTS-azd-2_12-cv-00601-57

1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
WO 
 
 
 
 
IN THE UNITED STATES DISTRICT COURT 
FOR THE DISTRICT OF ARIZONA 
 
 
Shawn Jensen, 
 
Plaintiff, 
 
v. 
 
David Shinn1, 
 
Defendant. 
No. CV-12-00601-PHX-ROS 
 
ORDER 
 
 
 
 This Order includes the requirements of the planned injunction. The parties, and 
Naphcare, will be allowed thirty days to file written objections as well as time to file 
responses to those objections. The terms set forth in the planned injunction are the product 
of extensive work by the Court and its experts. The experts worked with all counsel and 
personnel at ADCRR. Therefore, the parties should not anticipate significant changes will 
be made absent compelling reasons. 
 The parties are reminded this injunction must remedy the serious constitution al 
violations found at trial, as found in the June 30, 2022, Order. Any objection based on the 
belief that a proposed provision goes beyond the scope of the facts proven at trial must be 
supported by argument establishing th at provision has no relation to the claims and facts 
proven at trial. That is, the Court has already attempted to ensure each provision of th e 
proposed injunction is directly linked to a constitutional violation proven at trial. The 
 
1 The Court understands that David Shinn is no longer the Director of ADCRR. Pursuant 
to Federal Rule of Civil Procedure 25(a), his successor will automatically be substituted. 
In responding to this Order, Defendants shall identify the appropriate individu al to be 
substituted for David Shinn. 

 
- 2 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Court’s experts made additional recommendations which the Court did not include because 
they could not be specifically supported by what was proven at trial. Therefore, the Court 
is likely to overrule any objections asserting certain provisions cannot be linked to facts 
proven at trial. 
For any provision where the parties have an objection, they must set forth the basis 
for the objection and propose an alternative solution, using the same general framework 
set forth in the injunction. For example, the injunction bases staffing on the number of 
prisoners each medical professional may carry on a caseload. If Defendants believe those 
numbers are inappropriate, they must propose alternative numbers. Defendants may make 
a general objection that staffing should not be assessed in this manner, but they must al so 
set forth their own proposed numbers accepting the assumption that the Court will adopt a 
caseload-based staffing approach. 
 Finally, the parties shall confer prior to filing their objections to reach agreements 
on alternatives. If the parties can reach an agreement on an alternative for a particular 
provision, that agreement will have substantial weight when the injunction is finalized. 
 Accordingly, 
 IT IS ORDERED the parties and Naphcare shall file their objections to the attached 
injunction no later than February 10, 2023 . The parties and Naphcare shall file their 
responses to the objections no later than February 27, 2023. 
 IT IS FURTHER ORDERED the Motions for Leave (Doc. 4371, 4377) are 
GRANTED. 
 IT IS FURTHER ORDERED the Motions filed by class members (Doc. 4375, 
4378) are DENIED. 
 Dated this 9th day of January, 2023. 
 
 
 
Honorable Roslyn O. Silver 
Senior United States District Judge 
 
 

 
- 3 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
DRAFT INJUNCTION 
On June 30, 2022, the Court issued its Finding s of Fact and Conclusion of Law . 
(Doc. 4335). In that Order, the Court required the parties “nominate proposed experts to 
assist the Court with crafting an injunction that complies” with the statutory limitations on 
injunctions addressing prison operations. (Doc. 4335 at 180). The parties subsequently 
nominated their preferred experts. In the ir list, Defendants nominated Dr. Marc Stern. 
(Doc. 4339). Defendants in writing informed the Court “Dr. Stern’s dedication to the 
design, management, and operation of health services in corrections settings [would] 
provide this Court and the parties wit h valuable guidance in crafting an injunction 
regarding the provision of medical care at ADCRR.” (Doc. 4339 at 4). After reviewing 
the parties’ lists, t he Court solicited additional briefing. (Doc. 4340). In that additional 
briefing, Plaintiffs made no objection to the appointment of Dr. Stern. 
 On August 4, 2022, the Court held a hearing with the parties and Dr. Stern. (Doc. 
4351). During that hearing the Court noted Dr. Stern’s past work in this case made him 
experienced and therefore an “attractive expert” to help with crafting an injunction.2 (Doc. 
4358 at 8). Dr. Stern stated he could address medical care aspects of the planned injunction, 
but he would need additional assistance on the topics of mental health care and conditions 
imposed on the subclass. Dr. Stern stated he had individuals in mind who may be able to 
assist him on those topics. 
After finding Dr. Stern was an appropriate expert, the Court discussed with Dr. Stern 
and the parties the type of communications the Court’s experts could have with the Court 
and the parties. Both sides agreed the experts could have ex parte communications with 
Defendants, defense counsel, Plaintiffs’ coun sel, and the Court. (Doc. 4358 at 19 -20). 
Accordingly, the Court held the experts could have ex parte conversations as they deemed 
 
2 That hearing included some discussion of appointing a receiver. The Court stated it was 
“not prepared to consider, at [that] time, a receivership. That doesn’t mean it’s off the table 
forever in this case, but not now.” (Doc. 4358 at 4). The refusal to appoint a receiver was 
based on the Court’s expectation that Defendants appeared willing “to cooperate” and “act 
in good faith” in monitoring their performance under an injunction. (Doc. 4358 at 7). Any 
failure to act in good faith or to meaningfully comply with this injunction will revive the 
possibility of appointing a receiver. 

 
- 4 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
appropriate. The Court stated it would keep general notes regarding the contents of its 
communications with the experts. 
The day after the hearing, the Court formally appointed Dr. Stern and shortly 
thereafter the Court appointed two additional experts to assist Dr. Stern to which the parties 
had no objection . (Doc. 4352, 4362). Those three experts then began crafting 
recommendations for the final injunction. In doing so, the experts have had extensive back 
and forth communications with individuals who had relevant information. Thus, Dr. Stern 
and Dr. Bart Abplanalp spoke with Plaintiffs’ trial experts, Plaintiffs’ counsel, Defendants’ 
counsel, Defendants, ADCRR personnel, Centurion personnel, and NaphCare personnel. 
John McGrath spoke with some of the same individuals but he also spoke with wardens, 
deputy wardens, and other custody staff. Mr. McGrath visited some of the facilities to gain 
a better understanding of possible solutions to the flaws identified by the Court. The 
experts have also explained some of their recommended changes to the Court. Altogether, 
the Court-appointed experts have spent close to 500 hours investigating and identifying the 
appropriate solutions to the unconstitutional findings outlined in the Court’s Findings of 
Fact. 
The back-and-forth between the parties and the Court’s experts included discussions 
regarding specific recommendations the experts might propose. And the experts have 
incorporated some recommendations made by the parties or their agents that the experts 
may not have otherwise included. In other words, the experts have thoroughly made 
genuine efforts to assess the possible solutions to the unconstitutional conditions and they 
paid particular attention to the solutions proposed by Defendants and their agents. Over 
the approximately four -month period of the experts’ work , the parties or their 
representatives have had ample opportunity to explain to the experts why particular 
solutions were not feasible or why the experts should recommend some solutions over 
others. Accordingly, this detailed injunction contains little, if any, requirements that 
surprise Defendants. 
The Court’s Findings of Fact and Conclusions of Law establish Defendants’ basic 

 
- 5 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
model and staffing decisions for the provision of medical and mental healthcare create an 
unconstitutional substantial risk of serious harm to Plaintiffs. Therefore, the changes 
necessary to alleviate that risk will be substantial. Similarly, the insufficient staffing and 
a wide variety of conditions of confinement combine to create an unconstitutional 
substantial risk of serious harm t o subclass members. Again, the changes necessary to 
alleviate the risk of harm to the subclass will be substantial. Given the extent of the existing 
dysfunction in Defendants’ operations, the Court will provide significant detail regarding 
medical care, mental health care, and conditions imposed on the subclass to remedy the 
substantial constitutional violations.3 
The unusual scope of this injunction is informed by Defendants’ actions throughout 
this case. Despite their agreement and promise to the Co urt to do otherwise, Defendants 
have fought every aspect of this case at every turn. Defendants entered into a settlement 
agreement where they claimed they would improve the care provided to prisoners and 
improve the conditions of confinement for the subc lass. Defendants almost immediately 
failed to perform those obligations and continued in that failure. Instead of acknowledging 
their failures, Defendants kept inaccurate records and misinterpreted the settlement’s 
requirements to their advantage . D uring trial, Defendants present ed arguments and 
witnesses that were manifestly unpersuasive. And on some aspects, Defendants presented 
no meaningful defense. For example, Defendants did not present any expert testimony that 
the conditions imposed on the subclass were appropriate . Most importantly, trial 
established Defendants still had not made any serious effort to remedy the flaws 
highlighted by this litigation. Given this history, the Court cannot impose an injunction 
that is even minutely a mbiguous because Defendants have proven they will exploit any 
ambiguity to the maximum extent possible. 
Despite Defendants’ unsatisfactory past behavior, the Court appreciates that the 
 
3 As expressed multiple times throughout the almost ten years this case has been pending, 
the Court has no interest in micromanaging Defendants’ operations. At the hearing on 
August 4, 2022, the Court stated: “I am not -- and I have said this a number of times, I 
don’t know how many -- but the Court is not in a position, and never should be in a position 
of running the prison. That’s not my job.” (Doc. 4358 at 16). 

 
- 6 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
injunction is required to be narrowly drawn, extend no further than necessary t o correct 
Defendants’ ongoing violations of Plaintiffs’ constitutional rights, and be the least intrusive 
means necessary to correct and prevent violations. 18 U.S.C. § 3626(a)(1)(A). In addition, 
the injunction must “describe in reasonable detail ” what Defendants must do and must be 
specific and definite to allow for accurate monitoring and, if necessary, enforcement. Fed. 
R. Civ. P. 65(d)(1)(C) ; United States v. DAS Corp. , 18 F.4th 1032, 1039 (9th Cir. 2021) 
(“Civil contempt consists of a party’s disobedience to a specific and definite court order by 
failure to take all reasonable steps within the party's power to comply.”). In light of these 
requirements, the Court has reviewed the experts’ recommendations and has adopted only 
those recommendations ne cessary to correct the constitutional violations at issue. The 
injunction that follows is narrowly drawn, extends no further than necessary, and is the 
least intrusive means necessary. 
Quantitative and Qualitative 
The extended history of this case mandates a need for the Court to impose both 
quantitative and qualitative measures .4 Defendants’ performance under the quantitative 
performance measures required by the settlement established the quality of the underlying 
care often was abysmal, even when Defendants were reporting compliance with 
quantitative benchmarks. That is, history has established the quantitative performance 
measures were not adequate or suitable because of the enormous problems at ADCRR that 
were not immediately apparent. The only possible solution is to require a significant 
number of qualitative benchmarks that assess whether the underlying care is constitutional. 
Monitoring 
Unlike the attempt at monitoring under the parties’ settlement, t he Court will 
appoint its own experts to serve as monitors to evaluate Defendants’ performance. The 
Court appoints Dr. Marc F. Stern, Dr. Bart Abplanalp, Dr. Lara Strick, and an individual 
 
4 As used here, “quantitative” refers to measuring only the quantity of certain events or 
actions. “Qualitative,” on the other hand, refers to measuring the appropriateness of the 
events or actions. The Stipulation’s performance measures were “quantitative” in that they 
merely reflected a tabulation of acts or events. The performance measure scores did not 
require a “qualitative” inqu iry and did not reflect whether any of the acts or events that 
occurred were medically appropriate under the circumstances. 

 
- 7 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
devoted to custody issues 5 to assist the court in monitoring Defendants’ compliance with 
this Order. Dr. Stern may appoint additional appropriately qualified and credentialed staff 
as needed to assist the aforementioned monitors in their work . Defendants shall provide 
these monitors and additional staff remote access to the EHR and other electronic records 
(e.g., EOMS) that are available by remote access and necessary for monitoring. 
Monitors will generally provide advance notice prior to visits of facilities, however, 
they may make unannounced visits as needed. Monitors and their staff may bring into 
facilities cell phones, computers, tablets, and cameras necessary to conduct monitor ing 
activities. The monitors and staff will be responsible for securing such equipment and 
following rules with regard to the materials. Monitors may record any still or video images 
within all facilities necessary to document conditions relevant to this Order. Monitors will 
make every effort to avoid including the face of any individual (staff or prisoner) unless it 
is necessary for monitoring purposes and the individual agrees. In the event an image 
includes a face and the image is filed with the Court, the face will either be blurred to distort 
the image or the document itself sealed. The monitors will submit written reports to the 
Court as they deem necessary. 
Despite the appointment of monitors, m uch of the monitoring will depend on data 
collected by Defendants. Therefore, Defendants shall use reasonable judgment in selecting 
methodologies for monitoring compliance and shall exercise care in the underlying 
measurements. As part of Arizona’s decision to outsource prisoner healthcare, Defendants 
must monitor the performance of their healthcare vendor . Monitoring of this injunction 
will use that preexisting monitoring apparatus as much as possible. But Defendants will 
also be required to collect monthly data and perform analyses beyond what they are doing 
now. To do so Defendants will be required to employ sufficient staff of appropriate level 
of professional credential s and experience to conduct the monitoring described in this 
Order. For example, physicians will be required to conduct qualitative review of the work 
of all physicians. Defendants may not delegate such monitoring to the vendor (e.g., 
 
5 This is necessary due to Mr. McGrath’s passing. 

 
- 8 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Naphcare) providing health care services to prisoners, if there is one. 
Defendants shall monitor all elements of this order on a monthly basis. Monitoring 
shall be completed and available for inspection by the monitors by the last day of the month 
following the monitored month. Defendants shall maintain supporting evidence for their 
monitoring results. 
The Court’s monitors may rely on monitoring conducted by ADCRR and any 
additional information that the monitors obtain. Such additional information may come 
from a variety of sources including but not limited to: interviews with class members 
Defendants’ staff, or contractors; complaints from prisoners or others on their behalf; 
Plaintiffs’ counsel; random or purposive review of health care records; direct observation; 
site visits; review of paper or electronic records; and review of video records. 
In general, where performance can be measured by au tomated systems, a 100% 
sample will be required. Unless otherwise noted, where performance must be measured 
by review of individual cases, reports, health records, events, etc., Defendants will sample 
at least 50 items statewide, chosen in a n accurate and reasonable manner. As used here, 
“reasonable” means that the minimal sample is drawn from a relevant population at high 
risk if performance is poor and is drawn from venues roughly in proportion to relevant 
items at that venue. For example, if half of a ll maximum custody prisoners are held at 
Complex A and half at Complex B, minimal samples regarding maximum custody would 
be drawn in roughly equal numbers from Complexes A and B; samples beyond the 
minimum, however, may be drawn from anywhere. 
 As an additional way to monitor compliance with this Order, t he Court-appointed 
monitors will create a confidential mechanism for current prisoners, former prisoners, 
friends and family of prisoners, prison staff, contract staff (included the contracted 
healthcare vendor), and the public, to notify the Court of problems or complaints of unsafe 
and unsound health care conditions or conditions of confinement. As the monitors deem 
appropriate, the mechanism may receive submissions by postal mail, email, or phone. 
Within two months of this Order, Defendants shall design and implement a mechanism for 

 
- 9 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
prisoners to submit communications to the Court -appointed monitors. Submissions are 
solely for the purpose of providing relevant information to the monitors. The monitors will 
not necessarily investigate a submission or take action on behalf of a prisoner. Monitors 
may or may not provide a direct response to a submission. Defendants’ implementation 
shall inform prisoners and staff that this confidential mechanism does n ot replace any 
existing system by which prisoners or others are expected to inform Defendants of 
problems for which they require a resolution, such as the prisoner grievance system or staff 
reporting mechanisms. 
 This injunction does not set forth the full extent of the data that must be collected, 
analyzed, and made available to the Court-appointed monitors. Defendants shall cooperate 
with the monitors in devising all appropriate methods of data collection and data 
transmission.6 If u nforeseen changes in conditions or operations render any of the 
requirements in this Order obsolete, unnecessary, or impractical, will be identified by the 
monitors and recommended to the Court for alteration. The parties may petition the Court, 
to modify or annul requirements. Defendants will be allowed a reasonable amount of time 
to implement any modification.7 
Plaintiffs’ Monitoring 
 While the Court -appointed monitors will be a valuable source of information, 
Plaintiffs and their counsel will still have primary responsibility for assessing Defendants’ 
performance and, if Defendants do not perform, Plaintiffs will be responsible for seeking 
additional relief. This will require Plaintiffs’ counsel to have ongoing access to class 
members, medical records, and the locations where class members are housed. Plaintiffs 
and Defendants will be required to confer and reach an agreement regarding the extent of 
Plaintiffs’ access to information and locations. The parties will be file the terms of their 
agreement. To inform their discussion, the Court notes Plaintiffs’ counsel shall have access 
to the information necessary to assess Defendants’ compliance with all terms of this 
 
6 Defendants and their agents shall not take any retaliatory actions against anyon e who 
gathers or produces information relevant to Defendants’ performance under this injunction. 
7 This will be implemented considering the limitations set forth in 18 U.S.C. § 3626(b)(1). 

 
- 10 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
injunction. That access, however, shall not overly hamper Defendants’ operations. At 
present, the Court likely will order the following: 
• Plaintiffs’ counsel will have read-only access to class members’ electronic health 
records; 
• Plaintiffs’ counsel will receive monthly data reports already being produced by 
Defendants and Plaintiffs may demand the gathering of additional data and 
production of reports, as necessary to enforce all terms of this injunction; 
• Plaintiffs’ counsel will be able to conduct visits to speak to class members and staff 
and tour units. Those visits likely will be no less than 20 days but no more than 40 
days per calendar year; 
• Defendants will provide substantive and timely responses in writing to concerns 
raised by Plaintiffs’ counsel regarding individual treatment or systemic issues. 
 

 
- 11 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Medical and Mental Health Overall Requirements 
1. General Requirements 
1.1. All health care (including but not limited to: emergent; urgent; non-urgent episodic; 
chronic; palliative; scheduled; inpatient; residential; outpatient; referrals to other 
on-site professionals; off-site specialty referrals; modifications of specialty referral 
requests; action taken on pos t-hospital, post-ER, or specialist recommendations), 
and the documentation supporting that care, delivered to Plaintiffs during a medical 
encounter (primarily face-to-face encounter s), in response to an inquiry from a 
nurse, during a chart review or chart-based triage decision, or upon receipt of results 
from a test, a report from a consultant, or other external health record , shall be 
clinically appropriate , including, where relevant to the circumstance and 
professional’s credential, but not limited to, th e conducting of the history and 
physical examination, forming and testing a differential diagnosis, arriving at a 
diagnosis, and ordering treatment for that diagnosis. 
1.2. Defendants shall document all aspects of care to allow for monitoring of these 
requirements. 
1.3. All prisoners with physical or mental illness that require regular follow-up shall be 
designated on the medical or mental health caseload and shall be seen in clinically 
appropriate timeframes. 
1.4. Telehealth medicine may be used only when clinically appropriate. 
1.5. Emergency response and care provided by custody staff shall be appropriate given 
the skill level and knowledge expected of custody staff. 
1.6. Defendants shall provide sufficient space, equipment, and supplies for health care 
staff to deliver the health care services described in this Order, regardless of 
housing assignment, including housing assignments with restricted liberty. 
1.7. The space provided for clinical encounters shall be sufficient to allow for auditory 
and visual confidentiality from other prisoners or non -clinical staff. Visual 
confidentiality requirements apply at those times when an examination reveals 

 
- 12 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
portions of the prisoner’s body or the prisoner is touched in ways that would not be 
visualized or touched, respectively, in the typical prison environment. Exceptions 
may be made for encounters where providing such confidentiality would 
legitimately jeopardize safety , including emergency situations. In those cases, 
breaches of confidentiality are limited to the measures required to ensure safety, 
and all staff shall maintain the confidentiality of any information they acquire as a 
result of the breach. 
1.8. Emergency response equipment (“Man Down Bag,” Automated E xternal 
Defibrillators ( “AEDs”), oxygen) shall contain all items required by policy, all 
equipment shall be in working order, and all medications shall be unexpired. 
Naloxone is required to be kept on every living unit or with every AED. Emergency 
Response bag checklists shall reflect the equipment was checked daily and 
inventoried monthly. The checklists shall also reflect medications are within their 
expiration date and equipment is operational. Staff shall complete and document 
all AED manufacturer recommended checks (e.g., daily, monthly, annual). 
1.9. Directors of Nursing may not spend more than 15% of their time providing 
scheduled or unscheduled prisoner care. 
1.10. All staff hired in clinical supervising positions must have at least two years 
clinical experience. 
1.11. LPNs shall practice within their scope of practice set forth in Arizona 
Administrative Code § 4 -19-401. LPNs and Behavioral Health Technicians shall 
not independently assess prisoners or initiate a plan of care or treatment. 
1.12. No one hired for whom a health professions license is required may possess a 
restricted license if the restriction is related to clinical competency or is restricted 
to practice in a correctional facility. 
1.13. Health care staff responsible for direct prisoner care shall not be mandated to work 
beyond the following limits: more than 12 hours in any 24-hour period; less than 8 

 
- 13 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
hours off between any two shifts; more than 60 hours in a calendar week defined 
as Sunday through Saturday. 
1.14. The limits on overtime may be extended during emergency situations in which a 
prisoner’s safety is in jeopardy and no reasonable alternative can be found or during 
a declared emergency ( e.g., prison riot, natural d isaster, etc.). Time spent on -call 
is not included in the time limits. For purposes of the overtime limits, “emergency 
situations” are defined as unforeseen events that could not be prudently planned for 
and do not regularly occur. Failure to hire or re tain adequate staffing is not an 
emergency situation. 
1.15. Within three months of this Order, Defendants shall ensure there is a sufficient 
number of custody staff to support the functioning of the health care operation, 
including but not limited to: transport ing prisoners to on -site and off -site clinical 
encounters and appointments; administration of medications; and providing 
security in the venues of health care operations. Exceptions may be made for 
emergency lockdowns, natural disasters, and other unfores een emergency 
situations. Unforeseen emergencies do not include chronic understaffing. 
1.16. For all positions for which healthcare staffing is not based on medical or mental 
health caseload, no later than three months after this Order, Defendants shall fill all 
positions required by the current contract with the health care vendor including any 
modifications, addenda, or updates. A filled position is one in which there is an 
incumbent receiving a salary for the full intended time commitment of the position. 
An individual may not fill more than 1.0 FTE. 
1.17. Defendants shall hire additional staff, above the minima described in this section, 
as necessary, to provide constitutionally adequate health care. 
1.18. A staff position may be filled by persons employed by ADCRR, i ts health care 
contractor, or under temporary contract. 
1.19. Urgent Care 

 
- 14 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
1.19.1. When a prisoner expresses to a correctional officer that he or she has a need 
for health care (medical or mental health) the officer may not inquire as to the 
nature of the need or symptom s. The officer’s inquiry is limited to asking 
whether the need is immediate or if the prisoner can wait to sign up for the next 
scheduled clinic, or if the prisoner is thinking of harming themselves . If the 
prisoner is thinking of harming themselves, the officer shall immediately 
ensure the prisoner’s safety and contact health care staff according to policy. 
For other needs that are i mmediate, the officer shall contact health care staff 
immediately. An RN shall triage the prisoner immediately, either by seeing 
the prisoner, or talking to the prisoner directly over the phone. Based on the 
triage results, the RN shall discuss the prisoner with a medical or mental health 
practitioner in a clinically appropriately timeframe, not to exceed four hours. 
Based on that interaction the practitioner shall: 
1.19.1.1. see and treat the prisoner the same day; or 
1.19.1.2. instruct the RN on treatment to provide, and, if necessary, schedule the 
prisoner for further evaluation or treatment in a clinically appropriate 
timeframe; or 
1.19.1.3. determine the health care need is not urgent and that a reasonable 
prisoner would not have considered the health care need to be urgent, defer 
treatment, and instruct the prisoner to access non -urgent/non-emergent 
care for treatment. 
1.19.2. Nothing in the model of urgent care is meant to limit a correctional officer 
from making self-initiated inquiries to a prisoner when the officer has a concern 
about the prisoner’s condition or safety. 
1.19.3. Defendants shall track and report the number of urgent care visits conducted 
by RNs which shall be accessible to the monitors. 
1.20. A prisoner may refuse any on -site or off -site provider-initiated health visit and 
cancel any prisoner-initiated visit. All cancellations of prisoner-initiated visits shall 

 
- 15 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
be made directly to a health care professional by telephone, video, or face-to-face. 
All refusals of provider-initiated on-site health visits are made by telephone, video, 
or face -to-face with an RN or practitioner for medical visits or a masters level 
therapist, psychologist, or psychi atric practitioner (psychiatrist, psychiatric nurse 
practitioner, psychiatric physician assistant) for mental health v isits, within three 
days after the appointment. All refusals of off -site health visits are made by 
telephone, video, or face -to-face with an RN or higher at the time of the 
appointment. If a prisoner will not voluntarily displace themself to participate in 
the direct communication with health care staff required here, health care staff shall 
displace to the prisoner’s location. 
1.21. Orders from health care (medical and mental health) staff in the out patient and 
inpatient arenas shall be completed within the timeframe ordered. This includes, 
but is not limited to, diagnostic tests, follow-up visits with nurses or practitioners, 
requests for outside records, and treatments. 
1.22. Prisoners shall be informed in a timely manner of diagnostic test results and of 
any request staff make for additional consultation (e.g., off-site specialists). 
1.23. When prisoners on suicide watch are removed from a cell for a healthcare-related 
visit, including mental health encounters conducted in or near the living unit, they 
shall not be restrained or strip -searched unless they have been appropriately 
classified a t a custody level that requires such measures based on classification 
tools that are independent of their mental health classification. 
1.24. Defendants shall take all reasonable steps to fill all staffing vacancies. Presently, 
the Court will not mandate an increase in compensation to fill vacancies. However, 
the Court will do so in the future should chronic understaffing continue. 
2. Improvement Programs 
2.1. Mortality review 
2.1.1. Following a prisoner death, Defendants shall identify all significant health 
care and custody errors (i.e., near misses as well as preventable adverse events). 

 
- 16 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Based on prioritization of all errors identified, a root cause analysis shall be 
conducted if clinically appropriate, from which an effective and sustainable 
remedial plan shall be craft ed. A sustainable plan is one which outlives staff 
memory from a single training after the review or staff turnover. Defendants 
shall monitor the remedial plan for effectiveness and make appropriate and 
timely modifications to the plan based on the monitoring. 
2.1.2. The sustainable plan shall be implemented within one month of the death. 
2.1.3. The plan in this section shall be crafted and implemented whether or not the 
medical examiner’s report is available. If the medical examiner’s report was 
unavailable, the plan shall be revisited and modified, if necessary, within one 
month of receipt of the report. 
2.2. Near-miss reporting 
2.2.1. Defendants shall implement an appropriate near -miss error reporting policy. 
Defendants are encouraged, but not required, to incorporate the fol lowing 
elements in this policy: 
• Only errors which caused no (or minimal) harm to a prisoner may be 
reported through this system. 
• Reporting is voluntary. 
• Anyone can report (including prisoners). 
• The reporter is immune from discipline, punishment, or retalia tion 
related to the error unless the following are all true: the reporter is a 
staff member, the error is one they made themselves, and the error is 
one for which they have a current disciplinary or other performance 
improvement plan that addresses such errors. 
• Reporting is easy and fast for staff with a minimal amount of 
information required of the reporter initially, so that the reporting 
process itself is not a barrier to reporting. 

 
- 17 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
• Because minimal information is required initially, reports are 
confidential but not anonymous, so that the reporter can be contacted 
to obtain more and complete detail later if needed. 
• Reporters receive feedback about reports and their impact. While 
individual feedback might be optimal, even feedback to the whole 
workforce about specific prisoner safety changes that resulted from 
reporting can be valuable. 
2.3. Preventable adverse event reporting 
2.3.1. Defendants shall implement a preventable adverse event reporting policy that 
includes the following elements: 
2.3.1.1. The policy requires reporting of errors which cause more than minimal 
harm to a prisoner. 
2.3.1.2. All such errors shall be reported, not just medication-related errors. 
2.3.1.3. Reporting is mandatory for all staff. 
2.4. Continuous Quality Improvement program 
2.4.1. Defendants shall implement a robust continuous quality improvement 
program to monitor the quality of clinical care. As part of this program, 
Defendants shall monitor the absolute number and trend of various parameters 
on a monthly basis. Where metrics or trends in metrics show room for 
improvement, Defendants shall make appropriate efforts to understand the 
underlying reason for deviation, take reasonable ste ps to effectuate 
improvement, evaluate the effectiveness of these steps in a reasonable time, 
and make adjustments to its improvement efforts as needed. At a minimum, 
Defendants shall monitor: 
• percentage of individuals (regardless of whether diagnosed with 
hypertension) whose systolic blood pressure exceeds 140 mmHg 
or diastolic blood pressure exceeds 90 mmHg; 

 
- 18 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
• average hemoglobin A1C (regardless of whether diagnosed with 
diabetes); 
• percentage of individuals taking ten or more prescribed 
medications; 
• percentage of women receiving timely breast screening; 
• percentage of women receiving timely cervical cancer screening; 
• percentage of pregnant women who have the results of routine 
prenatal laboratory tests results as recommended in current national 
guidelines ( e.g., Guidelines for Prenatal Care, 8th Edition, 
American Academy of Pediatrics and American College of 
Obstetricians and Gynecologist, Table 6-2) documented within one 
month of diagnosis of pregnancy; 
• percentage of health care grievances which are appealed; 
• percentage of health care grievance appeal replies that are 
appropriate; 
• percentage of prisoners on antipsychotic medications receiving 
timely AIMS assessments; 
• percentage of prisoners on antipsychotic medications receiving 
appropriate and timely metabolic assessments; 
• percentage of prisoners receiving punishment for a rule violation, 
for whom a mental health intervention would have been more 
clinically appropriate than punishment; and 
• percentage of prisoners arriving at ADCRR for whom intake 
screening by an RN (or higher credentialed professional) is 
completed more than four hours after arrival. 
2.4.2. ADCRR shall monitor other parameters as reasonably dictated by the other 
Self Improvement activities described in this Order. 
2.5. Overall System Improvement 

 
- 19 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
2.5.1. Defendants shall evaluate errors, system problems, and possible system 
problems that come to their attention through sources, including but not limited 
to the near -miss and preventable adverse event reporting systems, mortality 
reviews, litigation filed by prison ers, grievances, the Court -appointed 
monitors, staff reports, continuous quality improvement, etc. Defendants shall 
address these errors and problems at a complex or statewide level, as 
appropriate. To prioritize analysis and remediation of errors and ot her system 
problems, Defendants shall maintain an active log of all such errors and 
problems to assist in deciding which issues to address and when, and to monitor 
progress in resolution. Based on this prioritization, either at the complex or 
state level, root cause analysis shall be conducted as appropriate, from which 
an effective and sustainable remedial plan is implemented in a timely manner. 
Such plan is one which outlives staff memory from a single training after the 
review or staff turnover. The r emedial plan shall be monitored for 
effectiveness. Appropriate and timely modifications shall be made to the plan 
based on the monitoring. 
3. Language Interpretation Services 
Within three months of issuance of this Order Defendants shall implement the 
following to ensure adequate interpretation services are available for every material 
encounter where needed. 
3.1. Defendants shall develop and implement policies to assess the English fluency of 
prisoners and, if not English -fluent, determine a language in whi ch the prisoner is 
fluent at the following times: 
3.1.1. during intake; 
3.1.2. upon request by a prisoner at any time; 
3.1.3. whenever staff have reason to believe a prisoner is not fluent in English; 
3.1.4. whenever a prisoner’s primary language of communication is not documented 
in the medical record. 

 
- 20 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
3.2. A prisoner’s language of choice shall be visible on all relevant screens of the 
prisoner’s EHR. 
3.3. For all individual and group health care encounters in all settings involving 
prisoners who are not fluent in English, interpretation shall be provided via: 
3.3.1. health care staff whose name appears on a list maintained by Defendants of 
people who, pursuant to written policies Defendants develop, is proficient in 
the language understood by the prisoner; or 
3.3.2. in-person or via video interpretation ser vice (for sign language) or audio 
language interpretation service that is compliant with federal law and uses 
licensed interpreters, where required by state law; or 
3.3.3. in an emergency and if the above is not feasible, by other available means, 
e.g., health care staff whose name is not on the above-cited list, non-health care 
staff, or other prisoners. 
3.4. The method of interpretation for all encounters (or, in the event interpretation 
consistent with this Order could not be provided) shall be documented in the EHR. 
3.5. The equipment used for interpretation shall allow for confidential communication 
in all circumstances ( e.g., dual hand - or head -set device in locations where a 
speaker phone or computer can be seen or overheard by other prisoners or custody 
staff). 
3.6. Written available notification (such as a poster) shall be hung in all housing units 
and medical clinics in all prisons advising prisoners, in the ten most common 
languages in Arizona, of the availability of interpretation services and that they may 
inform healthcare staff orally in any language, in sign language, or in writing in any 
language that they are not fluent in English, if that is not already documented in 
their EHR. 
4. Electronic Health Records (“EHR”) 
4.1. An EHR shall be used for prisoner medical and ment al health care. Defendants’ 
chosen healthcare vendor, Naphcare, currently uses TechCare. If Defendants 

 
- 21 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
discontinue use of TechCare, Defendants shall transition, without gap, to another 
EHR. 
4.2. In selecting an EHR, Defendants shall conduct a comprehensive needs assessment 
by seeking sufficient input from leaders, managers, and front -line users regarding 
essential functionality, and select an EHR that maximizes fulfillment of essential 
functions. The EHR shall include a computerized prescription order entry, 
electronic medication administration record, and electronic prisoner identification 
system ( e.g., ID card bar scan, biometric scan). The EHR shall include, at a 
minimum, all functionality of TechCare unless Defendants can justify why any 
non-included functionality is non -essential. Upon transition to another EHR, all 
existing data shall be transferred from the existing EHR to the next EHR retaining 
the same titles, metadata, and usability in the next EHR as it had in the existing 
EHR. 
4.3. The problem list in a prisoner’s health record shall be accurate, complete, and 
easily usable. “Easily usable” includes, but is not limited to the following qualities: 
4.3.1. Resolved or historical conditions or diagnoses are separated from current 
conditions. 
4.3.2. The date of onset or resolution of resolved or historical conditions or 
diagnoses is indicated, if known. 
4.3.3. Similar or identical diagnoses of current conditions are listed only once. For 
example, a problem list would not simultaneously list “heart disease,” “heart 
failure,” and “congestive heart failure, not otherwise specified.” 
4.4. Imported or scanned documents (including but not limited to diagnostic test results, 
consultation reports, hospital discharge summaries) in the EHR shall be filed in a 
clear and usable manner, including, but not limited to: 
4.4.1. Paper documents are scanned within two business days of receipt. 
4.4.2. Documents are reviewed by a practitioner within four business days of 
receipt. 

 
- 22 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
4.4.3. Documents are scanned right-side up. 
4.4.4. Documents are accurately labeled with meaningful titles/file names. Fewer 
than 1% of files are labeled/titled with names beginning with “Miscellaneous” 
or “Other.” 
4.4.5. Scanned documents are dated (and appear in any programmed or ad hoc list 
according to this date) based on the clinically relevant date of the document, 
not the date scanned. For example, the clinically relevant date of a: lab test is 
the date the test was reported by the lab; discharge summary is the date of 
discharge; a prior health record is the date it was received at ADCRR; an 
imaging study is the date of study. 
4.5. Defendants shall provide prisoners access to their own medical records as follows: 
4.5.1. Access to prisoners wishing to read a copy of their health record; 
4.5.2. Orally share with a prisoner information regarding their diagnosis o r any 
other information about their health care unless a practitioner documents in the 
prisoner’s EHR how disclosure of such information would jeopardize the 
health, safety, security, custody or rehabilitation of the prisoner or others or the 
safety of any officer, employee or other person at the correctional institution or 
of a person who is responsible for transporting the prisoner. 
4.5.3. Defendants may charge a reasonable per -page fee to non -indigent prisoners 
for paper copies, but no fee may be charged to indigent prisoners. A reasonable 
fee is one that has the same or lower ratio to the prevailing prisoner wage as 
the ratio of the prevailing fee in the Arizona medical community to the 
prevailing Arizona community wage. Alternatively, if the prisoner agrees , 
Defendants may provide the requested records, free of charge, in an electronic 
medium that the prisoner is able to access. 
5. Release Planning 
5.1. For prisoners with identified treatment providers in the community, if the prisoner 
consents, Defendants shall sen d each provider relevant health care information 

 
- 23 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
prior to the prisoner’s release. This includes, at a minimum, a problem list, list of 
active medications, current symptoms, functional impairments, a summary of 
relevant care provided during incarceration, any necessary care or follow -up care, 
one or more points of contact if a community provider requires further information, 
and, in addition, for mentally ill prisoners, name and contact information of the 
primary therapist, an aftercare plan that reflects progress in treatment, and a current 
treatment plan. The prisoner’s health record shall contain documentation of the 
above information that was provided, when, and to whom. 
Medical 
6. Staffing 
6.1. Within three months of this Order, Defendants shall maintain staff ing of 
practitioners in medical health according to the following minimums. These are 
based on the number of prisoners for whom the practitioner is listed in the health 
record as the prisoner’s primary care provider. “Physician” refers either to an M.D. 
or D.O. “ML” refers to mid-level practitioners with titles of nurse practitioner or 
physician assistant. 
 

 
- 24 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Setting 1.0 FTE 
Practitioner 
Max. Case 
Load Size 
Reduction of 
Case Load for 
Each ML 
Supervised 
Max. Number 
of MLs Under 
Supervision 
per MD/DO 
Outpatient, high 
intensity complex 
Physician 600 150 3 
Outpatient, high 
intensity complex 
ML 400 n/a n/a 
Outpatient, low 
intensity complex 
Physician 800 100 4 
Outpatient, low 
intensity complex 
ML 600 n/a n/a 
Outpatient, high 
intensity complex 
Facility Med. 
Dir. 
150 150 1 
Outpatient, low 
intensity complex 
Facility Med. 
Dir. 
200 100 1 
Inpatient Physician 50 n/a 0 
Inpatient Facility Med. 
Dir. 
10 n/a 0 
Special Needs 
Unit 
Physician 200 n/a 0 
Special Needs 
Unit 
Facility Med. 
Dir. 
40 n/a 0 
 
6.2. For purposes of this staffing formula, a “low intensity” complex is one where the 
average number of prescription medications, measured by the same method used 
by Defendants and shared with the Court-appointed monitors in November 2022, 

 
- 25 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
is no more than 1.75 active prescribed me dications on average per complex 
prisoner.8 All other complexes are “high intensity.” At present, the low intensity 
complexes are Douglas, Winslow, and Safford. That may change, however, based 
on population and prescription changes at each complex. 
6.3. The ratio for “Inpatient” is based on the assumption that no more than 5 of the 50 
prisoners are high acuity (“Level 1”) prisoners. When the number of Level 1 
prisoners exceeds 5, the maximum caseload is 25 Level 1 prisoners per 1.0 FTE 
physician. 
6.4. These assignments are mutually exclusive such that a facility medical director at a 
high intensity complex may directly care for 150 prisoners or supervise a single 
ML caring for 150 prisoners or directly care for 10 inpatient component (“ IPC”) 
prisoners. 
6.5. Prisoners are assigned to the ML caseload in a clinically appropriate manner, i.e., 
prisoners with multiple or complex medical conditions are only assigned to 
physician caseloads. 
6.6. All medical physicians–at hiring and during employment –shall be board certified 
in Internal Medicine or Family Practice, or board eligible if within 7 years of their 
completion of an ACGME approved residency in one of these 2 specialties, with 
the following exceptions: 
6.6.1. medical directors, shall be board certified at hiring and during employment; 
 
8 Eyman is a useful example to illustrate the impact of this staffing formula. At trial, Eyman 
had a prisoner population of 5,219 and had one staff physician , one medical director, and 
five MLs. (Doc. 4335 at 10, 182). Eyman qualifies as a “high intensity” facility, meaning 
this new staffing formula dictates a physician at Eyman will be allowed to carry a caseload 
of no more than 600 prisoners and a ML at Eyman will be allowed to carry a caseload of 
no more than 400. A physician’s maximum caseload must be decreased when supervising 
MLs. Moreover, this injunction dictates what types of prisoners may be on physician or 
ML caseloads. Therefore, the exact number of physicians and MLs that will be required 
will vary depending on the prisoner population and how Defendants choose to staff Eyman. 
But if permitted by the medical needs of Eyman’s population, Defendants might be able to 
use the maximum number of MLs and the minimum number of physicians . In that 
scenario, Eyman would be required to have approximately four physicians carrying 
caseloads totaling 600 prisoners and twelve MLs carrying caseloads totaling 4,800. (This 
example does not account for a medical director.) 

 
- 26 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
6.6.2. physicians providing obstetric and gynecologic services shall be board 
certified or board eligible if within seven years of their completion of an 
ACGME approved residency in obstetrics and gynecology; and 
6.6.3. physicians who are currently employed and are not board eligible may remain 
employed for no longer than one year after issuance of this Order. 
7. Model of Care 
7.1. A registered nurse ( “RN”) or higher credentialed professional shall conduct an 
intake screening within four hours of a prisoner’s arrival or, alternatively, a rapid 
screening shall be conducted immediately upon arrival, but the intake screening by 
an RN shall be conducted as soon as possible and before the prisoner proceeds to 
housing. If the rapid screening is conducted by a professional of lesser credential 
than an RN ( e.g., LPN, certified medical or nursing assistant), then the screening 
shall not include a clinical assessment, and any abnormal response found by the 
LPN or similar staff shall result in immediate consultation with an RN (or higher 
credentialed professional). 
7.2. A medical practitioner shall complete a history and physical examinatio n of each 
prisoner by the end of the second full day after a new prisoner arrives in 
Defendants’ custody. 
7.3. All prisoners shall be assigned a medical primary care practitioner. Assignment to 
physician or mid -level practitioner shall be based on the complexity of the 
prisoner’s health conditions. 
7.4. Non-Urgent/Non-Emergent Care 
7.4.1. Prisoners shall be given on a daily basis an opportunity to indicate their need 
to be seen for a medical clinic appointment at the next available clinic by one 
of the following mechanisms, depending on their living situation, freedom of 
movement, and access to electronics: 
• affixing their name to a time slot on a paper l ist maintained on the 
living unit or in the medical unit; 

 
- 27 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
• affixing their name to a time slot on an electronic list via tablet or 
kiosk; 
• informing the nurse who conducts daily (or more frequent) welfare 
checks on that unit; 
• an effective paper-based system developed by Defendants in the 
event of temporary non-functioning of the electronic system. 
7.4.2. Prisoners should only use th is system if they have a non -urgent need . 
Prisoners with urgent or emergent needs should notify a staff member. A 
reminder of these rules shall be communicated via the medium the prisoners 
use to make requests (e.g., a statement placed on the paper or electronic sign-
up list). 
7.4.3. Prisoners shall not be required to indicate the reason for the request to be seen. 
7.4.4. Defendants shall retain for the monitors to access all lists, paper or electronic, 
for their review. 
7.4.5. To allow for effective monitoring of healthcare staffing levels, any 
appointment made that does not occur shall not be erased but shall be notated 
as not completed. 
7.4.6. Defendants may continue to allow prisoners to submit HNRs for 
administrative requests that do not require a clinical encounter or clinical 
judgment, such as, but not limited to: a medication refill request; inquiring 
about the date of an appointment; a request for health records, etc. 
7.4.7. All non-urgent/non-emergent care at the request of a prisoner shall be 
completed in a reasonable time. In addition to other qualitative indicators, 
“reasonable time” means that on average, there shall be at least three unused 
appointment slots per week on each medical practitioner’s schedule who is 
expected to carry a full prisoner caseload for their job category; one unused 
appointment slot if the practitioner is scheduled for one day or less of prisoner 

 
- 28 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
visits; and two unused appointment slots if the practitioner is scheduled for 
more than one day but less than a full prisoner caseload. 
7.4.8. Except as noted in this paragraph, initial care shall be provided by a medical 
practitioner, or another health profe ssional as directed by a physician or ML, 
as clinically appropriate. The i nitial care provider shall be the prisoner’s 
primary care medical provider unless that provider is not on the premises nor 
conducting telehealth visits at the time. Pursuant to prisoner-specific direction 
provided by the medical practitioner, RN may provide initial care for a limited 
number of conditions that are simple, rarely serious, rarely confused with 
serious conditions, and appropriately treatable with self-care and/or over-the-
counter medications provided that the RN operates under clinically appropriate 
protocols approved by the monitors. This paragraph does not have any impact 
on the protocols LPNs or RNs use in the first few minutes of an emergency 
while waiting for contact with a practitioner or arrival of emergency services. 
Defendants shall track and report the number of initial care visits completed by 
RNs. 
7.5. Special Needs Unit (“SNU”) 
Within one year of this Order, Defendants shall: 
7.5.1. Determine the number of disabled, el derly, or developmentally disabled 
prisoners who require SNU housing (“SNU prisoners”), exclusive of those who 
have acute health care needs requiring placement in an IPC and exclusive of 
those whose assisted living needs are minimal enough to be met by the support 
normally provided to prisoners in general population, such as assistance with 
self-administration of medicines. To determine the number of SNU prisoners, 
Defendants shall be guided by the health/functional/physical needs criteria 
established by t he Arizona Health Care Cost Containment System 
(“AHCCCS”) for individuals to receive Elderly and Physically Disabled 

 
- 29 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
services as defined in Arizona Administrative Code R9 -28-304, including the 
Pre-Admission Screening Tool; 
7.5.2. Build (or modify existing) living units with at least the number of beds for the 
number of SNU prisoners at the appropriate custody levels. The per -prisoner 
floor space should be consistent with AHCCCS requirements for similar 
populations. 
7.5.3. Equip and staf f the units to meet the assisted living needs of the SNU 
prisoners; and 
7.5.4. Transfer all SNU prisoners to those beds. 
7.6. IPC Care 
7.6.1. A medical practitioner shall be contacted and collaborate on the creation of 
an immediate care plan immediately upon a prisoner being admitted to the IPC. 
7.6.2. An RN shall complete an admission nursing assessment immediately upon a 
prisoner being admitted to an IPC. 
7.6.3. A medical practitioner shall complete an admission history and physical 
within one calendar day of admission to the IPC for prisoners who are going to 
remain beyond 24 hours. 
7.6.4. An RN shall complete an assessment in the IPC at the frequency ordered. The 
spacing of the assessments are clinically appropriate. 
7.6.5. The call buttons of all prisoners admitted to an IPC level bed are determined 
to be working on the day of admission and once per month. If a call button is 
not working health care staff shall perform a welfare check at least once per 30 
minutes. 
7.7. Observation Beds 
Defendants shall discontinue the use of Observation Beds. Prisoners requiring 
monitoring or medical care beyond that normally available and safely used in non-medical 
living units shall be admitted to an IPC. 
8. Referrals 

 
- 30 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
As used in this section, “specialty referral” or “referral” includes any request for a 
consultation, intervention, test, provision of materials, or other service, that is performed 
or fulfilled by someone other than employees of ADCRR or than persons filling FTE 
positions described in the contract and amendments with Defendants’ health care 
contractor. Defendants shall comply with the following regarding specialty referrals: 
8.1. All specialty referrals shall be completed within the ordered timeframe, 
notwithstanding any time required for processing, reviewing, or consideration of 
alternative treatment plans. 
8.2. Unavailability of referral services shall not be a certain, acceptable defense for non-
performance, however it may be considered when evaluating Defendants’ 
performance. In other words, unavailability of referral services , such as not being 
able to find a specialist willing to see the prisoner, the specialist not having an open 
slot, or the specialist canceling the appointment, are situations over which 
Defendants might have had some control. Therefore, the onus remains on 
Defendants to complete the referral in the time period contemplated by the 
practitioner. In situations where Defendants prove they exhausted all reasonable 
measures, non-performance will be excused. 
8.3. The referral order shall be completed when the referr al or modified plan is 
completed or the referral is canceled. The referral shall be completed in the 
timeframe established in the practitioner’s order. If the timeframe is extended by 
the practitioner, the referral completion is timely as long as it is completed within 
the extended timeframe and the extension was ordered before the original 
timeframe expired. 
8.4. If Defendants or their medical care contractor utilize categorical referral 
timeframes, e.g., “emergency,” “urgent,” “routine,” for which i t applies default 
timeframes for completion of the referral, Defendants shall notify the Court of those 
categories and timeframes and shall notify the Court within fourteen days if any of 
those categories or default timeframes change. 

 
- 31 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
8.5. If a practitioner orders a referral to be completed in a specific timeframe (including 
any free text notation), that order supersedes any categorical classification of the 
referral. For example, if a practitioner orders a referral to be completed in ten days, 
and the referral request is classified as “routine” which normally indicates a longer 
period, the referral still shall be completed in ten days. 
8.6. The ordering practitioner’s order is the controlling order and is not merely a request 
for authorization. While suggestions or recommendations may be made by others, 
e.g., utilization management personnel, to modify the order, the order is only 
modifiable by the ordering practitioner, their direct clinical supervisor, or, in the 
ordering practitioner’s absence, another practiti oner covering for them. The 
practitioner writing, modifying, or cancelling the order has a patient -practitioner 
relationship with the prisoner and assumes clinical responsibility for the decision. 
8.7. If a practitioner orders, or informs a prisoner there will be an order, for an off-site 
test or referral, but circumstances change and the order is modified or rescinded, 
the prisoner shall be informed within one month of the change. 
9. Post-Referral Appointment, Post-Hospital Stay, Post-ER Management 
9.1. Defendants shall adopt and perform off-site orders from outside providers as soon 
as the records are available , unless a clinically appropriate basis exists to alter or 
forgo the off-site orders. 
9.2. Prisoners returning from a hospital stay or emergency room visit shall be evaluated 
by an RN or higher prior to returning to their living unit. A discharge summary, 
physician report, or documentation of this information received via phone shall be 
available for this evaluation. 
10. Medications 
10.1. Prescribed medications intended for directly observed therapy ( “DOT”) 
administration shall be administered as ordered or there shall be documentation of 
a valid reason for non-administration. Documentation shall include the identity of 
the administrator. 

 
- 32 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
10.2. For purposes of the preceding requirement, “as ordered” means: 
10.2.1. For medications ordered as weekly, every other day or certain days of the 
week, daily (“q.d.”), twice daily (“b.i.d.”), thrice daily (“t.i.d.”), four times 
daily (“q.i.d.”), or every 12 hours (q. 12 hrs”), within two hours of a specific 
time, set in policy, procedure, or orders, for administration. These set times 
shall be at reasonable times of the day. 
10.2.2. For medications ordered at an hourly frequency of every eight hours (“q. 8 
hrs.”) or more frequently, or intermediate acting insulin, within one hour of a 
specific time, set in policy, procedure, or orders, for administration. 
10.2.3. For regular insulin , within thirty minutes of serving a mea l, and for fast -
acting insulin within fifteen minutes of the serving of a meal. 
10.2.4. For all other medications, at the times of the day ordered. 
10.2.5. For a prisoner newly admitted to a facility ( e.g., transfer from another 
facility, return from a hospital stay, admission from a jail) and already on a 
medication in their previous venue, the first dose of a medication shall be 
delivered keep-on-person (“KOP”) or administered ( “DOT”) in time for their 
next regularly scheduled dose. 
10.2.6. For all other prisoners, the first dose of a newly ordered medication shall be 
delivered (“KOP”) or administered (“DOT”) within the timeframe ordered, or 
if no timeframe is specified, within twelve hours for antibiotics and pain 
medications, and within three days for all other medications. 
10.3. Unavailability of the prisoner (e.g., “no-show”) or unavailability of the 
medication (e.g., gap due to delayed refill or renewal) are not valid reasons for non-
administration. Refusal is a valid reason, but only if the refusal is expressed, face-
to-face between the prisoner and the health care staff, and if the medication refusal 
policy is followed. Defendants shall have a medication refusal policy containing 
the following elements: 

 
- 33 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
10.3.1. When a prisoner refuses a medication (or classes of medication), based on 
the specific medication or class and the number and pattern of refusals, the 
medication administrator shall be triggered to escalate the case to a higher 
authority and within a specified amount of time (which may differ by 
medication or class). Defendants should use clinical judgment in sett ing the 
refusal pattern for each medication or class and timeframe for escalation. The 
decision rules described above should be incorporated into the medication 
administration software of the EHR such that the EHR automatically alerts the 
medication admin istrator when action is needed and what action is needed, 
rather than relying on administrators’ memory. 
10.3.2. The higher authority referenced in the preceding paragraph shall be an RN 
or appropriately licensed practitioner who is then responsible for: determini ng 
the reason for the refusal and securing the prisoner’s adherence with the 
medication, or finding a clinically appropriate alternative treatment, or assuring 
that the prisoner is making an informed refusal, or assuring the execution of 
whatever clinically appropriate action is ordered by a prescriber. 
10.3.3. Signed refusals by the prisoner are not required. 
10.4. KOP Medication 
10.4.1. When prisoners request approved refills or renewals of a KOP medication, 
the medication shall be delivered to the prisoner before the medication runs out 
(based on the date of the previous fill) provided the prisoner attempted to 
submit the request within the required timeframe. A KOP medication shall be 
delivered either by providing the prisoner with the KOP supply or by staff 
administering the medication from stock, dose by dose, to bridge the gap until 
the KOP supply is delivered. Additional medication need not be delivered 
before the previous fill runs out if a clinically appropriate and documented 
determination was made by a prescriber that the medication should not be 
continued and the prisoner is so informed. 

 
- 34 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
10.5. Other Medication Provisions 
10.5.1. To decrease staff time spent on medication delivery, Defendants are 
encouraged, but not required, to modify their medication management practice 
by establishing a list of medications which are, by default, provided to 
prisoners as KOP. The list would be developed by health care staff in 
collaboration with custody staff to account for both medical and penological 
needs. Policy exceptions could be made for certain classifications or housing 
of prisoners, for example, prisoners in an inpatient medical or mental health 
unit, prisoners at high mental health level, etc. For all other prisoners, 
prescribers would be required to write a specific order and justification if they 
wanted a prisoner to receive a medication by DOT. Such orders would require 
renewal periodically. The policy could address the need for certain prisoners 
on DOT medications to learn how to manage and self -administer medications 
as they prepare for re-entry. 
10.5.2. To decrease staff time spent on medication delivery, Defendants are 
encouraged, but not required, to make some of the over -the-counter 
medications its practitioners prescribe available, free -of-charge and upon 
request, from living unit officers or health care staff in FDA-approved unit dose 
packaging. 
10.5.3. Prisoners released to the community shall receive a supply of medication 
sufficient to ensure either (a) the prisoner has medication available for a 
sufficient length of t ime to allow the prisoner to obtain and attend an 
appointment with a community practitioner qualified to order a new supply, or 
(b) to complete the course of therapy, whichever is shorter. 
10.5.4. Prisoners with asthma who are at significant risk of serious respiratory 
impairment if they do not use their rescue inhaler immediately, shall be 
provided a rescue inhaler KOP. Exceptions may be made for prisoners living 
in a unit with 24 -hour nursing and access to an emergency call button. 

 
- 35 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Exceptions may also be made for prisoners where Defendants can document a 
significant and serious penological need to prohibit a particular prisoner from 
having such an inhaler. This exception must be prisoner -specific and 
Defendants cannot apply a policy prohibiting KOP inhalers for all prisoners. 
Exceptions may be made for prisoners living in a unit with 24-hour nursing and 
access to an emergency call button. 
10.5.5. Prisoners with diabetes who are at significant risk of hypoglycemia shall be 
provided a source of glucose KOP. Exceptions may be made for prisoners 
living in a unit with 24-hour nursing and access to an emergency call button. 
10.5.6. Prisoners prescribed rapid-delivery nitroglycerin for cardiac disease shall be 
provided the me dication KOP. Exceptions may be made for prisoners living 
in a unit with 24-hour nursing and access to an emergency call button. 
11. Disease Specific Requirements 
11.1. Hepatitis C 
11.1.1. Prisoners shall receive treatment for hepatitis C infection ( “HCV”) 
according to the following requirements: 
11.1.1.1. All prisoners are screened (by blood test) for HCV within a month of 
arrival, and periodically, based on risk, in accordance with CDC 
recommendations. 
11.1.1.2. Defendants may wait up to six months after the date of first 
confirmation of the current infection (or a month after l earning such date 
if infection was established prior to admission to prison) to begin 
treatment to those with sustained infection who agree to treatment, 
regardless of degree of fibrosis. 
11.1.2. Exceptions to treatment may be made for those prisoners: 
11.1.2.1. with markedly reduced life expectancy who would not be expected to 
benefit from treatment, or 

 
- 36 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
11.1.2.2. prisoners who cannot complete treatment within the timeframe of their 
incarceration and linkage to care in the community for continuation of 
treatment cannot be established despite a good faith effort. 
11.1.3. Within two months of issuance of this Order, all current prisoners who have 
not been screened for HCV shall be offered screening, and all who screen 
positive and indicate willingness to be treated shall receive treatment within 
the time parameters set out within this Order. 
11.1.4. All prisoners with HCV infection shall be placed on a single list prioritized 
according to a scheme that considers degree of fibrosis, relevant comorbidities, 
likelihood of transmitting infection to others in the prison, and release date. 
11.1.5. Using the prioritized list, Defendants shall begin treatment each month of 
the following number of prisoners: 100 prisoners plus 90% of the number of 
newly admitted prisoners who tested positi ve for HCV during the previous 
month. For example, if 100 prisoners admitted during the month of January 
tested positive for HCV, Defendants shall begin HCV treatment of the next 190 
prisoners on the prioritized list, during the month of February. Defendants may 
calculate the number of newly admitted prisoners testing positive during 
January based on the date of admission or the date of the test results (because 
prisoners may not be tested during the month of arrival and test results may not 
be completed d uring the month of arrival). Once Defendants have chosen a 
method of calculation, they shall continue to use the same method. 
11.1.6. No later than one year after issuance of this Order, no prisoner who is 
released on their planned release date shall release without having been 
screened for HCV and if positive and they accept treatment, without having 
completed treatment. 
11.1.7. All prisoners with HCV shall be offered education about HCV, whether they 
receive treatment or not. 
11.1.8. All HCV screening is offered under opt-out conditions. 

 
- 37 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
11.1.9. All HCV treatment shall use the current standard of care medications. 
11.2. Tuberculosis 
Unless ADCRR, as a system, is determined by the monitors to be at minimal risk 
with regard to tuberculosis according to CDC guidelines, all newly admitted prisoners shall 
have a completed test for tuberculosis (skin test, blood test, or chest x -ray) by the end of 
the third full day after admission into the ADCRR system, unless the prisoner refuses. The 
men’s and women’s facilities may be considered separately in determining the CDC-based 
system risk level. 
11.3. Substance Abuse Disorder 
11.3.1. Prisoners shall be screened for, and if indicated then evaluated for, substance 
use disorder. 
11.3.2. Prisoners diagnosed with substance use disorder shall be offered and 
provided treatment, consistent with national standards of care. Prisoners with 
alcohol or opioid use disorder shall be offered and provided medication assisted 
treatment. For prisoners with opioid use disorder, they shall be offered, as 
clinically appropriate, buprenorphine, naltrexone, or methadone. P risoners 
admitted on treatment shall have the treatment continued without interruption. 
11.4. Immunization 
Prisoners shall be offered all immunizations recommended by a mainstream 
evidence-based national guideline. 
 

 
- 38 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Mental Health 
 Based on the credible trial testimony, the mental health treatment regime 
Defendants employ is profoundly lacking and results in grossly insufficient care , creating 
an unconstitutional substantial risk of serious harm. Similar to the medical care 
requirements, the central aspect of relief regarding mental health care will be a mandate 
that Defendants increase staffing. To ensure adequate staffing, and to allow for monitoring, 
Defendants shall adopt a caseload-based staffing formula. The staffing formula and other 
requirements are based on Defendants’ mental health scoring system already in place . 
(Doc. 4335 at 15 n.1). Any changes to that scoring system will necessitate changes to the 
staffing formula. Defendants shall inform the monitors immediately upon any changes to 
the scoring system. 
12. Mental Health Staffing 
12.1. Within three months of this Order, Defendants shall maintain staffing of mental 
health professionals according to the following limits. These are based on the 
number of prisoners for whom the mental health professional is listed in the EHR 
as the prisoner’s primary care provider. “PP” refers to psychiatric practitioner 
while “PT” refers to primary therapist (i.e., psych associate or psychologist): 
 

 
- 39 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Setting 
1.0 FTE 
Professional Max. Caseload Size 
Outpatient (MH-3) PT 100 
Residential (MH-4) PT 30 
Inpatient (MH-5) PT 10 
Crisis Stabilization/Suicide 
Watch PT 
10 (Unless PTs 
follow their 
prisoners when 
admitted to a crisis 
stabilization bed, in 
which case there is 
no change to 
caseloads) 
Outpatient, prisoners on 
psychotropic medications PP 200 
Residential, prisoners on 
psychotropic medications PP 50 
Inpatient, prisoners on 
psychotropic medications PP 25 
12.1.1. Outpatient psychologist shall supervise no more than five psych associates. 
12.1.2. Inpatient psychologist shall supervise no more than four psych associates. 
12.2. A MH Duty Officer shall be available at all times when facility mental health staff 
are not available. The MH Duty Officer shall be a licensed psych associate, 
psychologist, or psychiatric practitioner. 
13. Staffing Qualifications 
13.1. All psychiatrists –at hiring and during employment –shall be board certified in 
psychiatry, or board eligible if within 7 years of their completion of an ACGME 
approved residency in psychiatry, with the following exceptions: 1) supervising 
psychiatrists shall be board certified at hiring and during employment; 2) 
psychiatrists who are currently employed and are not board eligible may remain 
employed for no longer than one year of issuance of this Order. 
13.2. All psychologists and psychiatric practitioners shall have the appropriate state 
licenses. All psych associates shall be licensed or become licensed within one year 
of hiring or within one year of this Order, whichever is later. 

 
- 40 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
14. Model of Care 
14.1. Each prisoner on the mental health caseload, i.e., all prisoners in MH Levels 3, 4, 
and 5, shall be assigned a PT who serves as the single point of contact and 
coordination for providing care for that prisoner. PTs shall be psych associates or 
psychologists. When a prisoner’s assigned PT is unavailable, another psych 
associate or psychologist acts on their behalf. Except as noted elsewhere, generally 
a new PT shall be assigned when a prisoner’s living unit changes and the current 
PT does not cover that unit, e.g., when the prisoner’s yard or MH Level of Care 
changes. 
14.2. A psychologist shall review the records of each prisoner who is added to, or 
discharged from, the mental health caseload . The psychologist shall provide 
appropriate documentation of this review in the prisoner’s health record. 
14.3. Prisoners on the mental health caseload who believe they need mental health care 
shall submit HNRs. The primary therapist or, if necessary, another psych associate 
shall triage HNRs within 24 hours of receipt. “Triage” means determining whether 
the request requires immediate attention and resolution or whether the request can 
safely be deferred until the primary therapist can address it. Documenting the word 
“Triaged” is adequate evidence of triage. Primary therapists shall address the HNR 
within three business days of its submission . “Address” means evaluating the 
request, determining the clinical need, and if an action is required ( e.g., face-to-
face visit), planning that action to occur in a clinically appropriate timefr ame. 
When the primary therapist is absent, another psych associate or a psychologist 
completes these tasks in their stead within the same time. 
14.4. If a prisoner’s PT determines a visit is clinically appropriate, the prisoner shall be 
seen by the PT or referred to another professional as directed by the PT. 
14.5. Prisoners who are not yet on the mental health caseload but request mental health 
treatment shall submit requests to be seen through the procedures for seeking 
medical care. 

 
- 41 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
14.6. Defendants shall modify their policies to create a formal process for custody staff, 
families, or any other concerned party to refer a prisoner for mental health 
assessment and for timely response to the concern by mental health staff. 
14.7. Defendants are encouraged, but not required , to allow MH -3C and MH -3E 
prisoners who would otherwise meet the custody classification requirements, to be 
housed at the Douglas, Winslow, and Safford Complexes. Telehealth may be used. 
14.8. Defendants shall ensure the formulary for psychotropic medications is no broader 
than the formulary used by AHCCCS. For prisoners admitted to ADCRR on a 
psychotropic which is not on ADCRR’s formulary: 
14.8.1. The medication shall be continued if, based on the prisoner’s history, there 
is significant risk of worsening of the con dition if a different medication is 
prescribed. 
14.8.2. If no such risk exists, the medication shall be continued long enough to allow 
a safe transition to a different medication or medications. 
14.9. Defendants shall ensure there is sufficient physical space to meet th e treatment 
requirements of the mental health care system. This includes, but is not limited to, 
areas for mentally ill prisoners to be housed, engage in programming, and receive 
treatment (both individual and group) in a confidential environment commensurate 
with that unit/facility’s designated level of care. 
15. Content of Care 
15.1. Defendants shall ensure a psych associate or psychologist conducts a mental 
health assessment of each prisoner within one business day of that prisoner first 
entering the ADCRR system. This assessment shall occur in a confidential 
therapeutically appropriate setting unless there is a clinical or legitimate and 
substantial safety and security concern that is documented. 
15.2. The assessment shall identify and document sufficient relevant information 
regarding the presence and severity of mental health symptoms; current impact on 
functioning; past hospitalization/treatment including response to treatment; 

 
- 42 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
medications; suicide risk; behavioral observations of staff; and a preliminary 
designation of level of care. 
15.3. Outpatient 
15.3.1. Prisoners at an outpatient level of care (i.e., MH-3) shall have the following 
evaluations by their assigned PT: 
15.3.1.1. an initial comprehensive mental health evaluation within one month of 
arriving at the assigned facility if not already completed when the prisoner 
first entered the prison system; 
15.3.1.2. whenever clinically indicated to reflect a change in service delivery; 
15.3.1.3. at least once per year. 
15.3.2. A psychiatric practitioner shall conduct an appropriate clinical encounter 
with all prisoners in an outpatient level of care ( i.e., MH-3) on psychotropic 
medications as often as clinically required, but no less often than every three 
months. 
15.3.3. A treatment plan meeting shall be conducted with the prisoner and their PT. 
A psychologist or psychiatric practitioner shall also be present for complex 
cases. At that meeting, the prisoner’s treatment plan shall be reviewed and 
updated to determine adherence to treatment, efficacy of interventions, 
evaluation of the level of care need s, diagnostic impressions, progress t o date 
in treatment, and steps taken toward moving to a less restrictive environment, 
if applicable. The timing of the treatment plan meetings should be based on 
the needs identified in the treatment plan, but no less often than once a year. 
The treatment plan shall include a date for next review based on the content of 
the plan. If no timeline is identified, a treatment plan meeting shall occur at 
least once per year. 
15.4. Residential 
15.4.1. All prisoners in residential level of care (i.e., MH-4) shall have the following 
evaluations by their primary therapist: 

 
- 43 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
15.4.1.1. whenever there is a significant change in the course of treatment, e.g., 
new type of treatment including medication, significant decompensation; 
15.4.1.2. at least annually, documenting the prisoner’s need for residential level 
of care. 
15.4.2. Prisoners in residential level of care shall have face-to-face encounters 
with their assigned PTs as determined by the treatment plan. 
15.4.3. Prisoners in residential level of care shall have their treatment plans 
reviewed and updated as clinically indicated but no less often than every three 
months when the full team meeting described in the next section is conducted 
15.4.4. A full team meeting shall be conducted at least every three months to 
include: primary therapist, psychologist, psychiatric practitioner, and any 
other staff as necessary. Prisoners shall be included in the meeting unless 
there is a clinical or legitimate and substantial safety and security concern 
documented in the custody record. That meeting shall include: determination 
of adherence to treatment, efficacy of interventions, evaluation of their level 
of care needs, rationale for the need for residential care, diagnostic 
impressions, progress to date in treatment, and steps taken toward moving to 
a less restrictive environment. 
15.4.5. Prisoners in residential level of care shall have an appropriate clinical 
encounter with a psychiatric practitioner as often as indicated, but no less 
than every fourteen days. 
15.5. Inpatient 
15.5.1. All prisoners in inpatient level of care (i.e., MH-5) shall have the following 
evaluations conducted by their PT if already on the mental health caseload 
(otherwise by the mental health provider assigned to the inpatient unit): 
15.5.1.1. at least annually a comprehensive mental health evaluation reflecting 
rationale for inpatient placement including but not limited to current 
symptoms and functional impairment, timing and pattern of 

 
- 44 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
decompensation, interventions attempted, diagnostic impressions 
(including potential substance-related impacts), progress in treatment to 
date, goals for treatment in the inpatient setting, anticipated length of 
stay, and criteria for discharge; 
15.5.1.2. upon discharge from inpatient care, a discharge summary. 
15.5.2. Prisoners in inpatient level of care shall have a daily face-to-face encounter 
with their PT unless such an encounter would be clinically contraindicated. 
15.5.3. Prisoners in inpatient level of care shall have their treatment progress 
reviewed daily, and teams shall meet at least weekly with all providers (e.g., 
nursing, psychiatry, mental health, social work, custody/unit staff, behavioral 
health technicians) and providers from the prisoner’s previously assigned unit 
whenever possible. Prisoners shall be included in the meeting unless there is 
a clinical or legitimate and substantial safety and security concern 
documented. At a minimum, the focus of treatment teams shall be to provide 
updates on prisoner progress, the type and efficacy of interventions used, 
treatment adherence, potential obstacles to recovery, and rationale for 
continued placement in the inpatient unit. 
15.5.4. A psychiatric practitioner shall conduct a clinical encounter with all 
prisoners in an inpatient level of care (i.e., MH5) as often as indicated, but no 
less often than once per week. 
15.6. Mental health care shall continue without interruption despite non-clinical events 
or conditions. If a prisoner’s treatment team changes due to a change in the 
prisoner’s mental health level of care: 
15.6.1. The “original” PT shall provide the “new” mental health team with the 
rationale for the change in mental health level and the anticipated treatment 
needs; 
15.6.2. If the transition is to anything other than to residential or inpatient, the 
“new” PT meets with the prisoner within seven calendar days; 

 
- 45 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
15.6.3. If the transition is to residential or inpatient level of care: 
15.6.3.1. the PT meets with the prisoner as soon as possible, but no more than 
one business day after arrival; 
15.6.3.2. the psychiatric practitioner is contacted and collaborates on the 
immediate care plan as soon as a prisoner is admitted. 
15.6.4. If a prisoner’s PT changes without a change in mental health level of care: 
15.6.4.1. If the transition is to anything other than to residential or inpatient, 
the “new” PT meets with the prisoner within seven calendar days; 
15.6.4.2. If the transition is to residential or inpatient level of care, the “new” 
PT meets with the prisoner within one business day. 
15.7. All mental health encounters with all prisoners shall o ccur in a confidential , 
therapeutically appropriate setting unless there is a clinical or legitimate and 
substantial safety and security concern that is documented. 
15.8. Suicide Prevention 
15.8.1. During normal business hours a prisoner who presents as a suicide risk shall 
have a formal in-person suicide risk assessment completed by a licensed psych 
associate, psychologist, or psychiatric practitioner to determine the acute 
suicidal risk and the level of protection that is nee ded (e.g., return to current 
housing, placement in one -on-one observation, etc.). If an in -person 
assessment is not feasible or if the concerns are raised after normal business 
hours or on holidays, the on-duty mental health officer shall be consulted 
regarding the disposition of the prisoner (which may or may not include 
constant observation). If the prisoner is placed on suicide watch as a result of 
the concerns raised, they should be placed under constant observation until they 
are able to have an in -person assessment of suicide risk by a mental health 
professional. 
15.8.2. Defendants are encouraged, but not required, to engage appropriately trained 
and supervised Behavioral Health Technicians to substitute for correctional 

 
- 46 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
officers as the individuals responsible for providing safety observation of, and 
engagement with, an individual (or cohort of individuals) on suicide watch 
depending on staffing needs of a particular location. 
15.8.3. Upon recommendation from a psychologist or psychiatric practitioner that 
housing a prisoner on suicide watch in the same room with other suicide watch 
prisoners (“cohorting”) would be clinically safer than housing each prisoner in 
isolation, Defendants shall cohort such prisoners, provided that based on the 
prisoners’ custody classification (determined based on factors other than the 
fact that the individual is on suicide watch) such cohorting would not be 
contraindicated. 
15.9. Crisis Stabilization 
15.9.1. Crisis stabilization beds shall be used f or short term (typically only a few 
days) management of prisoners who require acute care, e.g., suicide watch. 
15.9.2. Continued treatment in a c risis stabilization bed requires review and 
approval by a psychologist initially at seven days and every three days 
thereafter. 
15.9.3. Prisoners in a crisis stabilization bed shall be evaluated at least daily by their 
PT (or another psych associate if they have not yet been assigned a PT or have 
transferred from another yard). Treatment providers shall document their 
intervention efforts, including but not limited to: assessing mental status; 
behavioral observations; documenting prisoner ability to independently care 
for activities of daily living; type(s) of treatment provided; response to 
interventions (including medication efficacy and compliance); anticipated 
length of stay; and criteria for discharge. 
15.9.4. For prisoners placed in a crisis stabilization bed for suicidal concerns: 
15.9.4.1. A suicide risk assessment shall be completed upon admission that 
identifies risk and protective factors and items/privileges they are allowed 
(based on treatment needs) while in crisis care. 

 
- 47 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
15.9.4.2. The prisoner shall be assessed by a psychiatric practitioner as soon 
after admission as possible but no longer than one business day, in order 
to ensure there is not a medication issue or a question of medication 
appropriateness that contributed to suicidal ideation. 
15.9.5. A clinical note shall be entered whenever the level of suicide watch is 
changed. 
15.9.6. Prior to being released from a crisis stabilization bed if placed there due to 
suicidal concerns, a discharge suicide risk assessment shall be completed which 
documents: the change/reduction in suicidal risk; the prisoner’s identified 
protective factors; and plans for follow-up treatment, and aftercare including a 
safety plan developed in collaboration between the prisoner and treatment 
providers. 
15.9.7. “Safety contracts” (forms signed by prisoners, agreeing not to hurt 
themselves) shall not be used. 
15.9.8. Transferring a prisoner in crisis to a differ ent yard or complex can be 
clinically disruptive . W hen possible and safe, Defendants shall attempt to 
provide stabilization at the complex at which the prisoner has been housed 
unless there is documented clinical justification for transfer based on the lo w 
likelihood of stabilization and/or clinical danger if the prisoner is maintained 
at the complex. 
15.10. Restraints used by mental health clinicians for clinical purposes shall comply 
with the following: 
15.10.1. Restraints shall be used only to prevent harm to oneself or to others and to 
ensure the safety and security of the staff and other prisoners. They shall not 
be used for punishment. 
15.10.2. Restraints shall be ordered and reviewed only by a psychiatric practitioner 
or psychologist. 

 
- 48 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
15.10.3. Restraints shall only be applied for the minimum amount of time necessary 
to accomplish the stated need ( e.g., prisoner and staff safety, requisite 
transports, etc.). 
15.10.4. Soft restraints shall be used whenever possible. 
15.10.5. Subject to the following section, restraints shall not be used for more than 
four hours at a time. Every effort shall be made to minimize the length of time 
in restraints. 
15.10.6. Renewal of restraints beyond four hours shall be approved by the Facility 
Medical Director/designee. If the Medical Director/designee are not available, 
a licensed mental health provider may approve continued use. The justification 
for continued use shall be documented in the prisoner’s medical records . 
Renewals occurring after hours shall be done in collaboration with the Facility 
Medical Director/designee, a psychiatric practitioner, or a psychologist. 
15.10.7. Prisoners shall be restrained only in settings that allow nurses sufficient 
access to perform wellness checks and provide necessary medical care. Nurses 
shall ensure that the restraints do not impair any essential health needs, such as 
breathing or circulation to the extremities. These checks shall be documented 
in the prisoner’s medical records. 
15.10.8. Prisoners in restraints shall be under direct observation at all times. If an 
observer notes any ill effects of the restraints, every effort shall be made to 
remedy the ill effects and a psychiatric or medical practitioner shall be notified 
immediately. 
16. Training 
16.1. The Court recommends , bu t does not require, Defendants provide additional 
training for all custody staff regarding mental illness and suicide prevention and 
response. 
16.2. Additional training would be conducted in-person at orientation/CORE training, 
annual in-service, and whenever clinically indicated at any given facility. 

 
- 49 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
16.2.1. Topics would include, but not limited to: signs and symptoms of mental 
illness and decompensation patterns ; w orking with mentally ill prisoners; 
suicide risk detection, prevention, and response ; i ndividualized Behavior 
Management Plans ; d e-escalation techniques ; a dditional training for staff 
assigned to living units that house sub -class members, those in isolation, and 
those in Crisis Stabilization/Suicide Watch regarding therapeutic intervention 
strategies specifically suited to this population. 
17. Release to Community 
17.1. Defendants shall comply with the following regarding a ny prisoner designated 
serious mental illness (“SMI”), MH-4, or MH-5 who shall be released and who is 
presumptively eligible for federal or state assistance by virtue of their mental 
illness: 
17.1.1. Defendants shall develop and document an aftercare plan that reflects th e 
prisoner’s c urrent symptoms and functional impairments, progress in 
treatment, and treatment plan; 
17.1.2. Defendants shall facilitate evaluation for SMI designation and placement in 
the community, as clinically indicated; and 
17.1.3. Defendants shall arrange follow -up care with an appropriate community 
provider where possible. 
18. Involuntary Medication 
18.1. Defendants are encouraged, but not r equired, to modify their policy to include 
grave disability as an indication for involuntary antipsychotic medications. 

 
- 50 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
Relief for Subclass 
The subclass consists of “[a]ll prisoners who are now, or will in the future be, 
subjected by the ADC to isolation, defined as confinement in a cell for 22 hours or more 
each day.” (Doc. 4335 at 123). This definition is broader than those prisoners housed at 
particular complexes or those prisoners with particular classif ications (e.g., maximum 
custody). The evidence at trial, however, established the members of the subclass were 
those prisoners: 
(a) Formally classified as “maximum custody” pursuant to DO 801; 
(b) Housed in a detention unit pursuant to DO 804; 
(c) Placed on mental health watch pursuant to DO 807; and 
(d) Placed in close management status pursuant to DO 813. 
(Doc. 4335 at 136). It is possible prisoners outside of these four classifications will become 
subclass members. For example, if Defendants restricted minimum custody prisoners to 
their cells for more than 22 hours each day , such prisoners would then become members 
of the subclass. However, there was no evidence at trial of this actually occurring. For 
purposes of the injunction, the subclass will be construed as encompass ing the four 
classifications outlined above as well as those possible additions referenced in Section 
27.1. 
As with the medical care and mental health care, the unconstitutional conditions 
imposed on the subclass can be attributed in large part to the lack of adequate staffing. The 
Court found the staffing levels at two locations housing subclass members were “far below 
what prison officials acknowledge as necessary to operate the units safely.” (Doc. 4335 at 
148). The lack of adequate staffing resulted in D efendants perform ing fewer welfare 
checks on subclass members and the checks actually performed were perfunctory. (Doc. 
4335 at 147-48). The lack of adequate staffing also meant offers for out-of-cell time were 
“not made, [were] not legitimate, or [were] accompanied by unreasonable consequences.” 
(Doc. 4335 at 156). 
Connected to the lack of staffing, the Court found Defendants’ recordkeeping 

 
- 51 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
practices were haphazard and often unreliable . The Court found D efendants knowingly 
created documents in a false or misleading manner. (Doc. 4335 at 152). Th e Court also 
found Defendants “pre-filled” forms for entire weeks, meaning there was no evidence of 
“what truly happened.” (Doc. 4335 at 157) . Even when documentation was generated 
indicating unconstitutional treatment, there was no evidence Defendants took corrective 
action. 
Finally, t he Court found Defendants’ initial classification decisions are not 
supported by legitimate penological interests. In addition, Defendants place or keep 
prisoners in conditions rendering them subclass members even when Defendants agree 
those prisoners should be housed elsewhere. For example, two Deputy Wardens admitted 
there were prisoners being held in maximum custody who should have been housed in less-
restrictive environments. (Doc. 4335 at 142-43). While Defendants have a policy allowing 
prisoners to “earn their way” into placement in less-restrictive environments, that policy is 
administered “in a random and chaotic way.” (Doc. 4335 at 162). Thus, Defendants’ 
administration of their policies for placing, keeping, and removing prisoners from the most 
restrictive environments were not supported by legitimate penological purposes. 
The unconstitutional treatment of the subclass can be directly attributed to 
inadequate staffing, unreliable or nonexistent records, Defendants’ failure to review their 
records indicating there were problems , Defendants’ classification policies, and 
Defendants’ failure to implement their own policies. These basic findings support the 
expert’s recommendations for the following requirements. 
19. Basic Requirement 
 Defendants shall ensure all custody decisions and reviews made by custody officers, 
supervisors, and committees are reasonable and consistent with legitimate penological 
interests. Defendants shall implement a system to facilitate the return to lower levels of 
custody for those prisoners who have been housed in maximum custody or close 
management for longer than two months.9 
 
9 The expert recommended the Court prohibit Defendants from transferring subclass 
members to private prisons. This prohibition would prevent Defendants from avoiding the 

 
- 52 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
20. Staffing 
20.1. To determine the minimum number of staff to safely operate the locations where 
subclass members are held, including sufficient staff to allow for out -of-cell time, 
the Court will appoint an expert to be named to conduct a staffing plan of custody 
positions at each location. That expert’s services shall be paid by Defendants. The 
staffing plan shall be filed with the Court within three months from the date of this 
Order. The plan shall designate each post as Mandatory, Essential, or Important. 
The plan shall contain recommendations that shall be reviewed and, if approved, 
ordered by the Court. Any objections to the staffing plan and recommendations 
shall be filed within ten days and a response to the objections shall be filed within 
ten days thereafter. 
20.2. Upon receiving the staffing plan from the expert, the Court anticipate s ordering 
Defendants to comply with the following. Defendants shall take all necessary steps 
to ensure performance of the following once the staffing analysis has been 
completed. 
20.2.1. Defendants shall staff all Mandatory Posts at all times; Essential Posts shall 
always be staffed at least 75%; Important Posts shall always be staffed at least 
50%. If ADCRR falls below the se levels, it shall immediately inform the 
Court. The failure to maintain the required staffing levels will not be an 
acceptable excuse for any other failure to meet requirements in this Order. 
20.2.2. Defendants shall document on an annual basis an assessment of the 
operative staffing plan and document any requests for necessary adjustments 
to the plan. The assessment shall be provided to the Court on the last business 
day of January each year. 
 
requirements of this Order by transferring subclass members to locations where they might 
still be subject to unconstitutional conditions of confinement. At present, the Court does 
not have the authority to prohibit such prison transfers. However, at some point, the private 
prisons may be considered under the control of Defendants such that Defendants could be 
required to ensure prisoners who are transferred are held in conditions that do not violate 
this Order. 

 
- 53 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
20.2.3. Whenever Defendants fail to comply with the staffing levels, Defendants 
shall file with the Court a “Deviation from Staffing Plan Report” by the tenth 
day of the following month . That report shall specifically identify the 
deviation(s) that occurred and provide acceptable justifications for the 
deviation(s). 
20.3. While awaiting the expert’s staffing plan, Defendants shall begin compiling data 
such that they can submit the following information: 
20.3.1. Beginning on March 31, 2023, and continuing every quarter thereafter (i.e., 
June 30, September 30, and December 31), Defendants shall file with the Court 
a “Correctional Staffing Report.” Each quarterly report shall include: 
• the number of correctional staff assigned to each facility; 
• the number of correctional staff still employed by each facility 
at the end of the quarter; 
• the turnover rate, that i s, the number of voluntary and 
involuntary terminations during the quarter divided by the 
total number of correctional staff assigned at the end of the 
quarter, including each figure in the calculation in addition to 
the ultimate result; 
• the retention rate, that is, the total number of correctional staff 
at a facility who have worked for that facility for twelve 
months or longer divided by the total number of correctional 
staff assigned at the end of the quarter, including each figure 
in the calculation in addition to the ultimate result; 
• the total number of overtime hours for correctional staff at 
each facility for the quarter; and the vacancy rate (number of 
vacant positions at the end of the quarter divided by the total 
number of correctional staff and vacant positions at the end of 
the quarter). 

 
- 54 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
20.4. Increased salaries may be necessary for Defendants to reach adequate staffing 
levels. The Court will not order increased salaries at this time. Defendants are 
warned that if they remain unable to recruit and retain sufficient staff, the Court 
may later mandate salary increases. 
20.5. In the future, the Court may require custody staff be afforded at least 8 hours of 
rest between shifts and that staff who are required to commute more than 130 miles 
shall not be subjected to additional work assignments that occur before or after their 
normal working hours. These limits may be imposed if Defendants are deemed 
overly reliant on overtime to perform critical duties. Reliance on overtime can be 
a temporary solution but ultimately it creates a significant risk of staffing shortages 
should individuals discontinue volunteering for overtime. 
21. Recordkeeping10 
21.1. Defendants shall install and fully implement an electronic offender management 
record keeping Web -based software application (“EOMS”) that is accessible via 
standard Web browsers. Within six months of this Order, this system shall be 
installed at all areas housing subclass members. 
21.2. The EOMS chosen by Defendants shall have the following capabilities. 
21.2.1. Ability to automate key operational workflows, tasks, and reporting 
requirements such as: tracking prisoner movement out of cell , via passive, 
high-frequency RFID Cards, and mobile devices and/or fixed RFID readers; 
logging cell checks and security checks via fixed RFID Tags; store photographs 
and video with audio, automating prisoner activity logging, and automating 
whether prisoner services such as meal delivery, recreation, medications, 
supplies, laundry and bedding , have been completed or refused, as wel l as 
functionality Defendants believe will help validate their actions; 
 
10 Normally, requiring data collection in whatever form Defendants deemed appropriate 
would be the less intrusive way of tracking compliance. However, Defendants’ 
documented inability to generate reliable and accurate paper records requires the Court 
mandate installation of an electronic recordkeeping system that ensures against 
falsification of records. 

 
- 55 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
21.2.2. Ensure that all electronic log entries as well as other electronically captured 
data cannot be edited, deleted, or altered in any way; 
21.2.3. Support a real -time or near real -time interface w ith ADCRR’s electronic 
prisoner management system to share prisoner demographics information and 
housing assignments; 
21.2.4. Use portable devices that support Wi -Fi and an embedded high -resolution 
camera capable of taking photographs and recording videos; 
21.2.5. Use RFI D tags that are high -frequency and capable of near -field 
communication. RFID tags shall contain a unique identification number that 
cannot be duplicated or altered, support secure mounting, be enclosed in a 
tamper-proof, shatter-proof unit, and have the ab ility to identify prisoners by 
name when scanned; 
21.2.6. Support digital incident codes that can be customized by system 
administrators and used by end users to collect observations of prisoners and 
other activities; 
21.2.7. Enable users to create a unique PIN to authenticate login privileges or login 
via RFID fob or ID card; 
21.2.8. Support Web browsers, such as Chrome, Firefox, or I.E. that is password 
protected; 
21.2.9. Support prisoner level documentation where log entries positively identify 
prisoners by name and housing assignment; 
21.2.10. Generate prisoner level reports that identify prisoners by name and 
identification number; 
21.2.11. Support the ability to log meals, movements, recreation, refusals, 
headcounts, medications, supply passes, security checks, etc. by prisoner name, 
officer ID, and time/date; 
21.2.12. Automatically distinguish (visually) between log entries created by RFID 
scan versus those manually recorded without an RFID scan or “read”; 

 
- 56 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
21.2.13. Include a real -time module that tracks system usage to display the date, 
time, and location of completed activities; and 
21.2.14. Support electronic signature captures. 
21.3. To ensure accurate monitoring, the EOMS chosen by Defendants shall support 
the following reporting capabilities: 
21.3.1. Export data into multiple file formats, such as PDF, Excel, HTML, and XML 
to be printed and/or saved to a local area network; 
21.3.2. Retain data in accordance with required state record -retention laws and 
rules; 
21.3.3. Automatically generate and send reports via email to select recipients; and 
21.3.4. Filter reports by date, time, housing unit, prisoner name, booking number, 
and officer ID. 
21.3.5. Produce the following: 
• Prisoner Activity Report 
• Housing Activity Report 
• Round Compliance Report 
• Meals Report 
• Recreation Report 
• Movement Report 
• Population Report 
• Use of Confinement Report 
• Maintenance and Equipment Report 
22. Access to Staff 
22.1. Defendants shall not house any subclass member in a housing location where a 
subclass member lacks the ability to effectively contact a staff member 
immediately, either via in-person or via a call button/intercom system. 
22.2. The installation of call buttons or an intercom system in every cell housing a 
subclass member is ideal but would require significant expenditures that, at present, 

 
- 57 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
does not appear merited. The Court recommends but will not require, installation 
of such a system. 
23. Building Conditions 
23.1. Within three months of this Order, all showers used by subclass members found 
in disrepair (rusted, leaking, broken pipes, etc.) shall be repaired and , if needed, 
resurfaced, professionally painted after appropriate preparation, and/or new shower 
pans installed.11 
23.2. Defendants shall maintain all showers used by subclass members in good 
operational state. Showers shall be sanitized daily or more often if needed and shall 
be free of filth and mold/mildew. Showers shall be resurfaced and/or painted on 
an as-needed basis and all new paint should be mixed with a mildewcide additive 
to reduce the presence and growth of mold and mildew. 
23.3. Recreation areas used by subclass members shall be cleaned at least daily and 
kept free of filth, rodents, and insects. A log entry shall be made in the EOMS 
application for each housing unit at the time a recreation area is cleaned. 
23.4. Defendants shall, within three months of this Order, take the following actions 
regarding cells or areas used by subclass members: 
23.4.1. repair or replace essential equipment or structures in cells found in disrepair 
(rusted, leaking or broken pipes, sinks and toilets, etc.); 
23.4.2. cells found in need of painting shall, after appropriate preparation , be 
professionally painted. New paint should be mixed with a mildewcide additive 
to reduce the presence and growth of mold and mildew. 
23.5. Defendants shall, at all times after three months of this Order, ensure the 
following regarding cells or other areas used by subclass members: 
23.5.1. maintain all cells in a serviceable, good operational state, ensuring the cells 
are kept free of filth, mold, mildew, rust, vermin, and insects. 
 
11 Obviously, as a matter of common decency, i t should not require a formal injunction to 
prompt Defendants to repair leaking pipes, repair inoperative toilets, or collect trash. 
However, Defendants’ behavior throughout this litigation showed they cannot be relied 
upon to perform such basic tasks. 

 
- 58 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
23.5.2. professionally re-paint cells after appropriate preparation as needed. New 
paint should be mixed with a mildewcide additive to reduce the presence and 
growth of mold and mildew. 
23.5.3. All areas used in conjunction with subclass members to include, but not 
limited to dayrooms, showers, recreation areas, classrooms, etc., shall be kept 
in a clean and sanitary condition, free from any accumulation of dirt, filth, 
rubbish, garbage, rodents, vermin or other matter detrimental to health 
(mold/mildew). 
23.5.4. Housing unit staff shall daily ensure the removal of trash and garbage from 
all areas. Each unit’s housekeeping program shall include a daily general 
sanitation inspection by a supervisor . The inspector shall make a log entry in 
the EOMS application for each housing location inspected. 
23.6. Access to Cleaning/Sanitation Supplies 
23.6.1. Subclass members shall have access to effective cleaning and sanitizing 
supplies necessary to properly clean their own living area. Supplies shall 
include, as consistent with operational safety, access t o cleaning detergents, 
rags, sponges, scrub brushes, mops, mop bucket, broom, dustpan, etc. A log 
entry shall be made in the EOMS application for each housing location that 
includes the date and time the supplies were provided and the date and time the 
supplies were collected. 
23.7. Pest Control 
23.7.1. Defendants shall utilize a pest control contractor on a semi-monthly basis to 
eliminate vermin, insects , and rodents by safe and effective means in all 
common areas used by subclass members. This pest control service shall 
include all cells where the subclass member occupying the cell agrees to the 
service. A log entry shall be made in the EOMS application indicating the 
location, date, time, na me of the company representative performing the pest 
control service, and the service performed. 

 
- 59 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
24. Subclass’ Members Access to Services 
 This Order contemplates almost all prisoners will be able to submit requests for 
medical services and other matters via electronic tablet s. Therefore, Defendants shall 
ensure the following: 
24.1. Within six months of this Order, the tablets provided to subclass members shall 
allow them, in a language they understand, to make direct requests for services 
including medical/mental health services, file a letter or other request that is 
required before filing a grievance, file a grievance, file an appeal, access and send 
electronic mail (both personal and professional), check their commissary account 
balance, obtain current program schedules and curriculum, purchase commissary 
items, access case notices regarding letters and grievances, access to the prisoner 
handbook, access their disciplinary documents, access their hearing documents, 
access their appeal decisions and access to their current classification level and 
progress towards the next step down. The tablet should also allow access to 
entertainment such as books, educational materials, music and movies , consistent 
with a subclass member’s classification and step levels. Until tablets are issued and 
have this functionality, and thereafter for prisoners who are not permitted to have 
electronic tablets or who do not have access to an electronic tablet due to tablet 
malfunction, Defendants shall provide paper or other means to access documents 
and make requests consistent with the subclass member’s custody level. 
25. Body Scanners 
There was evidence at trial that subclass members undergo routine strip searches. 
The expert recommended Defendants use full-body scanners to reduce the use of and 
reliance on strip searches. Full-body scanners are preferable but, at this time, the Court 
will not mandate the installation of full -body scanners at all locations housing subclass 
members. 
26. Food Service and Meals 

 
- 60 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
26.1. All subclass members shall be provided a minimum of three separately provided 
meals a day (breakfast, lunch, dinner) consisting of two hot meals and one cold 
meal with no more than 14 hours between dinner and breakfast. Breakfast and 
lunch may be served together on weekends and holidays, provided one is a hot meal 
and nutritional needs are met. These meals shall be of the same qual ity and have 
the same nutritional and caloric content as meals served in general population. 12 
26.2. When a subclass member refuses three meals of any kind in a seven-day period 
or displays a significant change in eating habits ( e.g., accepts meals but does not 
consume them; does not consume significant portions of a meal; refuses meals 
intermittently, etc.,) corrections officers shall immediately notify medical staff. 
26.3. The following log entries shall be made for subclass members: 
26.3.1. when a meal is provided or r efused, an entry that includes the type of meal 
(regular diet, therapeutic, religious) and, if the meal was refused, a video 
recording of the refusal; 
26.3.2. when a therapeutic or religious diet begins and/or ends , an entry that 
includes the type of diet and the reason for the beginning or ending of the diet 
(which, for medical diets may be that the order from a medical provider began 
or ended). 
27. Out-of-Cell Activities 
27.1. Subclass members , including any prisoners in the Restrictive Status Housing 
Program and the Enhanced Management Housing Status who do not qualify under 
one of the four categories outlined previously , shall be offered 14 hours or more 
per week of out -of-cell time to include opportunities for recreation, showers, 
individual/group therapy where eligible for such services , visitation, phone calls, 
or other offered activities. 
 
12 The expert recommended Defendants have food service areas inspected by a health 
department official and that Defendants ensure they have an emergency meal plan to cover 
situations where food or water is temporarily unavailable . Oddly, Defendants have 
contested these requirements. The Court will not order them at this time. 

 
- 61 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
27.1.1. If the subclass member is offered out-of-cell time, but the subclass member 
voluntarily does not accept, the time they would have been out -of-cell counts 
towards out-of-cell time. 
27.1.2. If out-of-cell time is scheduled but not available, not offered, or offered at 
unreasonable times (e.g., 4:00 A.M.), that time shall not count towards out-of-
cell time. When out -of-cell time must be canceled due to an unforeseen 
situation, reasonable efforts shall be made to re-offer the out -of-cell time. 
Chronic insufficient staffing is not an unforeseen situation. 
27.1.3. A log entry shall be made in the EOMS application that includes the type of 
activity, the time the activity began and ended, or, if the prisoner refuses, a 
video recording of the refusal. 
27.1.4. Defendants must co ntinue to perform and monitor their obligations under 
this Order even after s ubclass members are offered more than fourteen hours 
of out -of-cell time in one week . Defendants shall continue to document 
activities of those locations housing subclass members as the date of this Order 
until such time as this Order is terminated. 
27.2. All subclass members shall be provided regular access to showers, at a minimum 
of three times per week with no more than three days between showers. 
27.2.1. For each subclass member who takes a shower or refuses to take a shower, 
a log entry shall be made in the EO MS application that includes a video 
recording of the refusal if the prisoner refused. 
27.2.2. When a subclass member refuses to shower on a continual basis or displays 
a significant change in hygiene habits, medical staff shall be immediately 
notified. 
27.3. Within one month after issuance of this Order, all subclass members shall be 
provided the following: 
27.3.1. Regular access to outdoor recreation areas at least consistent with the 
subclass member’s classification and, for those in Max imum Custody, their 

 
- 62 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
step level as described in Department Order 812 as of November 21, 2022; at 
a minimum each subclass member shall have three separate 2.5 -hour blocks 
per week in enclosures of at least 100 square feet and, for all those not in Max 
Custody Step 1, some ability to socialize with others. 
27.3.2. Recreation areas shall have constant supervision, in -person, by qualified 
staff members and have available shade and clean drinking water. 
27.3.3. A log entry shall be made in the EOMS application for each housing unit 
when a portable beverage cooler for a recreation area is provided clean drinking 
water. 
27.3.4. For each subclass member who refuses to recreate, a log entry shall be made 
in the EOMS application that includes a video recording of the refusal. 
28. Personal Property 
The expert recommended Defendants take steps to ensure the proper distribution 
and laundering of clothing, the proper distribution of bedding supplies, and the proper 
distribution of personal care items such as soap and toilet paper. Defendants object to this 
recommendation and at this time the Court will not order Defendants to distribute and track 
these items. 
29. Classification 
29.1. Defendants shall assign a corrections officer (“Classification Monitor”), with no 
other collateral duties, to each individual unit housing subclass members to ensure 
all classification reviews, step progression (up or down) and movements to an 
appropriate new housing location are processed and completed within ten days. 
The reasons and evidence considered shall be documented in the subclass 
member’s classification record. 
29.2. Defendants are required to provide s ubclass members in maximum custody or 
close management a written or electronic copy of their individualized case plan, in 
a language the subclass member understands that describes the actions need ed, as 
well as associated timeframes, to progress in their steps in maximum custody and 

 
- 63 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
generally to gain more privileges and to lower their classification level (less 
restrictive housing). 
29.2.1. Defendants are required, a t intervals not to exceed one month, to conduct 
and document an evaluation of each of the subclass member’s progress under 
the individualized plan. The evaluation should also consider the state of the 
subclass member’s mental health; address the extent to which the subclass 
member’s behavior, measured against the plan, reasonably justifies the need to 
maintain, increase, or decrease the level of controls and restrictions in place at 
the time of evaluation; and recommend full classification review when 
appropriate. The documentation shall be sufficiently detailed to show the basis 
for any decisions made in the evaluation (including increasing, decreasing , or 
maintaining privileges). 
29.2.2. Defendants are required, at intervals not to exceed six months, to conduct a 
full classification review involving a meeting of the subclass member and the 
classification committee , except in exceptional circumstances justified by 
legitimate safety concerns the subclass member need not attend. At t hat 
meeting it shall be determined whether the subclass member’s progress toward 
compliance with the individual case plan or other circumstances warrant a 
reduction of restrictions, increased programming, or moved to a lower level of 
custody. If a subclass member has met the terms of the individual case plan, 
there should be a presumption in favor of releasing the subclass member from 
maximum custody or close management. The documentation shall be 
sufficiently detailed to show the basis for any decisions made in the 
classification review (including increasing, decreasing , or maintaining 
privileges or classification). A decision to retain a subclass member in 
maximum custody or close management following consideration by the 
classification review committee should be reviewed by the facility warden or 
deputy warden, and approved, rejected, or modified as appropriate. When the 

 
- 64 - 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
 
warden or deputy warden disagrees with the classification committee’s 
recommendation, the Regional Operations Director shall review the matter and 
make a determination. The Regional Operations Director’s decision is final. 
29.3. Defendants are required to ensure enough beds are available for the number of 
subclass members placed in each classification le vel. When a higher or lower 
classification level is achieved, the Classification Monitor shall within ten days re-
house the subclass member into a location associated with their new classification 
level and step as well as afford them the appropriate privileges associated with the 
new classification level and step. 
30. Detention Unit Supervision 
Defendants shall assign a full -time qualified staff member, with overall unit 
authority and no other duties, to each detention unit to ensure all services, assessments , 
programs and activities in the detention unit are completed as required and shall ensure 
those prisoners who are eligible to leave the unit are re-housed within ten days. 
31. Disciplinary Process 
The evidence established at trial that p risoners are placed in detention units , often 
remain there indefinitely, and that the disciplinary system was “irrational[] and unfair[].” 
(Doc. 4335 at 142). The Court’s expert made many reasonable recommendations for how 
Defendants should restructure their discipli nary process es. The Court will not require 
Defendants implement them at this time. The other limitations Defendants are ordered to 
comply with will ameliorate the harm caused by Defendants’ irrational disciplinary policies 
and procedures. 
 

Passage view · GavelSight