Jensen et al v. Thornell et al

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WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Shawn Jensen, et al.,
Plaintiffs,
v.
Ryan Thornell, et al.,
Defendants.
No. CV-12-00601-PHX-ROS
ORDER
This litigation commenced almost 14 years ago. At the outset the Court engaged in
a patient and comprehensive undertaking with the parties to find an agreed-upon solution
to resolve the serious constitutional violations, which gave rise to the Joint 2014 Plaintiffs’
and Defendants’ Stipulated Agreement, also referred to as the 2014 Stipulation.1 But within
a short time, Defendants failed to abide by the Agreement. The violations persisted, and
following a five-week trial in 2022, the Court issued extensive Findings of Fact and
Conclusions of Law finding that there were pervasive and systemic unconstitutional
violations in Defendants’ provision of healthcare. Defendants chose not to appeal the
Court’s decision. Rather, they unreservedly agreed to abide by the terms and conditions of
the Permanent Injunction jointly crafted by Defendants and Plaintiffs with the active
participation of the Court and Court experts, who were selected and approved by
Defendants, i.e., the Court Monitors (hereinafter referred to as “Monitors”.)2 Since
1 The parties agreed to have the Honorable Magistrate Judge David Duncan preside over
enforcement of the agreement.
2 The Monitors include lead Monitor Dr. Marc Stern, board certified internist; Dr. Lara
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agreeing to the injunction, Defendants have never been substantially compliant, have
engaged in repeated, persistent violations, and the chronic unconstitutional prison
healthcare has continued.
Before the Court is Plaintiffs’ Motion for a Receiver (Doc. 4795.) All parties have
submitted extensive briefing on the Motion. The Monitors provided comprehensive
comments and opinions to which the parties fully responded. Oral argument was held on
September 10, 2025.
To declare a government will not accept the constitutional responsibility to provide
adequate healthcare is huge. Ordering the implementation of a receivership is
extraordinary, and the Court has exercised caution and critical reflection in making the
decision. But since the beginning of the case, the Court has forborne imposing the harshest
penalties, opting instead to guide Defendants with the help of the Monitors towards
comprehensive constitutional compliance. But now after nearly 14 years of litigation with
Defendants having not gained compliance, or even a semblance of compliance with the
Injunction and the Constitution, this approach has not only failed completely, but, if
continued, would be nothing short of judicial indulgence of deeply entrenched
unconstitutional conduct. Plainly, only the imposition of the extraordinary can bring an end
to this litigation and the reasons it was brought. An end to unconstitutional preventable
suicides. An end to unconstitutional preventable deaths. An end to unconstitutional failures
to treat those in severe pain. The Motion for a Receiver will be granted.
I. Background
Defendants operate ten prison complexes across Arizona. This action was filed in
2012 by a class consisting of all prisoners in Defendants’ custody seeking healthcare and
conditions of confinement in compliance with the Eighth Amendment of the United States
Constitution. In March 2013, the Court certified the class of prisoners seeking injunctive
relief in the form of constitutionally adequate medical, dental, and mental healthcare, and
Strick, board certified in Internal Medicine and Infectious Diseases; Dr. Bart Abplanalp,
licensed clinical psychologist; Dr. Karie Rainer, licensed psychologist; and Donna Strugar-
Fritsch, BSN, MPA, CCHP. See footnote 37 for further information.
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a subclass of prisoners confined to their cells for more than 22 hours a day and subject to
conditions including inadequate out-of-cell time, social isolation, inadequate nutrition, and
inadequate mental health treatment.
In October 2014, the parties negotiated a settlement agreement, the Stipulated
Agreement, which was approved by the Court in 2015 and was intended to resolve all
claims. It contained 103 agreed upon healthcare and maximum custody requirements called
Performance Measures, which, upon compliance, would free Defendants from monitoring
and reporting (Doc. 1185) to establish the healthcare was constitutional.
However, what followed between 2015 and July 2021 were twelve motions,
initiated by both the Court and Plaintiffs, to enforce the Stipulated Agreement, which were
resolved against the Defendants. The Court held multiple, lengthy evidentiary hearings,
status conferences, and issued dozens of Orders with clear guidance for mandating
compliance with the Stipulation and the Constitution. Concomitantly, the Court issued
three Orders to Show Cause why Defendants should not be held in contempt, appointed
two investigative experts, and lengthy hearings were held to determine liability. Defendants
were held in contempt twice, and ordered to pay millions of dollars in fines, which were
upheld on appeal.3
Finally, after five years of refusals to comply; findings by the Court that Defendants’
legal and factual theories were baseless; the imposition of substantial fines; threats of even
more fees and sanctions; and the payment by Defendants of substantial attorney’s fees, the
Court rescinded the Stipulation and vacated the settlement under Rule 60(b) of the Federal
Rules of Civil Procedure (Doc. 3921.) A fifteen-day bench trial followed (See Doc. 4335),
and, in 2022, the Court issued a 200-page Order with Findings of Fact and Conclusions of
3 “The Stipulation provides the district court the authority to ‘enforce this Stipulation
through all remedies provided by law,’ subject to a few limitations. Ordering Defendants
to comply with a specific subset of the Performance Measures they agreed to in the
Stipulation is one such ‘remed[y] provided by law,’ namely, an Injunction requiring
specific performance. We have previously upheld the district court’s power to issue such
Injunctions to enforce the Stipulation in this case.” (Doc. 3577-1 at 15, Mandate of the
Ninth Circuit Court of Appeals Case No. CV 18-16358 (alterations in original.))
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Law identifying the same persistent, unconstitutional conduct by Defendants regarding
healthcare, and housing certain prisoners in isolation. (Id.) The Court identified the
overarching failures in the delivery of healthcare as seriously insufficient staffing,
inappropriate use of nurses beyond the scope of their licensure, failure to manage complex
patients or employ a differential diagnosis approach, substantially inadequate mental health
treatment, and a deficient electronic health care record system. All these critical
deficiencies were found to exist at every one of Defendants’ complexes, rendering the
healthcare delivery systemically unconstitutional.
Defendants chose not to appeal. Rather, they agreed to an Injunction that complied
with the statutory limitations on injunctions addressing prison operations that was designed
to end unconstitutional healthcare within Arizona’s prisons. (Doc. 4335 at 180.) The parties
proposed experts to assist with crafting the Injunction, and Dr. Marc Stern was strongly
recommended by Defendants as “[dedicated] to the design, management, and operation of
health services in corrections settings, [who would] provide this Court and the parties with
valuable guidance in crafting an Injunction regarding the provision of medical care at
ADCRR.” (Doc. 4339 at 4.) It was uniformly agreed, and expressly by Defendants, that
Dr. Stern’s past work in this litigation uniquely qualified him to assist with drafting the
Injunction requirements, and he was appointed.4 (Doc. 4358 at 8.) Without objection, Dr.
Stern’s recommended additional experts for mental healthcare and custody conditions
imposed on the subclass were also appointed.5
From January to March 2023, the Monitors, the Court, and Plaintiffs’ and
Defendants’ counsel engaged in lengthy discussions; suggestions and objections were
made and mutually resolved by both parties. (Doc. 4410 at 3.) Finally, a stipulated
Injunction was filed with the Court by the parties with the tacit promise that compliance
4 It is crucial to note Defendants recommended Dr. Stern despite his testimony in 2018
before Magistrate Judge Duncan reporting Defendants had serious problems that
“precluded accurate monitoring” and that Defendants’ poor compliance may actually “be
worse” than what the experts found. (Doc. 3921 at 13.)
5 The Court appointed Dr. Bart Abplanalp and John-Michael McGrath to assist Dr. Stern.
(Doc. 4362.)
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would bring an end to the system-wide unconstitutional healthcare and end the Court’s
involvement in the litigation. (Doc. 4402) The parties informed the Court:
Since [the issuance of the draft Injunction], the parties have
engaged in extensive negotiations with each other and the
Court-appointed experts regarding the terms of the draft
Injunction and how best to expeditiously remedy the
constitutional violations found at trial. [See Doc. 4335.] The
parties are pleased to report that they have come to an
agreement with each other and with the Court-appointed
experts as to the terms of an Injunction.6
(Doc. 4402 (emphasis added.)) On April 7, 2023, the Court signed the jointly agreed
Injunction, stressing and underscoring the reasons that brought it about. (Doc. 4410 at 11-
67.) The Court noted:
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. . . .Yet almost immediately Defendants failed
to perform those obligations and continued in that failure.
Instead of acknowledging their failures, Defendants kept
inaccurate records and unreasonably misread the settlement’s
requirements to their advantage. During trial, Defendants
presented arguments and witnesses that were manifestly
unreliable and unpersuasive. And on some aspects, Defendants
presented no meaningful defense at all. . . . [T]rial established
Defendants blatantly had not made any serious effort to
remedy the flaws highlighted by this litigation.
(Id. at 4-5 (emphasis added.))
To evaluate Defendants’ performance throughout the Injunction, again with the
mutual approval of the parties, the Court appointed the same experts to serve as neutral
6 The parties agreed that “by filing this Stipulation [and if] the Court enters the Injunction
attached as Exhibit A as an order of the Court, neither party will appeal the order, in whole
or in part.” (Doc. 4402 at 2.)
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Monitors: Dr. Marc F. Stern7 and Dr. Bart Abplanalp8 (who had assisted in crafting the
Injunction), Dr. Lara Strick,9 and Mr. Scott Frakes.10 The agreed fundamental imperative
of the Injunction was that Defendants were required to monitor all elements of the
Injunction on a monthly basis and make their findings available for inspection and analysis
by the Monitors. (Id. at 7.) And, as also required by the Injunction, the Court appointed Dr.
Stern and Ms. Donna Strugar-Fritsch to “conduct a staffing analysis and plan of health care
positions at each location”11 (Id. at 14.)
From the beginning, the mandate of the Injunction was that Defendants were to fill
all required vacant staff positions. The Injunction expressly states, “increased salaries may
be necessary to reach adequate staffing levels.” (Doc. 4410.) Moreover, the Injunction
anticipated the Staffing Plan would ultimately require hiring many more staff, and in
particular, the Injunction required that vacant staff positions were to be filled no later than
July 7, 2023. (Doc. 4445.) But on July 14, 2023, Dr. Stern sent a letter informing the Court
that staffing as of July 7 was “markedly inadequate to meet the immediate requirements of
the [Injunction].” (Doc. 4446 at 1.) This was a disturbing revelation in light of the June
2022 Findings of Fact Order in which the Court found one of the “core issues” was that
7 Dr. Stern has been appointed as an expert pursuant to Rule 706 of the Federal Rules of
Evidence to assist the Court in various aspects of this case since December 11, 2018. (See,
e.g., Docs. 3089, 3127, 3133, 4352.)
8 Dr. Abplanalp has been appointed as an expert pursuant to Rule 706 of the Federal Rules
of Evidence to assist Dr. Stern in addressing mental healthcare since May 30, 2019. (See,
e.g., Doc. 3269, 4362.) In April 2025, the parties stipulated to appoint Dr. Raner as a Rule
706 expert to assist with mental health monitoring. (Doc. 4859.)
9 On March 17, 2023, the parties stipulated to appoint Dr. Lara Strick as a Rule 706 expert
to assist the Court in monitoring Defendants’ compliance with Injunction. (Docs. 4402,
4410.)
10 On January 13, 2023, the Court appointed Scott Frakes as an expert pursuant to Rule 706
of the Federal Rules of Evidence to serve as an independent expert to the Court to address
the maximum custody aspects of the Injunction, replacing former Rule 706 expert John
Michael C. McGrath. (See Docs. 4381, 4362.)
11 On May 9, 2023, Donna Strugar-Fritsch was appointed as a Rule 706 expert to assist in
monitoring and performing a staffing analysis in compliance with the Injunction. (Doc.
4425.)
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staffing levels “are so inadequate” that “the provision of constitutionally mandated care
[was] impossible.” (Doc. 4335.) In other words, within three months of the effective date,
Defendants were already in violation of the Injunction. On July 20, 2023, the Court set an
immediate hearing to develop a timeline for Defendants to achieve compliance, expressing
alarm that “Defendants have been fully aware since at least January 9, 2023, they needed
to begin hiring additional staff.” (Id. at 1-2.)
On August 17, 2023, the Court held a status conference to address Defendants’
staffing non-compliance, emphasizing, “there must be complete compliance with the
Injunction to get the federal court out of the case.” (Doc. 4469 at 4-5.) Plaintiffs pointedly
expressed their concern regarding Defendants’ failures but informed the Court they did not
then intend to seek immediate sanctions. Plaintiffs reflected that Defendants appeared to
be “making sincere” attempts to comply with the Injunction. (Id. at 5.) Defendants
expressed solidarity with Plaintiffs, Dr. Stern, and his team, to reach compliance. However,
it was also noted as very troubling that Defendants lacked, or at least failed to produce,
critical information needed to discern exactly what staff existed and what was
constitutionally required. (See generally, Doc. 4469.) However, it was clear, under any
methodology, Defendants needed significantly more staff to achieve compliance with the
Injunction and the Constitution.12
A follow-up status conference was held on December 1, 2023 (Doc 4510) where
Plaintiffs’ counsel repeated, without disagreement from Defense counsel, “I don’t think
there is any dispute about the fact that staffing in the prisons at the moment is grossly
deficient.”13 (Doc. 4521 at 12.) Plaintiffs added their specific observations that while
visiting Lewis Prison, it was obvious the significantly low staffing was impacting “patient
care because there’s no providers and not enough nurses to provide care.” (Id. at 13-14.)
12 Plaintiffs’ counsel, the Monitors, and the Court also expressed strong concern about
Defendants’ excessive use of overtime and registry personnel in an attempt to meet staffing
requirements, which were specifically prohibited by the Injunction. These temporary
workers hired from healthcare employment agencies were specifically prohibited because
of high turnover leading to significant risk to patients.
13 Dr. Ryan Thornell, Director of ADCRR, was in attendance at this hearing.
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Defendants provided a highly unacceptable response by first disavowing
responsibility, repeatedly claiming the obligation for staffing was with the contractor,
NaphCare. “We’re not satisfied with the rate in which staffing has been increased. And
we’re continuing to put on---put on pressure on NaphCare to increase their hiring, to
increase their salaries in order to successfully recruit and successfully retain good staff
members.”14 (Id. at 8.) The most daunting revelation was Defendants’ admission that
existing staffing did not even meet the levels of the prior NaphCare contract, which
required that at least 300 positions be immediately hired. This was appalling because the
Court found in the June 2022 Findings of Fact that personnel at each of Defendants’
facilities was “profoundly understaffed.” (Doc. 4335 at 22.) Further, Defendants
effectively admitted at trial in 2021 that their staffing levels were insufficient. (Id. at 24.)
What is more, the evidence presented showed Defendants’ former private contractor,
Centurion, opined that even if all prisons were fully staffed under Defendants’ calculation,
such staffing would be insufficient to provide adequate healthcare. (Doc. 4335 at 22.)
Because of serious concerns about the nature and type of non-compliance with the
Injunction, the Court ordered the Monitors to conduct an evaluation of Defendants’
compliance and file a report early the next year. And on February 2, 2024, the Monitors
filed the First Interim Report. Some very minor improvements in healthcare services were
first noted, but otherwise the Monitors found Defendants “substantially noncompliant” and
that Defendants’ efforts to self-assess were totally “unreliable.” The Monitors provided a
written, detailed discussion of the specific deficiencies as they had done in response to the
monthly reports and offered useful suggestions to Defendants for resolution. Of gravest
concern, the report included comprehensive medical evaluations conducted by the
Monitors of some patients, finding the patients had received very poor medical treatment,
including a patient who committed suicide, which the Monitors deemed preventable and
that occurred because of “wholly inadequate” care.15 (Doc. 4539 at 15.)
14 Precisely what pressure, if any, was ever brought to bear was never identified at the
hearing or anytime thereafter.
15 On February 2, at the joint urging of the parties because of the critical failure of staffing,
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On February 16, 2024, Defendants filed a response to the Monitors report beginning
with the astonishing complaint that “distinctively absent” was the Monitors’ failure to
provide Defendants with “a comprehensive plan of how to achieve compliance with the
Injunction” or a “how-to guide.” (Doc. 4553 at 2.) Such a bizarre undertaking by the
Monitors was never contemplated by the Injunction or ordered by the Court.16 Remarkably,
despite having collaborated with the Monitors for well over a year, and having
wholeheartedly recommended and approved them as highly competent, Defendants
broadly and incomprehensively questioned whether the Monitors’ opinions were too
“subjective” and not “clinically appropriate.” (Id. at 3-4.)
In contrast, Plaintiffs provided a very critical assessment of Defendants’ quality of
care: “Nearly one year after the courts issuance of the injunctive relief, and more than 18
months after it found the provision of medical and mental healthcare . . . violate the
Constitution, the Court’s monitoring team’s Status report details widespread and
substantial violations of the Injunction.” (Doc. 4552 at 2.) Emphasizing the blatantly
obvious, Plaintiffs added Defendants were already in violation of the Injunction:
[The] failure to create a viable self-monitoring system, and
inability to measure or demonstrate compliance, must be
presumed to be noncompliance.
(Doc. 4552.)17 Plaintiffs also declared Defendants did not deserve even the minor credit
offered them by the Monitors.
the Court reluctantly granted the parties’ Motion to Amend Section 1.16 of the Injunction
to allow Defendants a very limited use of Registry and Agency staff to fill some portion of
the full-time equivalent positions (FTE) in each job Category. (Supra footnote 12.)
16 The total agreed upon fees and expenses paid to the Monitors for their work required by
the Injunction is substantial. To date, the Monitors have cost in excess of $4 million on
healthcare alone. Prior to agreeing to the specific parameters of the detailed Injunction,
Defendants never indicated they required a tutorial as how they would comply. If the
Monitors had also been ordered to undertake extensive tutoring to help Defendants achieve
compliance, the cost to the Defendants would have skyrocketed. What is more, the
Monitors informed the Court they readily offered oral or written training and assistance to
Defendants, who expressed no interest in accepting it.
17 Plaintiffs were specifically concerned: (1) Whether meaningful post-mortem plans were
occurring; (2) that no English fluency assessments were being made; (3) with failures
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In Reply, Defendants acknowledged the “excessive amount of time it has taken to
obtain adequate healthcare staffing,” but made the shocking argument that they should be
excused because of Legislative “budget limitations,” and offered “to submit a request for
supplemental appropriation,” but warned: “it might not be approved” and, worse yet, the
“earliest the funds would be distributed (was) July 1, 2025,” that is, one and a half years
later. Finally, Defendants, in closing, made the startling request that the Court order non-
party contractor, NaphCare, to increase salaries so Defendants could avoid “the necessity
of engaging in the legislative budget approval process.” (Doc. 4583 at 3-4.)18
On March 14, 2024, in advance of the next status hearing to assess compliance by
the Defendants or to proceed with enforcing the Injunction, the Court, by Order,
emphatically reminded Defendants that the Injunction had been in place for almost one
year, and Defendants had not yet developed the fundamental and essential “mechanism for
assessing compliance with 130 provisions.” (Doc. 4570 at 1.) The Court categorically
clarified the Monitors were never required to provide a “how-to guide” or train Defendants
how to competently achieve compliance with the Injunction. And relying on the Monitors’
reports and responses, the Court declared the healthcare system “remains fundamentally
lacking, and the Monitor’s report documents continued adverse outcomes that show
regarding specialty care; and (4) with lack of evidence supporting that mental health
patients were not being placed in restraints.
18 The Injunction terms and requirements were drafted and agreed upon, and presumably
negotiated, in good faith by the Defendants, and then approved and ordered by the Court
on April 7, 2023. (Doc. 4410.) The Injunction expressly states, “increased salaries may be
necessary for Defendants to reach adequate staffing levels.” (Doc. 4410.) And, if so, those
increases by contract with NaphCare were explicitly to be borne by Defendants. (Docs.
4555; 4566; 4583.) At no time prior to the effective date of the Injunction was the Court
informed by Defendants they were unable to, or unwilling to, comply with all terms of the
Injunction for any reason, and particularly because funds were not, or would not be,
available to ensure compliance. (See also Docs. 4555; 4410; 4583.) Defendants have been
constantly reminded orally and in writing for the almost 14 years of this litigation of Ninth
Circuit authority mandating “lack of resources is not a defense to a claim for prospective
relief because prison officials may be compelled to expand the pool of existing resources
in order to remedy continuing Eighth Amendment violations.” Peralta v. Dillard, 744 F.3d
1076, 1083 (9th Cir. 2014.)
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prisoners remain at risk.” (Id.) Significantly, the Court made the express finding that
Defendants were in violation of the Injunction because it mandated they “fill all positions
required by the current contract with the healthcare vendor” no later than “July 7, 2023.”
(Id. at 2.) The Court voiced serious concern with Defendants’ repeated ill-conceived
requests that the Court engage in enforcing Defendants’ contract with NaphCare by
sanctioning NaphCare for not filling staff positions. Defendants were directed to the critical
provision in the Injunction: “Defendants must comply with the Injunction and any disputes
between Defendants and the private healthcare contractor are beyond the scope of the
Injunction,” and pointed to the very contract provisions with NaphCare that called for
“staffing offsets/paybacks for unfilled hours of service” and the imposition of “monetary
sanctions,” and, of substantial significance, even “termination” of the contract if NaphCare
failed to perform under the contract. (Doc. 4570 at 4.) This was to forcefully bring to
Defendants’ mind the abundant, viable contractual enforcement tools they had to force
NaphCare’s compliance with the Injunction and Constitution. And, most importantly,
Defendants were warned if those remedies were not pursued, it would “be exceptionally
difficult for Defendants to show they ‘took all reasonable steps to comply with the
[Permanent Injunction].’” Kelly v. Wengler, 822 F.3d 1085, 1096 (9th Cir. 2016.)”19 (Doc.
4570 at 4.) Finally, the Court warned of an Order to Show Cause why Defendants should
not be held in contempt. (Id. at 2.)
On March 15, 2024, the Court held another hearing to determine if Defendants had
reached compliance with the Injunction, and, if not, whether they were prepared to face the
consequences. (Doc. 4581.) The Monitors, who had spent hundreds of hours evaluating
Defendants’ performance and engaging with Defendants to assist them with compliance,
testified Defendants were plainly not in compliance and the healthcare they were providing
was constitutionally deficient. (See generally id.) Again, the Monitors’ greatest concern
was the persistent understaffing and the numerous temporary positions, resulting in a lack
19 Critically, the contract explicitly states: “NaphCare must “meet all federal and state
constitutional amendments [and] court orders.” (Doc. 4570.)
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of continuity of care, and that the care was not patient-centered and lacked follow-up,
particularly for those too sick to advocate for themselves. (Id.) Specifically, the Monitors
reported from their review of documents and their many interviews of staff and patients,
overall (1) documentation of care was “poor,” (2) the electronic medical record had not
been repaired, (3) there was a failure to pursue the fundamental change in the model of
care which mandates “a patient centered model,” and (4) because the prisons continue to
be poorly staffed, it was impossible to reach that goal. (Id.) The Monitors called attention
to some specific individual cases that demonstrated grave danger to prisoners. One patient
was locked in a room without one-to-one monitoring; the patient was never allowed to
leave his room and was always “on a mattress on the floor of his cell.” (Id. at 24.) In mental
health, there were patients who were too delusional and schizophrenic to be able to seek
help through the telemonitoring system and confidential communications with patients
were “nearly impossible.” (Id. at 29-31) One patient committed suicide that likely could
have been avoided, who had a known history of self-harm, but was only seen monthly,
“cell-side,” with a simple inquiry: “Are you okay?” The Monitor stated the “lack of care,
in [his] opinion, likely contributed to [the patient’s] death.” (Id. at 47-48.) And it was
reported there was an alarming “spate of suicides within the past several months.” (Id. at
40.)
Plaintiffs reported they spent numerous hours evaluating healthcare compliance
through conversations with staff and prisoners. Plaintiffs learned of reported failures to
diagnose “serious problems,” including cancer. Female prisoners stated they put in
healthcare requests describing serious medical and mental health problems and received
delayed and inadequate responses, such as “just drink more water.” (Id. at 55.) And
Plaintiffs reported those who complained of mental health problems were not given care.
Rather they were advised “to go on suicide watch” in order to receive any type of individual
care. (Id. at 56.)
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Director Thornell offered a promise to attempt to “pressure” NaphCare to ensure it
provided adequate salaries and adequate staffing to comply with the Injunction and the
Constitution.20 The Court addressed Director Thornell:
THE COURT: And you’re going to hear this again as long as—
until it’s solved, and you’ve heard it before. Have you
discussed or considered increasing staff, increasing salaries?
As you know, that is the footprint we’ve had as a problem in
this case. And you know that, Director Thornell. Right?”
DIRECTOR: “Yes, Your Honor, and we discuss it.”
THE COURT: “So you’ve heard it. Focus on staff, salaries,
either within the contract you have now or whatever you’re
going to do in the future.”
DIRECTOR: “Yes, Your Honor.”
THE COURT: “Have I made myself clear?”
(Id. at 80.)
Plaintiffs and the Court accepted the Director’s promise, and the Court again
resisted imposing contempt sanctions, but warned continued failures would prompt severe
consequences. (Id.) The parties agreed to attempt to offer the Court a stipulated order
mandating Defendants comply with the Constitution by forcing NaphCare to provide full
staffing and higher salaries. But a joint stipulated order was never filed. Rather, Defendants
again advanced the startling proposal, contrary to law, that the Court issue an order that
expressly mandated the Defendants order NaphCare to “pay wages in accordance with the
contract if vacancies continued.”21 The Court flatly rejected the unwarranted request.
20 Again, no further details were ever provided to the Court as to what measures were taken
to ensure NaphCare’s compliance other than Director Thornell mentioning sending
“multiple letters” to NaphCare. (Doc. 4602.)
21 NaphCare filed a Motion to Intervene, boldly claiming it had “significantly improved
the healthcare system.” Because the Motion was untimely, it did not meet the procedural
requirements, and NaphCare implied it had no obligation to comply with the Injunction
and thereby the Constitution, it was denied without prejudice, and never refiled.
Particularly appalling was that Defendants did not object to the motion despite NaphCare’s
claim that NaphCare had significantly improved the healthcare system and NaphCare’s
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On April 18, 2024, the Court issued another order regarding Defendants’ failure to
address the lack of adequate staffing and reminded Defendants of the obligation to
determine if NaphCare was in violation of the contract and, if so, to proceed to enforce it.
(Doc 4602.) On April 16, 2024, Dr. Stern and Ms. Strugar-Fritsch submitted the ADCRR
Health Care Staffing Analysis and Plan required by the Injunction, definitively establishing
the staffing necessary to comply with the contract and the law and calling for significant
increases.22
On May 16, 2024, the Court held the final status conference of the year, where the
proposed staffing plan was discussed23 (Doc. 4634), and the Monitors recommended a Pilot
Project to thoroughly test the findings, stating: “We proposed shifting from a hundred
percent implementation [of the staffing plan.]” (Doc. 4634 at 27-28.) The Pilot Project was
designed to allow Defendants to evaluate and report to the Court precisely how significant
of a staffing increase was necessary, and what specifically would be required for the
statewide implementation of staffing. (Id. at 107.) Plaintiffs favored and endorsed the Pilot,
and Defendants tentatively agreed, but demurred, again, complaining of lack of funding.
In particular, Defendants stated “we’re operating at a significant deficit . . . . Because for
this fiscal year they’re already many millions of dollars over budget because of the
Injunction and the healthcare and the NaphCare contract.”24 (Id. at 112.) At the close of the
hearing, the Court declared that after a careful review of “all of the paragraphs of the
Injunction, it is likely 75 percent of them have been violated . . . the State is already clearly
statement that though it did not intend to relitigate the Injunction, it fully intended to engage
in “tinkering” with provisions of the Injunction such as “staffing levels” in clear violation
of the Injunction.
22 The Plan was developed after “extensive collaboration and coordination with the
Monitoring team . . . site visits to three complexes, consultation with Plaintiffs and
Defendants including extensive consultation with the ADCRR Health Services Division,
and conversations with NaphCare Facility Health Administrators, providers, mental health
leads, and others.” (Doc. 4599.)
23 Director Ryan Thornell was in attendance.
24 Defendants continued: “Well, here’s the problem, Your Honor, we don’t have the money
to do this. It would require a new contract with NaphCare. It would require approval of the
JLBC.” (Doc. 4634 at 118.)
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in violation of the Injunction.” (Id. at 123-24.) Defendants did not respond. However, the
Court opted to forgo issuing an order to show cause until the Pilot was completed because
of the parties’ joint agreement to implement the Pilot.
On June 3, 2024, with the agreement of all parties, the Court ordered
implementation of the Pilot Project, but expressed serious concerns regarding Defendants’
ongoing failure to aggressively undertake the dramatic improvements required by the
Injunction:
Finally, the Court notes its concern that over one year after the
Permanent Injunction was issued and two years since entry of
the Court’s Findings of Fact and Conclusions of Law, much of
the briefing regarding the staffing plan reflected Defendants’
continued resistance to meaningful efforts to increase staffing
to achieve constitutional levels and avoid catastrophic
outcomes. At this point, Defendants have admitted more
staff is necessary and it is difficult to view their behavior as
anything other than attempts to delay issuance of a
statewide staffing plan. The Court’s patience has run out.
Too many individuals are needlessly suffering while
Defendants have deployed many delay tactics. Defendants
shall immediately establish the Pilot program and in a
subsequent Order, Defendants will be required to establish
they have taken all reasonable steps to comply with the
Permanent Injunction.
(Doc. 4637 at 8 (emphasis added).) The Court also traced Arizona’s decades long history
with numerous private healthcare companies’ failure to provide adequate staffing and
healthcare in accordance with the Constitution. The Court stated the jointly agreed-upon
Injunction was intended to resolve understaffing and incompetent staffing by requiring
Defendants to immediately fill the positions and Defendants refused. However, both
Plaintiffs and the Court decided against urgently pursuing sanctions because Defendants
promised they were committed to filling positions and engaging in the Pilot in good faith.
The Pilot was initiated at two units selected by Defendants.25
On September 25, 2024, the Monitors filed their first Pilot report, stating Defendants
25 The Arizona State Prison Complex–Yuma, Dakota Unit (Dakota), and the Arizona State
Prison Complex–Perryville, San Carlos Unit (San Carlos).
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showed a lack of will and no commitment to success. (Doc. 4681.) On October 7, 2024,
Plaintiffs specifically identified numerous failures by Defendants to comply with the Pilot,
including the failure to hire any of the critical positions, and to backfill those borrowed for
the Pilot, and the failure to provide sufficient space. Plaintiffs reluctantly recommended
the Pilot continue, but requested the Court consider imposing severe financial sanctions
against Defendants for their substantial violations of the Pilot, and order full briefing on
other remedies, including appointment of a receiver and declaring unconstitutional the
privatization of prison healthcare. On November 15, 2024, a second Pilot report from the
Monitors showed Defendants continued to resist and plainly refused to engage in good
faith implementation of the Pilot (Doc. 4700.)26 The Court declared once the Pilot
concluded, the Court would order comprehensive briefing on all possible sanctions and
appropriate remedies against Defendants. (Doc. 4699.)
In early October 2024, Monitor Dr. Abplanalp informed the Court of an
investigation of a cluster of suicides and filed a report on October 17, 2024, revealing
staggering deficiencies in Defendants’ mental healthcare delivery. Not only were numerous
specific Quality Indicators of the Injunction violated, but Dr. Abplanalp concluded if
Defendants had adhered to the requirements in the Injunction, “it would have decreased
the probability of, if not prevented, these deaths.” (Doc. 4691.) Further, he emphasized the
flaws were the same as those he had frequently observed since his evaluation began in
April of 2023.27 Defendants attempted to refute the Monitor’s evaluation with the
26 In particular, the Patient Centered Care Model (“PCCM”) Pilot operations were
indefinitely suspended at San Carlos; in short, Defendants unilaterally abandoned the Pilot
at San Carlos. (Id.) The experts noted the project required additional space to be successful,
and that allocating this space was the “highest priority,” but Defendants refused. (Doc.
4800.)
27 It was reported that one suicide patient had auditory hallucinations that did not prompt
Defendants to consider undertaking a prompt comprehensive evaluation. Another patient’s
father called the day before the suicide and informed Defendants his son was not receiving
medication and was in distress, but no action was taken. A third suicide patient had
previous diagnoses of schizophrenia, antisocial personality disorder, psychosis, and
anxiety disorder, but no record of a comprehensive mental health evaluation existed.
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dismissive comment “they do not tell the full story,” and offered beyond-the-pale excuses
for their failures to comply with the Quality Indicators required by the Injunction that were
designed to save lives. (Doc. 4818 at 11-12.)
On January 7, 2024, the Monitors filed the Second Interim Report dated December
20, 2024, reflecting evidence gleaned and analyzed since their work began on April 7,
2023. (Doc. 4755.)28 The Monitors acknowledged improvements in the conditions of
confinement for the subclass, but found the delivery of all healthcare was “poor” with little
improvement since the Injunction became effective, placing prisoners at “significant risk
of serious harm, including death.” (Id. at 2.) And in fundamental violation of the core
principle of the Injunction, they found advance practice practitioners—nurse practitioners
and physician assistants—were still caring for the complex and emergency medical patients
that mandate care by physicians. Further, there were numerous mentally ill patients still
not receiving treatment necessary to ensure their safety. And still, over 100 positions that
were compelled by the prior and existing contract with NaphCare had not been filled,
reflecting lack of fundamental compliance with the Injunction. The Electronic Health
Records (“EHR”) were still “poorly adapted,” thousands of consultations with off-site
specialists were delayed, and “virtual visits [were] rampant.” The report concluded in
summary: “And patients are dying.” (See generally id.)
In addition to the cluster of five suicides Monitor Dr. Abplanalp reported in October
2024, another, more recent suicide was identified and determined to have been “likely
avoidable” because the patient had received incompetent care. And the Monitors identified
four recent, newly discovered non-suicide related deaths that were determined to have been
caused by “serious and pervasive systemic health care delivery failures.” The report
28 Significant reliance by the Monitors was always placed on Defendants’ self-evaluations,
Defendants’ documents, including electronic health records, complaints by prisoners,
concerns submitted by everyone involved, conversations with staff and Plaintiffs’
attorneys, and site visits. Generously, the Monitors made mention of the efforts and
devotion of the front-line and supervisory staff. The “systems are broken” but “they try
hard” and have been “asked to do something beyond their capabilities or outside their
expertise.” (Doc 4755 at 1.)
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concluded these deaths likely could have been avoided if there had been compliance with
the Injunction. (Doc. 4755 at 2.)
Regarding Defendants’ claim that “they are closing in on 100%” compliance, the
Monitors found this patently false because Defendants’ method of measuring compliance
was wrong. (Id. at 3.) For example, Defendants alleged their mental health evaluations are
“comprehensive” whereas the Monitors found Defendants’ performance measure is “closer
to 0%.” (Id.) Regarding off-site specialist referrals, Defendants readily admitted from their
self-evaluations the care provided “is often not clinically appropriate” (id. at 5), and in
violation of the Injunction. And the Monitors emphasized the “degree to which [Defendants
are] failing to comply . . . is hard to imagine.” (Id. at 6.) For example, only 3% of the
referrals outside the prisons were timely, meaning a shocking “7,140” or 97% of these
critical, life and death referrals were “not timely” or never occurred at all. (Id.)
The mortality reviews have always been of vital significance, and the Monitors
reported Defendants “missed critically important errors.” (Doc. 4755 at 7.) The Monitors
stated they repeatedly brought the overuse of nurses and LPNs in violation of the Injunction
to the attention of Defendants, which in fact contributed to the cause of one patient’s death.
But when this failure was brought to the attention of Defendants, they flatly responded that
it was a “one-off.” (Doc. 4755 at 7.) As poor as the mortality reports were, the Monitors
found, “almost all other reviews . . . were worse.”29 (Doc. 4755 at 8.) Despite the
monitoring team having provided repeated feedback, there had not been systemic
improvements through the “implementation of a sustainable remedial plan as required by
29 The failures to correct mortality review reports is of great concern because when
deficiencies were brought to Defendants’ attention by the Plaintiffs in March 2024,
Defendants first denied any problems, but also claimed they were aggressively making
improvements: “[Defendants’] Medical Director, Dr. Phillips, is currently in the process of
revamping the entire mortality review process to provide a greater transparency and
ownership regarding the care provided. [Defendants] will work with NaphCare to ensure
that the improved process is robust and thoughtful.” (Doc. 4566 at 10.) The Court finds the
mortality reports reviewed by the Monitors do not support that a review process was
meaningfully completed.
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the Injunction.” (Id. at 71)30
The Monitors discovered medications had been maladministered, placing patients
at serious risk of harm. The poor mental health treatment included one patient who “spent
15 minutes banging his head on a wall” that required an emergency response. Again, the
fundamental underpinning of the Injunction for establishing a minimally safe mental health
system has been substantially unmet because of the use of nurses and LPNs as first line
healthcare, “over- and mis-use of telehealth” and the electronic health record was described
as a “sprawling, disorganized warehouse.”31 (Id. at 15.) Fundamental to the Injunction has
been Defendants’ failure to fill critical staff positions in that there continue to be a dearth
of physicians “medical APPs,” and “nurses,” and Defendants’ recruitment remains poor.
One of the most urgent concerns expressed by the Monitors was that Defendants
were still unable to accurately analyze Injunction-related data. The Monitors reported they
have spent “hundreds of hours” providing detailed feedback, orally and in writing, and
mentoring to Defendants regarding errors, analyses, and interpretation of the Injunction to
assist them in first understanding and then reaching compliance. In fact, Dr. Strick
specifically offered on more than one occasion to provide mentoring to nurses and others
“to no avail.” (Doc. 4755 at 96.) Initially after the Injunction, the Monitors reviewed
Defendants’ monthly reports and provided objections, comments, and instructions. The
Monitors would meet with Defendants to enhance improvements. Over time, the meetings
ceased because Defendants showed no interest in accepting advice from the Monitors.
30 The Monitors reported in December 2024 they alerted Defendants more than a year
earlier that the reports indicated significant medical equipment was available, but the
inspection showed it “was missing,” raising the possibility of “false documentation.”
(Doc.4755 at 9-10) Not until this same issue was raised again in the Monitors’ Third
Interim Report in August 2025 did Defendants provide any response. Their explanation,
while alleviating the concern regarding false documentation, raised the issue that
“emergency response bags are sealed without confirming that they are complete.” (Doc.
5040 at 11.)
31 The Monitoring Team in their evaluation “spent hours on individual patient records” to
understand what were the “conditions and treatment.” But even assuming a clinician would
be better informed than the Monitors, the Monitors were “unable to piece together”
necessary information that would allow for the safe care of a patient. (Doc. 4755 at 17.)
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Finally, the Monitors expressed dismay about the leadership available in order to
reach and maintain compliance with the Injunction. The primary reason was Defendants,
through their leadership, maintain the system that embraces using nurses as the primary
care givers supplemented by LPNs.32
Defendants offered objections to the Monitors’ report, and the Monitors provided a
detailed response on October 4, 2025, (Doc. 5040), emphasizing the essence of the
violations.33 Defendants still contend “there is no problem” with nurses providing “most
of the care” in clear violation of the foundation of the Injunction. In fact, the Monitors
reported Defendants have failed abysmally, emphasizing the failure of Defendants to
aggressively enforce the contract with NaphCare by refusing to impose any of the
numerous potential sanctions available, which is inexcusable. In fact, few sanctions have
been imposed against NaphCare for healthcare violations.
The Monitors reflected on Defendants’ false claim that the Monitors, for the first
time in the report, provided them a detailed and understandable review of the Injunction
requirements and methodology, which is startling and absurd. The Monitors have given
significant feedback, which has been ignored or refused by Defendants. Remarkably, only
since the Motion for Receiver was filed have Defendants, for the first time, offered, through
declarations, detailed, specific comments, criticisms, and complaints concerning each
requirement of the Injunction, the Quality Indicators. Regarding Defendants’ response
concerning a hypertensive patient, the Monitors correctly concluded the healthcare
management was still “dangerously inadequate.” (Doc. 5040 at 3.) Regarding another
patient’s death, the excuse offered by Defendants only strengthened the Monitors’
conclusion that the mortality review process has failed. Regarding Defendants’ attempt to
excuse other mortalities, the Monitors found they remain inexcusable because they involve
32 The Monitors found that Defendants do not have and, more importantly, have no system-
wide imminent plan to acquire the space necessary to provide constitutional healthcare.
33 For example, the Monitors addressed a correction to their calculation of backlogged
appointments; Defendants were correct that the number of medical appointment backlogs
is 61,479 rather than the initially reported 123,403, but the Monitors found this number
still inexcusable and dangerous.
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avoidable delays in care, care not consistent with required standards of care, failure to
timely review tests, and gross mismanagement by nurses of a patient’s condition. And
concerning one particular patient identified by the Monitors: “If not for [Defendants’]
mismanagement of the patient . . . [the patient] likely would not have needed the elective
surgery . . . from which he died.” Finally, the Monitors stated, “the specific problems with
clinical care that led to one patient’s death had still not been analyzed and remedied.” (Id.
at 16.)
In conclusion, the Monitors stated Defendants’ remarks do not change “our
conclusion that [Defendants’] mortality review process is flawed,” which was supported
by the Monitors’ analysis of “three . . . deaths in 2023 and 2024 associated with the same
clinical mismanagement.” (Id. at 17 (emphasis in original).)
On January 3, 2025, the Monitors submitted the final report on the Pilot, referencing
the fundamental requirement of the Injunction set forth in section 1.17 that mandates a
“Patient Centered Care Model,” that was to be achieved by the Pilot. (Doc. 4761 at 1.) But
the Monitors reported Defendants “disagreed in writing with each of these assumptions at
various times throughout the Pilot.” (Id. at 3.) Consequently, the Pilot failed: it was never
fully implemented at either location and operated for only 8 days at one of two locations.
(Id. at 3-4.)34
On February 12, 2025, Plaintiffs filed the Motion for a Receiver. (Doc. 4795.)
Defendants responded (Doc. 4818), and Plaintiffs replied. (Doc. 4878.) In combination
with the Third Interim Report to the Court, the Monitors provided their response to the
Motion (Doc. 4968.) On June 11, 2025, the Court ordered implementation of the Final
Staffing Analysis and Plan (Doc. 4858) as modified by the Experts’ Analysis of Parties’
Responses to Staffing Analysis and Plan (Docs. 4900, 4916.)35
34 The Monitors detailed repeated, direct violations of specific Court Orders without notice
to them or the Court. In particular, the Pilot healthcare staff were to be permanent, but
Defendants failed to ensure NaphCare complied with the requirements of the Pilot. (See,
Doc. 4761 at 7.)
35 Defendants appealed that Order on July 9, 2025 (Doc. 4935), which remains pending,
but this Court’s Order directing implementation has not been stayed.
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On July 17, 2025, the Monitors filed their Third Interim Report (Doc. 4942; 4968
(revised)) and, on October 4, 2025, the Monitors filed their Analysis of Parties’ Response
to Monitors’ Third Interim Report to Court (Doc. 5040.)
II. Plaintiffs’ Motion to Appoint a Receiver
Plaintiffs argue that given the systemic constitutional violations from the inception
of the Injunction to the current day, the lack of substantive progress, and Defendants’
obvious inability to recognize and remediate their mistakes, the least intrusive means of
assuring prisoners within Arizona prisons receive constitutionally adequate healthcare is
to appoint a receiver. (Doc. 4795.)
In Response, Defendants claim they have continued “to make progress across all
aspects of the Injunction,” (Doc. 4818 at 2), and argue a receiver is premature because the
Injunction has been in place for less than two years, the current director has only been in
place for two years, there have been additions to the numbers of full time equivalent
employees (FTEs), NaphCare has only been contracted for the past two years, and
Defendants have expended additional funds on healthcare, have made some improvements
on certain types of healthcare in certain facilities, and have had success in the opioid use
disorder program and Hepatitis-C treatment. Finally, Defendants claim NaphCare “has
steadily increased staffing since the start of the Injunction.” (Doc. 4818 at 15.)
In Reply, Plaintiffs argue that Defendants’ argument against a receiver boils down
to a meritless request for more time based on declarations of alleged virtuous good
intentions. Defendants admit their contractor has not met even the staffing requirements of
the current contract and offer no plan to achieve the necessary enormous increases
anticipated in the final statewide staffing plan. Finally, Plaintiffs maintain Defendants’
anecdotal examples of improvements are overcome by the ongoing, substantial
noncompliance with the Injunction allowing systemic unconstitutional violations to persist
for over 10 years.
A. Legal Standard
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“[A]ll prospective judicial relief (necessarily including the appointment of
receivers) must be accompanied by findings that the relief is ‘narrowly drawn, extends no
further than necessary to correct the violation of the Federal right, and is the least intrusive
means necessary to correct the violation of the Federal right.’” Plata v. Schwarzenegger,
603 F.3d 1088, 1095 (9th Cir. 2010.)
“Receiverships are recognized equitable tools available to the courts to remedy
otherwise uncorrectable violations of the Constitution or laws.” Id. at 1093-94. A receiver
is “appointed by the court to take over the day-to-day management of a prison system or a
segment of it” “where unconstitutional conditions persist despite repeated orders to
remediate.” Id. at 1094; United States v. Hinds Cnty. Bd. of Supervisors, 128 F.4th 616,
636 (5th Cir. 2025) (A receivership appointment is an appropriate sanction when necessary
to remedy a prison’s repeated failures to ensure constitutional prison conditions).
In determining whether appointment of a receiver is appropriate, the Court must
consider (1) whether there is a grave and immediate threat or actuality of harm to plaintiffs;
(2) whether the use of less extreme measures of remediation have been exhausted or would
prove futile; (3) whether continued insistence on compliance with the Court’s orders would
lead only to confrontation and delay; (4) whether there is a lack of leadership to turn the
tide within a reasonable period of time; (5) whether there is bad faith or repeated failure to
implement changes; (6) whether resources are being wasted; and (7) whether a receiver is
likely to provide a relatively quick and efficient remedy. Hinds Cnty., 128 F.4th at 637;
Plata v. Schwarzenegger, No. C01-1351 TEH, 2005 WL 2932253, at *23 (N.D. Cal. Oct.
3, 2005.) The district court should consider each factor, but “the first two . . . are given
predominant weight.” Plata, 2005 WL 2932253 at *23.
B. Discussion
Ordering a receivership is a drastic remedy. The Court has sought and received
extensive briefing and has carefully considered the law, arguments, and evidence presented
by the parties and experts. The Court asked the Monitors to opine on Plaintiffs’ request that
a receiver be appointed. The Monitors filed a 306-page report (Doc. 4968) chronicling
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Defendants’ failure to comply with the Injunction and enumerating the ongoing
unconstitutional medical care within the entire prison system, concluding: “The system
changes required by the Injunction to protect human life and limb and prevent suffering
are still broken.” (Doc. 4968 at 5.) The Monitors posit this finding is brought to bear by the
reality that Defendants are “still struggling to identify and prioritize the changes [they]
need[] to make, let alone actually make those changes.” (Id. at 5.)
Great weight has been placed on the factually well-supported, reliable opinions of
the Monitors. “[T]he most important question a court must consider when deciding whether
to appoint a neutral expert witness is whether doing so will promote accurate fact finding.”
Gordon v Todd, 793 F. Supp.2d 1171, 1179 (E.D. Cal. 2011.) Here, the Court appointed
the Monitors as “its own experts to serve as neutral monitors to evaluate Defendants
performance” under the Injunction (Doc. 4410 at 6.) And it is impossible to exaggerate the
importance of Defendants’ enthusiastic choice of the Monitors as revered experts, to assist
in first drafting the elements of the Injunction, and then to function as Monitors to ensure
Defendants’ compliance. And it is particularly noteworthy that despite Dr. Stern’s previous
criticisms of Defendants’ healthcare when he testified in this case as a witness in 2018, the
Defendants nonetheless welcomed his selection as the Monitor. (Doc. 3921.)
The Injunction required Defendants to provide a monthly report on their compliance
with all elements of the Injunction that were then thoroughly analyzed by the Monitors to
determine Defendants’ performance, and where Defendants specifically failed. As
discussed above, the Monitors offered lessons and suggestions for improvement. In the
beginning the Defendants were receptive to conversations and meetings with the Monitors,
but, after a few months, Defendants refused the Monitors’ overtures and rejected or ignored
most of the Monitors’ recommendations without providing explicit reasons. Now that the
appointment of a receiver looms large, Defendants have become highly critical of the
qualifications, expertise, and opinions of the Monitors, even proffering the astonishing
position that the Monitors’ qualifications and opinions fall far short of the requirements of
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Federal Rule of Evidence 702.36 Either the Defendants are amnestic, or duplicitous, or both.
The Monitors’ reports are thorough, amply supported, and their reasoning is fully
explained. Defendants’ contentions to the contrary border on bad faith.
36 Dr. Stern is a board-certified internist with 25 years’ experience as a correctional
physician in a variety of settings, including as a jail medical director, a regional medical
director for a state DOC, a regional medical director for a for-profit prison health care
vendor, and as assistant secretary/medical director for the Washington State Department of
Corrections. He has provided consultation and assistance on correctional health care to a
variety of organizations and agencies including DHS, USDOJ, Bureau of Justice Statistics,
Bureau of Justice Assistance, National Institute of Corrections, California Attorney
General, Human Rights Watch, ACLU National Prison Project, Federal courts, and the
Namibian Correctional Service, and currently serves as medical advisor to the American
Jail Association and National Sheriffs’ Association. Dr. Stern also conducts research and
teaches at the University of Washington School of Public Health, serves on the editorial
board of the Journal of Correctional Medicine, and is past chair of the education
committees of the American College of Correctional Physicians and the Academic
Consortium on Criminal Justice Health.
Dr. Strick is board certified in Internal Medicine and Infectious Diseases with almost 20
years’ experience working in carceral settings. Her roles in the Washington State
Department of Corrections have included Statewide Infectious Disease Physician, Chair of
Infection Prevention, and Hepatitis C Director. She also established a reentry program to
transition patients with HIV back to the community. She is the Carceral Director for the
Mountain West AIDS Education & Training Center and travels throughout the 9-state
Mountain West region to do education and technical assistance for carceral and community
providers to improve the care of individuals in jails and prisons. Dr. Strick is also a Clinical
Associate Professor at the University of Washington where she sees patients, conducts
research, and teaches medical students and residents about the carceral healthcare system.
Dr. Abplanalp is a licensed clinical psychologist with over two decades of experience in
carceral settings. He received his Ph.D. in Clinical Psychology from the University of
Texas at Austin and completed postdoctoral forensic work at Court Diagnostic and
Treatment Center in Toledo, Ohio and Dorothea Dix Forensic Hospital in Raleigh, North
Carolina. He began working for the Washington State Department of Corrections as both
a psychologist and clinical supervisor in 2001 and, in 2011, he became the first Chief
Psychologist of the Department. During his tenure, he has worked as a clinician, supervisor,
and educator and he developed the statewide curriculum for Suicide Prevention and Mental
Illness, which he presented to health services, custody, and front-line staff in over 300
trainings. In the wake of Hurricanes Maria and Irma in 2017, Dr. Abplanalp was deployed
as part of an Emergency Management Assistance Compact to assist in rebuilding and
fortifying the mental health infrastructure in the U.S. Virgin Islands. He has also served on
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The substantial evidence in the record and the factors required to be established
strongly support granting the Motion for Receiver.
1. Grave and Immediate Threat of Continuing Harm and Actuality
of Harm
There can be no credible disagreement by Defendants that this litigation was
initiated because of a seriously inadequate healthcare system that imperiled the lives of the
prisoners. If not immediately apparent to Defendants at the outset of the case, Defendants
effectively conceded the healthcare was in need of substantial improvement because they
jointly stipulated in 2014 to comply with the numerous terms and requirements
(Performance Measures) of the Stipulated Agreement in response to Plaintiffs’ compelling
allegations of unconstitutional healthcare. And those requirements were strikingly similar
the Crisis Negotiation Team, has been involved in high-risk extraditions with specialized
security teams, and is certified in performing Psychological Autopsies. Over the past
decade, Dr. Abplanalp has been intensely involved in the development, implementation,
monitoring, and improvement of a coordinated system of integrated mental health and
medical care within the Washington Department of Corrections and has worked as a
Correctional Mental Health Consultant in a variety of carceral settings, including prisons,
jails, community mental health agencies, and ICE detention centers. Dr. Abplanalp also
serves as the Mental Health Advisor on the Board of Directors of the American Jail
Association.
Dr. Rainer has been licensed in Washington State as a psychologist for 32 years. She has
worked 26 years as a correctional Psychologist in both direct care and leadership roles, to
include the Director of Behavioral Health and Chief of Psychology. She consults with
correctional agencies committed to improving the care delivered to incarcerated people.
Donna Strugar-Fritsch has more than 30 years of health care policy, administration,
program development, research and evaluation and clinical nursing experience. As a
consultant, she built a strong national consulting capacity in correctional health care over
more than 20 years, and is a nationally recognized expert in the interface of the Affordable
Care Act, Medicaid, and correctional settings; design and implementation of innovative
models for staffing and delivering correctional health care services; and comprehensive
addiction treatment including all FDA-approved forms of Medications for Addiction
Treatment in prisons and jails. She has a deep understanding of health care staffing and
operations in correctional health systems and has helped many prisons and jails improve
access to care and vendor contracting for correctional health services.
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to the requirements of the Injunction, i.e., the Quality Indicators. But as early as 2016,
Defendants largely failed to perform across all Performance Measures and those violations
uncannily resemble the same violations of the Injunction.37 Defendants resolutely denied
violating the Stipulated Agreement, just as they now deny violating the Injunction. And
Defendants’ excuses in 2016 mirror the same excuses they offer in response to their
violations of the Injunction.38
The appalling healthcare conditions culminated in a two-week trial in 2021 where
the dire threat of harm to prisoners was established. The Court found the healthcare
“grossly inadequate” and held it “placed patients at a substantial risk of serious harm,”
staffing was incompetent, and the poor treatment and indifference to patients was
“pervasive,” and in some cases inhumane. (Doc. 4335 at 19-20, 69.)39
Instead of appealing, Defendants engaged with Plaintiffs, the Court, and the
Monitors to devise an Injunction that would end “the unconstitutional substantial risk of
serious harm to Plaintiffs.” The Court declared because of Defendants’ chronic defiance,
the Injunction was Defendants’ last resort to comply with the Constitution. (Doc. 4637 at
8.) And to maximize success, strict adherence was mandated. The Court stated, “The
Court’s patience has run out,” (Id.) and it is clear the Court “cannot impose an injunction
that is even minutely ambiguousb because Defendants have proven they will exploit any
ambiguity to the maximum extent possible.” (Doc. 4410 at 5). The Court demanded the
“changes necessary to redress [Defendants’] failings be substantial.” (Doc. 4410 at 4-5.)
37 Those failures then included deficiencies in prescription medication, the medical record
system, reviewing medical records, diagnostic and chronic care visits, mortality reviews,
and failures regarding overall delays in providing access to care.
38 Between 2016 and 2021, Defendants claimed they “barely missed compliance,”
“noncompliance was based on a technical violation,” violations were “due to third parties’”
“inaction or omissions,” and Defendants claimed their overall compliance with the
Stipulation was allegedly “77-94%.” But the overall administration of healthcare was
demonstrated in numerous hearings as extremely poor. (Doc. 3921 at 24.)
39 “The Mortality reviews demonstrated that despite ten years of litigation, [Defendants
have] never created . . . a policy to [find] systemic issues identified in mortality reviews
and ha[ve] not taken steps to remedy them” and “this constitutes systemic, conscious
disregard of the risk prisoners face.” (Doc. 4335 at 3.)
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Now almost three years after the effective date of the Injunction, Defendants have
continuously violated the Injunction, perpetuating the same unconstitutional risk of grave
harm to the prisoners that has persisted since the outset of the litigation.
The Monitors expressly found Defendants were non-compliant with 131 of 154
Quality Indicators relating to healthcare.40 Corroborating the Monitors’ opinions,
Plaintiffs’ investigators analyzed Defendants’ self-compliance using their database, based
on a recent two-month sample (December 2024 and January 2025), that substantiates the
Monitors’ compliance findings and methodology. (Doc. 4838.) And using Defendants’
database, Plaintiffs’ investigator found substantial support for the Monitors’ conclusions
and methodology regarding the percentage of Defendants’ compliance. (Id.)
Defendants admit violating a number of the Quality Indicators, and, for many where
they differ with the Monitor’s findings of violations, Defendants often (a) acknowledge the
Monitors may be correct; or (b) commit to investigate to determine if the Monitors are
correct; or (c) claim it is impossible to comprehend what the Monitors contend, despite that
the Quality Indicators were drafted by the Defendants and have been in existence since
2023; or (d) assert the objectives and problems identified by the Monitors will likely be
resolved when the PCCM required by the Injunction is finally established, which is
unimaginable because Defendants are nowhere close to attaining it; or (e) commit to
continuing resolving issues with NaphCare.41
40 The Court relies on the Monitors’ Third Interim Report for the number of Quality
Indicators. (Doc. 4968.)
41 Defendants filed the Declaration of Micaela McLane, Director of Nursing, who has been
assigned since April 2025, and who has the lead responsibility to ensure monthly Quality
Indicator assessments align with all requirements and to recommend improvements, and
the Declaration of Raymonda Matheka, who has been the Mental Health Director since
2024. Some examples of their comments in their declarations include:
§ 1.1 Medical acknowledges Monitors “disagreement of selection of cases and
commits to following up with physicians responsible for the assessments.”
§ 1.1(f) Regarding Monitors’ findings that Defendants continue to use favored
samples, Defendants “will determine if functionality can be improved and discuss
issues with physician reviewed.”
§ 1.22 Acknowledge Monitors’ report says tests are not performed because of
transportation issues. Defendants will “follow up” and this is a “priority project.”
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The Court finds the overwhelming evidence establishes Defendants are in violation
of the Injunction perpetuating the grave and immediate threat of actual harm to prisoners.
The Monitors, in reaching their analysis, used information from a variety of sources.
Pursuant to the Injunction, the Monitors were given substantial authority to investigate,
evaluate, and verify compliance through access to the electronic health records, conducting
visits, and analyzing the data collected by Defendants and their agents. The Monitors were
permitted to use information from a variety of sources, including interviews of prisoners,
Defendants’ staff and contractors, complaints from prisoners and all other persons,
Plaintiffs’ counsel, random or purposive view of health records, clinical observations, site
visits, papers, and videos. And Defendants were mandated to cooperate with the Monitors
in data collection.
§ 1.22(d) Defendants acknowledge the error that offsite referrals have included
those not completed and “will improve this.”
§ 1.21(a) Defendants acknowledge Monitors’ report questions the number of
refusals and claims Defendants are “reviewing the process” and will “look whether
improvements are feasible.”
§ 7.4.7 Defendants recognize assessments of the Patient Center Care Model “has
not captured all of the issues encompassed in the Quality Indicators,” particularly
the “role of PCCM.”
§ 11.16 (testing and treatment) Defendants promise to collaborate to improve the
testing.
§ 2.4.1 Regarding mental health: Significant work has been completed very recently
in 2025 that “may address Monitors’ concerns.”
§ 6.2 and § 7.3, which criticize failure to assign a mental health therapist:
Defendants state the “issue may change when PCCM is implemented.”
§ 1.1 Regarding necessary Tech Care modifications, Defendants promise they “will
work with NaphCare.”
§ 1.1(b) Regarding urgent care and whether Defendants have not collected required
data, Defendants admit they have “not successfully implemented the methodology
to date and it is a priority.”
§ 1.21(a) Regarding suicide prevention Defendants state they are “addressing the
issue and anticipate improvements.”
§ 3.4 Language interpretation: Defendants admit it “needs improvement.”
§ 16.3.1 Comprehensive mental health evaluation “to the extent the Monitors are
correct that the assessments are relying on initial assessment . . . rather than more
comprehensive evaluations their criticism is well taken.”
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Apart from establishing serious non-compliance, the Monitors identify the
substantive effects of non-compliance. Attached is a chart demonstrating where
Defendants are non-compliant based on the Monitors’ reliable assessments.i
The Monitors determined Defendants were non-compliant with the core of the
Injunction at sections 1.1 and 1.3, which “describe the backbone of any health care
system,” and are inextricably included in the Injunction. Id. at 45-47. Section1.1 requires
all healthcare and documentation thereof be clinically appropriate, “including, where
relevant to the circumstance and professional’s credential, but not limited to, the
conducting of the history and physical examination, forming and testing a differential
diagnosis, arriving at a diagnosis, and ordering treatment for that diagnosis.” (Doc. 4410
at 11.) Section 1.3 provides “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.” (Id.) Care that is non-compliant with these
provisions “by definition places patients at significant risk of serious harm.” (Doc. 4968 at
45-47.)42
The Monitors noted, according to the most recent contract with NaphCare,
Defendants were required to have 18.8 full-time employee staff physicians and 9.0 full-
time employed medical directors, for a total of 27.8 full-time employed physicians. (Doc.
4968 at 27.) Defendants’ reporting and response to the Motion for Receiver demonstrate
42 See Doc. 4968 at 48 (Defendants self-assess 96% compliance with urgent care provision
in sub provisions 1.1b of Injunction, but Monitors assess as closer to 33%); id. at 49
(Defendants self-assess 79% compliance with non-urgent, episodic care in subprovision
1.1c of Injunction, but Monitors calculate 35% compliance); (id. at 52 (Defendants self-
assess 86% compliance with chronic care provision in section 1.1d of Injunction, but
Monitors assess closer to 35%); id. at 53-57 (Monitors assess noncompliance with inpatient
care provision in 1.1e, but find percentage is inappropriate methodology); id. at 58-59
(Monitors assess non-compliance with off-site specialty referrals provision in section 1.1f
of Injunction and that percentages do not fully capture methodology, Defendants self-
assess at 96% compliance, but Monitors assess 65% compliance.); id. at 60 (Defendants
self-assess 84% compliance with 1.1g of Injunction regarding action taken on post-
hospital, post-emergency room, or specialist recommendations and that percentages do not
fully capture methodology, Defendants self-assess at 96% compliance, but Monitors assess
10% compliance).
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an inability to recognize their own failures and incompetence. Defendants have what they
consider to be 11.5 FTE staff physicians positions filled by 18 physicians (approximately
61% filled), but only 11 of those physicians are board certified or board eligible as required
by the Injunction. (Id.)43 Likewise, although Defendants contend all 9 of the medical
director positions are filled, because only 6 of the 9 physicians are board certified or board
eligible, only 66% are actually filled. (Id.) And Defendants claim NaphCare is offering
competitive salaries, but this is wrong. The Monitors correctly found the increase is
“woefully insufficient,”44 and continues despite the constant entreaties by the Court in the
presence of the Director and his staff that this must be immediately cured. (Id. at 28, 273.)45
And it cannot be overemphasized that Defendants have been frequently told by the
Court that their incompetent and inadequate staffing of healthcare is unconstitutional.
When the case was filed, the Class certification order “identified longstanding staffing
deficiencies.” Then in May 2017, Magistrate Judge Duncan found a “a mere seven staff
physicians and five psychiatrists for the entire ADC prisoner population” was seriously
inadequate. Concomitantly, Defendants heard the shocking testimony of Defendant
Richard Pratt, Interim Director of the Health Services Division, expressing the flagrant
indifference of Corizon, the then-contractor, that: “[The contractor] may well have decided
to pay a fine rather than fill staff positions.” (Doc. 2071 at 85.) Then during the two-week
43 These numbers have changed slightly while the Motion has been pending, but the
underlying issue remains. (See, e.g., Doc. 5040 at 3 (Monitors assert that “Defendants
report that they currently engage 15.3 FTE staff physicians. In fact they only engage no
more than 11 FTE. Second, Defendants focus on informing the Court where they are
compared to where they were. We believe that the focus should be on where they are
compared to where they should be. It is this latter comparison which is much more
determinative of patient safety and led us to the conclusion that staffing remains
dangerously inadequate.”)).
44 The Monitors state “based on [their] experience, employers must pay a premium to
attract health care professionals to work in a prison” and point out that the software used
to evaluate NaphCare’s salaries cannot distinguish prison-based from community work
settings or on-site from remote employment, and likely has little comparative data for the
remote locations where ADCRR prisons are situated.
45 The Director attended all hearings in 2023-2024 where the Court brought poor staffing
to his specific attention.
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trial in 2022, Defendants effectively agreed their current staffing levels were insufficient,
and acknowledged their then-contractor, Centurion, admitted that “if [the contractually
required] staffing levels could be obtained,” it “would be insufficient” to meet healthcare
standards. (Doc. 4335 at 22.) Finally, only three months after the effective date of the
Injunction, the Court was compelled to order Defendants to immediately hire new staff
because they were already in violation of the Injunction, but Defendants failed to comply
with the Court’s order. For Defendants to now suggest they be absolved of their staffing
violations and even exalted with praise because today only 100 contract positions remain
unfilled is preposterous and sustains that they are oblivious to their constitutional
obligations.
The Monitors documented critical deficiencies in implementing the Injunction
requirements relating to patient refusals and informed consent despite the Monitors’
feedback on making relatively simple changes to the refusal process and documentation.
(Doc. 4968 at 29-35.) The Monitors’ investigation found these failures have resulted in
dangerously misinformed refusals of treatment. (See id.)
Defendants, despite the Monitors’ findings, claim there is no grave and immediate
threat, or actuality of harm to the Plaintiff class. In making this assertion, they challenge
the Monitors’ methodologies and state they have a “difference of opinion” of what is
appropriate prison healthcare, without offering a scientifically valid basis. And Defendants
suggest that meeting a high percentage of the Quality Indicators is sufficient compliance.
But it is unimaginable Defendants would disagree that delivery of clinically required
healthcare in prison often presents emergencies and life and death situations for which a
percentage of compliance is consistently inadequate.46
46 For the most recent publication by the Bureau of Justice Statistics on inmate medical and
mental health problems, see Laura M. Maruschak, Jennifer Bronson & Mariel Alper,
Survey of Prison Inmates: 2016: Medical Problems Reported by Prisoners (2021) and
Laura M. Maruschak, Jennifer Bronson & Mariel Alper, Survey of Prison Inmates: 2016:
Indicators of Mental Health Problems Reported by Prisoners (2021); see also Jill Curran,
Brendan Saloner, Tyler N.A. Winkelman & G. Caleb Alexander, Estimated Use of
Prescription Medications among Individuals Incarcerated in Jails and State Prisons in the
US, JAMA Health Forum (Apr. 14, 2023), doi:10.1001/jamahealthforum.2023.0482.
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Moreover, the model of care established by the Injunction with all Quality
Indicators, after months of negotiations, was jointly drafted by the Court, Defendants,
Plaintiffs, and the Monitors. It was to be strictly enforced by the Court. (Doc. 4637 at 8.)
Accordingly, nowhere in the language of the Injunction, or the Court’s approval of it, is
there the slightest implication that partial compliance, i.e., a percentage, would be tolerated.
And describing the Monitors’ findings and analysis, which are supported by voluminous
evidence, as a “difference of opinion” does not overcome their factually reliable
evaluations and conclusions.47
Consistent with the Court’s 2022 Findings (Doc. 4335), these violations were not
then, and are not now, abstract. They are brought to life—or death—by the individuals who
experienced profound delays in receiving treatment or who failed to receive treatment at
all. The Findings included evaluations of fourteen mortality reviews that highlighted the
deficiencies in the care the prisoners received. Those mortality reviews were appalling in
their illustration of the callous, inhumane indifference displayed on a regular basis. But
more than that, the Findings revealed not just that the care received was shocking but, in
many instances, Defendants demonstrated they did not believe the care was in any way
deficient. And it is this belief of Defendants that creates the catastrophic risk of harm to
Plaintiffs.
The Court’s finding that Defendants are in violation of the Injunction establishes a
grave and immediate threat of harm to prisoners, but the same threat of harm is also
independently manifested by the eight deaths reported in the mortality reports occurring in
2023 and 2025. Moreover, the grave continuing harm to the prisoners is separately
demonstrated by the Monitors’ identification in the 300-page report of numerous recent
incidents of Defendants’ maladministration of medical care, including inhumane treatment.
The Monitors evaluated Defendants’ four most recent deaths (as of the date their
report was drafted) and compared those deaths to Defendants’ first four deaths following
47 Again, it is inexcusable for Defendants to now falsely claim the Monitors, for the first
time, provided them with “a detailed review of the healthcare Injunction requirements . . .
for determining compliance and a critique of [Defendants’] performance.”
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issuance of the Injunction. The Monitors believe this comparison sheds light on whether
progress has been made in the delivery of constitutional healthcare and whether Defendants
have implemented the critically necessary self-review process required both by the
Injunction and as necessary to identify problems and correct them so they do not recur.
The relevant facts are below and establish the prisoners experienced “a lack of
timely access to appropriate care by the appropriately skilled professionals.” (Doc. 4335 at
30.)48
a. Death 1
Patient 20 died on March 24, 2025 at the age of 78. He had a history of multiple
stroke and seizure disorder (in addition to other serious issues.) He was seen by a
neurologist on July 11, 2023, and was prescribed an antiseizure medication that improved
his seizures. But on February 20, 2025, the Facility Medical Director saw Patient 20 and
discontinued his seizure medication. The provider failed to review Patient 20’s medical
history because, if he had, the provider would have immediately identified Patient 20 had
an ongoing seizure disorder. Two weeks after discontinuation of the medication, Patient 20
suffered a prolonged seizure requiring intubation and placement in the hospital intensive
care unit. He eventually returned to the prison, and died four days later.
The Monitors acknowledged his co-morbidities contributed to his death, but the
critical failure to review Patient 20’s medical history and his removal from antiseizure
medication “hastened his death” and the Monitors also noted numerous other deficiencies
in Patient 20’s care. Yet, Defendants’ own mortality review “did not identify a single error
nor any room for improvement.” (Doc. 4968 at 8.)
b. Death 2
48 The Monitors outlined their analysis of the eight patients. (Doc. 4968.) In their response,
Defendants submitted the declaration of Dr. Embrey, the Corporate Medical Director for
NaphCare, who disputed some of the Monitors’ factual assertions regarding the patients’
care. (Doc. 4973, Ex. 12.) The Monitors then submitted a supplemental response to
Defendants’ response. (Doc. 5040.) In relevant factual recitations, the comments and
disagreements from Dr. Embrey and the Monitors’ responses are included where relevant.
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Patient 21 was a 78-year-old male who also died on March 24, 2025. He had a
history of cardiac issues, including high blood pressure, high cholesterol, and a cardiac
arrhythmia. On February 9, 2025, he suffered a heart attack that required placement of a
stent in his main coronary artery.
The Monitors “identified several issues of grave concern regarding Defendants’
management of his condition upon return from the hospital.” Specifically, Patient 21 was
prescribed two new blood thinners and was instructed to discontinue his aspirin as the
combination of the medications “greatly increases the risk of serious if not fatal bleeding.”
Yet Patient 21 continued to receive aspirin for an additional 10 days. Second, Patient 21
was referred for a specialty consultation with a cardiologist within one week (by February
21.) It was not scheduled to occur until April 17, at which time Patient 21 had been dead
for nearly one month. Finally, Patient 21 experienced a hypertensive emergency, which
requires emergent treatment, but that treatment was “inappropriately managed at the
facility.” By March 7, Patient 21’s blood pressure had increased to 200/86, which,
according to the Monitors, required emergency intervention. Instead, he was “seen on
March 8 by an RN, acting independently, who failed to recognize the urgency of the
situation.”
Despite the serious errors in Patient 21’s care, Defendants’ mortality review “did
not identify a single error nor any room for improvement.” (Doc. 4968 at 9.)
c. Death 3
Patient 22 was a 48-year-old male who died on March 12, 2025. He developed lung
cancer, which was not diagnosed until it metastasized to the brain.
Patient 22’s friend “was so concerned about the patient’s health that he accompanied
him to medical to help advocate for him to get urgent help.” The friend communicated the
symptoms to the nurse, that his symptoms were urgent, and that Patient 22 said he did not
know how to communicate his symptoms on his own. When Patient 22’s friend mentioned
a possible mental health issue, the nurse—despite that Patient 22 was not on the mental
health caseload—scheduled Patient 22 for a mental health follow-up. The Monitors
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identify this as a “serious error” because the Permanent Injunction explicitly states patients
not on the mental health caseload are required to see a medical provider before placement
on the mental health caseload. The reasoning is straightforward: patients experiencing
clinical symptoms who do not have a mental health diagnosis are frequently experiencing
a physical condition. And here, the change in behavior experienced by Patient 22 was the
result of metastatic brain lesions.
Thereafter, on January 16, medical staff witnessed Patient 22 experience urinary
incontinence. The Monitors point out, this symptom in a 48-year-old male with no history
of incontinence is alarming and suggestive of “a brain lesion or spinal cord damage
requiring emergent treatment.” Instead, the symptom was ignored and Patient 22’s physical
exam was deemed normal.
Patient 22 then received the appointment with the psychiatric provider, who
diagnosed Patient 22 as experiencing “recurrent major depressive disorder” and
“adjustment disorder” despite having had no mental health history and no new
circumstances to which he was adjusting. The Monitors found both diagnoses were
“nonsensical.” The provider also attributed Patient 22’s incontinence to his depression. The
Monitors explained even if Patient 22’s incontinence were attributable to a mental health
condition (that he did not have), it “would be such an extreme symptom of depression that
it should have resulted in immediate admission to a MH Inpatient Unit.” But, instead, the
practitioner gave Patient 22 an antidepressant.
Thereafter, while in the hospital, Patient 22 was diagnosed with metastatic lung
cancer and had one brain lesion surgically resected. He was discharged back to the facility.
Patient 22 was seen by a radiation oncologist on February 11, 2025, and additional imaging
was ordered to prepare for ablative radiation to his brain metastases. The imaging done on
March 10 revealed a “critical situation”: patient 22’s brain was swelling and was “about to
destroy the brainstem.” At that point, Patient 22’s vital signs were “very abnormal,”
including a rapid heart rate of 120. The radiologist documented that the radiologist’s
“critical results team[]” attempted to notify Defendants by phone of Patient 22’s status but
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despite seven attempts, none were successful. According to the Monitors, Patient 22 needed
emergency surgery—i.e. “within minutes to hours.” And the “clinical results team” sent a
fax to Defendants, which was reviewed, but Defendants took no action that day or the next
day. They took no action until March 12, when “there was clinical evidence of actual
herniation of the brain.”
Despite the errors in Patient 22’s care prior to his death, Defendants’ mortality
review “did not identify a single error nor any room for improvement.” (Doc. 4968 at 10.)
d. Death 4
Patient 23 was a 35-year-old male who died on March 21, 2025. Patient 23 had a
history of bipolar disorder. The Monitors “identified several issues of grave concern
regarding [Defendants’] management of his case.” Patient 23 was seen by a nurse (acting
independently) on February 12 for a cough and sore throat that lasted for four days. Patient
23’s oxygen was low—93%—but the nurse ignored it. The nurse also did not do any testing
or arrange for follow-up.
The Monitors explain Patient 23 was “brewing the infection or infections that would
lead to his death . . . .[And] [h]ad the patient been seen by a competent practitioner at this
point, his death would likely have been prevented.” Instead, the nurse ordered over-the-
counter medication and nothing else.
Patient 23 was seen again by a nurse (acting independently) on February 18. Patient
23 declined a physical exam, and he was not referred to a provider. Thereafter, on February
21, when seen at his cell-front for medication distribution, he was found in “acute
respiratory distress.” His cellmate reported Patient 23 had been “very ill for 3 to 4 days.”
Patient 23 “was pale, ‘almost gray,’ and his heart rate was fast (pulse 117.)” Patient 23’s
pulse oxygen was 45%; the Monitors explain levels below 75-80% are considered
“critically low.” The Monitors opine Patient 23 required “immediate evacuation to the
hospital.” But Patient 23 was sent to the medical clinic. Patient 23 died in the hospital of
severe pneumonia. The Monitors conclude the “nine-day delay in the patient receiving
appropriate care from Defendants for a brewing pneumonia erased any chance he had to
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survive the infection.”
Again, despite the errors in Patient 23’s (a 35-year-old) care, Defendants’ mortality
review “did not identify a single error nor any room for improvement.” (Doc. 4968 at 10.)
e. Death 5
Patient 24 was a 48-year-old male who died on July 10, 2023 from pneumonia. The
Monitors identified “at least two significant errors in this patient’s care.” The first was
Defendants’ failure to offer an influenza vaccination, in violation of section 11.4 of the
Permanent Injunction. Because “at least a third of severe cases of influenza can be
prevented by vaccination, failure to provide vaccination likely contributed to his death.”
The second failure was Patient 24 was evaluated by a nurse acting independently on
July 6, 2023. The Monitors further opine that if Patient 24 had been evaluated by a
competent practitioner, his death might have been avoidable.
Despite these two errors, Defendants did not identify any errors or opportunities for
improvement. (Doc. 4968 at 12.)
f. Death 6
Patient 25 was a 60-year-old male who died on July 23, 2023 from metastatic liver
cancer as a result of end stage liver failure due to hepatitis C and alcohol abuse. The
Monitors identified at least three significant failures in Patient 25’s care.
Despite a history of cirrhosis of the liver, Patient 25 was not appropriately screened
for liver cancer. The second error occurred when a provider that saw Patient 25 on July 12,
2023 inappropriately referred him for an urgent paracentesis (procedure to remove excess
fluid) without doing necessary laboratory testing first. This is dangerous according to the
Monitors because of the risks associated with paracentesis without attempting to eliminate
fluid in the abdomen through other means. Finally, the paracentesis was ordered on July
12, 2023 as “urgent,” meaning it needed to take place within one month. But the electronic
health record reflected it was not scheduled to take place until December 4, 2024, almost
18-months later and long after Patient 25 died. This erroneous entry reflected a software
error when the original request was cancelled because Patient 25 died.
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Defendants did not identify any errors in Patient 25’s care. (Doc. 4968 at 12-13.)
g. Death 7
Patient 28 was a 69-year-old male who died on July 29, 2023 from a perforated
stomach ulcer. The Monitors identified at least four significant errors in Patient 28’s care.
Patient 28’s platelet count was noted to be low (112,000; normal range is 150,000-
450,000) on May 17, 2023. A low platelet count can result in bleeding and is concerning
because of the possibility of serious disease. The Monitors noted that because there was
nothing in Patient 28’s electronic health record to explain this low platelet count, a workup
should have been conducted to determine the cause, but it was not. Patient 28 did have
repeat lab work on June 23, 2023. The low platelet count was still present, and in addition,
Patient 28 was now anemic; his hematocrit dropped from 43 to 35.8 in approximately one
month. According to the Monitors this “would raise concern the patient had internal
bleeding.” Moreover, the June 23 test results should have been reviewed within four days
but were not reviewed until July 7, in violation of section 4.4 of the Permanent Injunction.
On the evening of July 4, 2023, Patient 28 was brought to the medical unit by
custody staff. He presented with “low blood pressure, fast heart rate, fever, and low oxygen
levels.” He was sent to the hospital and discovered to have internal bleeding from a stomach
ulcer. He underwent emergency surgery but did not recover. The Monitors also discovered
that, starting in October 2022, Patient 28 was prescribed naproxen twice daily. Patient 28
had low platelets and cirrhosis, which means NSAIDs (like naproxen) are contraindicated
unless absolutely necessary.
Defendants did not identify the first two errors but did identify the third. Their
recommendation was that “patients with risk factors for gastrointestinal bleeding (e.g.,
cirrhosis and low platelets) should only be prescribed chronic NSAIDs when other
treatment options have been explored and the patient has been provided with education
about the risks and benefits of treatment. When chronic NSAIDs are prescribed, then
appropriate treatment with gastro-protective medications (e.g., proton pump inhibitors)
should be utilized.” But the Monitors pointed out that Defendants did not take any action
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with this recommendation; i.e. “analyze why the error occurred,” “incorporate addressing
of the error into the statewide improvement plan, and if remediation is called for, develop
and execute an effective and sustainable remediation plan. Instead, their remediation plan
amounted to just wishful thinking.” (Doc. 4968 at 13-14.)
h. Death 8
Patient 29 was a 40-year-old male who died on July 30, 2023, from complications
following surgery for a bowel perforation due to diverticulitis. Patient 29 was seen in the
medical unit five times (four times by a nurse and one time by an advanced practice
provider) for abdominal symptoms that began on December 29, 2022, including “severe
abdominal pain, nausea, vomiting, and blood in the stool.” No practitioner physically
examined Patient 29 until January 3, 2023, and it was not until the afternoon of January 4,
“after seven days of suffering severe abdominal pain that [Defendants] failed to control,
that [Defendants] finally sent [Patient 29] to the hospital.” Upon arrival at the hospital,
Patient 29 had a perforated colon and surgery was performed immediately.
The Monitors opine that Patient 29’s colon perforated hours or days before he was
sent to the hospital, thereby greatly increasing the risk that surgery was not successful. This
is on top of Defendants’ failure to treat the severe pain Patient 29 experienced.
Defendants identified two errors in Patient 29’s care: that severe abdominal pain
should be escalated to a higher level of care and NSAIDs should be used cautiously in
patients in a high risk of bleeding. But, like Patient 28, Defendants did not take any action
with respect to the identified errors. And the Monitors determined three subsequent deaths
contained the same recommendation regarding escalation of care for prisoners
experiencing severe abdominal pain, thereby “highlighting that the issue had not been
adequately addressed.” (Doc. 4968 at 14-15.)
i. Conclusions from Recent Mortality Reviews
In the Court’s 2022 Findings of Fact following the trial (Doc. 4335), the Court
concluded from the mortality reviews:
The mortality reviews illustrate the harm that routinely befalls prisoners
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because they do not receive timely and adequate health care. The common
theme is nurses repeatedly are unable to properly diagnose health care issues
and fail to refer prisoners to a provider.
***
The deaths outlined above, some very recent, were not aberrations or
corrective action would have been implemented. No such evidence was
introduced because it does not exist. Defendants’ failure to take any action
in response to such obvious deficiencies up to the date of trial is evidence
Defendants are content to continue using nurses
***
Using nurses as the first line, and often last line, for providing care is
medically unacceptable. While using nurses in this way is driven by a lack
of higher-level staffing, that does not excuse Defendants from adopting a
system that leads to preventable deaths.
(Doc. 4335 at 41-44.)
The Monitors’ reviews of the deaths in 2023 and 2025 show not only has that
practice continued unabated but, when performing mortality reviews, Defendants continue
to fail to identify serious failures or take any action to prevent their recurrence. Moreover,
Defendants have shown a complete inability or unwillingness, or both, to recognize and
correct their failures, exacerbating the grave and continuing threat of harm and actual harm
suffered by inmates. Further, it is important to note that in contrast to the numerous
mortality reports presented as evidence at the 2021 trial, which were some of the most
egregious examples of failures, the Monitors restricted their selection to a very few in 2023
and 2025. Notably, however, all eight selected demonstrated poor analysis and review. And
it deserves repeating, Defendants represented to the Court in March 2024 that Dr. Phillips
intended to “aggressively make improvements in the mortality reports.” (See, supra,
footnote 29.) Clearly Dr. Phillips was unsuccessful as four of the deaths reported in the
Monitors’ recent analysis occurred in 2025.49
49 Defendants, in response to the Motion for Receiver, noted that the Mortality Review
Committee has very recently made “several recommendations for corrective action” of
poor treatment of patients, which is painfully overdue. (See Doc. 4973 at 15.)
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In addition, the Monitors have pinpointed systemic failures that directly violate the
Injunction and place prisoners at grave risk of imminent harm.50 In evaluating whether
prisoners are given enough information for informed refusals of medical care, the Monitors
found common situations where prisoners’ refusals were not informed in violation of the
Injunction. This was exemplified by Patient 33, who decided to stop his medication to treat
his opiate use disorder after an 11 second interaction with an LPN at his cell front in April
2025. (Doc. 4968 at 30.) The Monitors concluded there was no chance Patient 33 could
have been informed of the serious harmful consequences of discontinuing medication for
opiate use disorder during the 11-second interaction. Similarly, Patient 43 had a chronic
care visit scheduled for April 30, 2025, but because he incorrectly believed he no longer
had hepatitis-C, he signed a blank refusal form that was slipped under his cell door, which
he signed at 10:07 a.m.; a medical assistant signed the document in the space under the
patient’s signature 53 minutes later falsely indicating that they were present to obtain the
refusal from the patient, but at no point within the 3-day window required by the Injunction
did any practitioner meet with Patient 43 to explain to him that he still had hepatitis-C or
the consequence of refusing his visit for hepatitis-C treatment. (Id. at 31.)
Additionally, Patient 34 had an off-site appointment scheduled with a
gastroenterologist on April 23, 2025 for a colonoscopy due to his familial history of colon
cancer; Patient 34 was not told why he was being sent to a “stomach doctor” and when he
refused the appointment, a nurse spent 15 seconds at his cell administering medication and
the Monitors concluded she could not have obtained informed consent for the refusal while
administering medication in that short period of time. (Id.at 33.) The refusal form was again
signed 5 hours later by a medical assistant falsely indicating that the assistant was present
to obtain refusal from the patient. (Id.)
In August 2024, Patient 37 reported to the Monitors that refusals are sometimes just
50 Although the Court highlights some examples here, the Monitors have documented
numerous examples of violations of the Injunction and the serious risks of harm posed to
prisoners as a result of the noncompliance, as set forth in their Reports, in addition to their
statistical analysis of non-compliance with the Injunction.
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based on “word of mouth” from officers. (Id. at 34.) Patient 60 submitted an HNR on
February 3 stating, “I recently fell from the top bunk directly on to my back. Not only was
the wind completely knocked out of me, but I also may have dislocated a rib as I can’t
hardly move left to right, up & down. Struggling to climb to bunk.” Though the patient
only submitted one request, there are 3 separate entries closing out this request in the
patient’s EHR on February 7, two indicating that the appointment was cancelled and one
that it was refused, but there is no evidence that he actually refused or that any health care
staff member had a direct interaction with the patient to confirm he no longer needed to be
seen. (Id. at 74.)
Patient 61 had an appointment to see a practitioner as a follow-up to a visit with an
orthopedic surgeon who recommended the patient have surgery to repair a torn ligament in
his knee. There is a document with the word “refusal” executed by a medical assistant who
somehow heard from a correctional officer that the patient “did not want to come to
medical.” His visit was cancelled in direct violation of Injunction provision 1.21b. (Id. at
75.)
Patient 62 was referred to see a cardiologist on February 12, 2025 due to an
abnormal EKG that raised concerns that he might have blockages of arteries in his heart.
A refusal form indicates that the patient is refusing a “med run” with the reason given,
“don’t need it” and was signed by an LPN. The refusal does not address cardiology, but
the referral to the cardiologist was cancelled by an unidentified person without explanation
and without rescheduling in direct violation of Injunction provision 1.21c. (Id. at 76.)
Likewise, in evaluating whether emergent and urgent care is given in compliance
with the Injunction, the Monitors noted examples of seriously deficient emergent and
urgent care, in violation of the Injunction posing an obvious risk to the prisoner’s health
and safety.
Patient 44 has a history of coronary heart disease, high cholesterol, asthma, and
gastric reflux disease. At 11:45 PM on February 19, 2025, he complained of acute, severe
(7 to 10 out of 10) left-sided chest pain with left hand numbness, and initially accompanied
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by nausea. Despite two dangerously high blood pressure readings, an EKG showing an
electrical abnormality, abnormal skin color, and pain reproducible with palpation, a
practitioner who neither saw or examined the patient made the decision to give a single
dose of a blood pressure medication, a prescription for a stomach medication, and a drug
test in the morning. (Id. at 46.) The Monitors concluded that “[f]ailure to arrange [the
patient’s] immediate evacuation put the patient at significant risk of death from a heart
attack.” (Id. at 47.)
Patient 45 is a 71-year-old male with 21 problems on his problem list, including
asthma, hiatal hernia, gastric polyps, prediabetes, H. pylori infection, gastroesophageal
reflux, traumatic brain injury, hyperlipidemia, seizure disorder, and a lumbar spine
compression fracture for which he is on 12 medications. He had an acute episode of
vomiting “coffee grounds” just past midnight on February 25, 2025, and was seen by an
RN, acting independently, using a nursing protocol prohibited by the Injunction. The nurse
ordered medication (without a legal physician’s order) to stop the vomiting and ordered no
further monitoring, and although the patient vomited again 5 more times, absent any
instructions from the nurse, staff did nothing in response to additional vomiting. The
Monitors concluded that “[t]his care put the patient as significant risk of massive blood
loss and possible death” given that emesis described as coffee grounds is indicative of
internal bleeding until proven otherwise requires, at a minimum, close observation for the
next several hours and an emergent blood test to check for bleeding. (Id. at 48.)
The Monitors also detailed examples regarding non-urgent, episodic care creating
grave harm to patients.
Patient 46 had 6 separate non-urgent encounters over a 6-month period starting in
November 2024 that “all demonstrated a failure of multiple different professionals to fulfill
the requirements of this provision to provide clinically appropriate episodic care, ultimately
leading to a potentially life-threatening complication.” (Id. at 49.) In his first visit, despite
showing symptoms of a bladder obstruction, a practitioner, without seeing Patient 46
simply ordered antibiotics for a bladder infection, even though the patient’s complaints
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indicated a need for urgent treatment. In his second visit, a week later, Patient 46 reported
his symptoms had not improved with the antibiotics and an RN acting independently (in
direct violation of the Injunction) failed to examine the bladder, prostate, or kidneys. A
week later, the patient was seen again by an RN reporting burning while urinating and back
and flank pain; the RN again directly violated the Injunction and repeated the failures of
the week before. Four months later, the patient was again seen by an RN for urinary
symptoms, and the RN practicing independently (in violation of the Injunction) did not
examine the prostate, bladder, or kidney and inappropriately ordered antibiotics. About two
weeks later, the Patient reported incontinence and requested to be seen ASAP, but despite
the emergent nature of his complaint, he was not seen until six days later; at which point,
he had urinary incontinence for two weeks and a non-physician practitioner, in violation of
the Injunction, who treated Plaintiff, did not conduct a prostate, bladder, or kidney exam,
failed to appreciate the urgency of the situation, and instead ordered non-urgent blood tests,
without including a blood test measuring kidney function, and ordered a non-urgent
ultrasound of the patient’s prostate, despite the urgency of the symptoms.
A week later, the patient was still incontinent, asked for the insertion of a foley
catheter despite that the patient knew insertion of such catheter is extremely painful, which
would have prevented future hospitalization, but the patient was instead placed on more
antibiotics. Four days later, the patient exhibited acute changes in his mental status and was
finally sent to the emergency room with the findings: “His mental confusion was a result
of urinary retention resulting in acute kidney failure complicated by potentially life-
threatening blood electrolyte abnormalities (hyperkalemia, hyponatremia, and acidosis),
and a urinary tract infection due to a multidrug resistant organism, potentially the result of
the misuse of several antibiotics.” “Given the high degree of antibiotic resistance of this
organism, infection prevention precautions should have been put in place upon return to
ADCRR to prevent the spread of this very dangerous and difficult-to-treat organism to
other sick patients, putting them at significant risk of serious harm. No such precautions
were put into place.” (Id. at 50-51.)
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Patient 47 also suffered a kidney function that significantly declined in the latter
half of 2024 and both an ultrasound on November 20, 2024 and then a CT scan on
December 31, 2024 showed severe back-up of urine into his kidneys (hydronephrosis), but
his providers failed to recognize the urgency of the problem, and “[d]ue to the delay in
clinically appropriate care, the patient now has irreversible kidney damage that the kidney
specialist thinks will likely require hemodialysis.” “Despite the complexity of his case, the
patient is assigned to an APP, instead of a physician (in violation of Injunction sections 6.2
and 7.3.) However, the assignment is meaningless because over the course of six primary
care visits in nine months, the patient has never seen the assigned PCP, saw the same APP
for only two of the visits, two different APPs for two other visits, a physician for one visit,
and a different physician for a second visit.” (Id. at 52.)
Patient 49 was undergoing treatment for opioid use disorder, and although a relapse
was indicated from the inappropriate care he received in June 2024, in July 2024, a MOUD
practitioner wrongly discontinued buprenorphine when the patient did not come to the
appointment and an LPN and correctional officer subsequently signed a “refusal” form on
July 22, 2024 (in violation of Injunction section 1.21) “which has no meaning nor value as
neither actor is competent to conduct an informed refusal.” “Thus, despite the ongoing
significant risk of overdose associated with his opioid use disorder, ADCRR failed to
engage this patient.” On August 1, 2024, the patient presented with acute urinary
symptoms and was diagnosed with a kidney infection, but though his urine also showed
large amounts of glucose and ketones consistent with diabetes and possibly ketoacidosis, a
life-threatening and urgent complication of diabetes and his kidney infection and diabetes
required an examination by a provider and immediate blood testing, no further testing was
done, and he was merely started on medications for diabetes and sent back to his living
unit. On August 2, 2024, an ICS was triggered because the patient had worsening
abdominal pain, he was sent to the ER and diagnosed with sepsis that had resulted in the
kidney infection (pyelonephritis) and uncontrolled diabetes and he was started on
intravenous antibiotics, but left the hospital against medical advice after two days. A blood
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infection from MRSA requires a minimum of 10 days of antibiotics (ideally intravenously)
and without proper treatment often causes secondary infection in the body (e.g., heart
valve, organs, bone.) The remote APP, charged with reviewing his condition immediately
upon return to the facility on August 4, 2024, failed to seek any records regarding his
hospital stay until almost two weeks later on August 14, 2024. Due to this information
vacuum, Defendants did not provide any effective antibiotics for his serious kidney and
blood stream infection and never addressed with this patient the ongoing risk of inadequate
treatment of his life-threatening infection. His diabetes also remained out of control (blood
glucose greater than 400, extremely elevated.) Thus, he remained at ongoing risk of serious
medical harm from both infection and diabetes. An on-site practitioner saw the patient on
August 23, 2024, almost 3 weeks after he left the hospital, but failed to address the patient’s
blood infection or high sugars, which were urgent clinical issues. A different practitioner
started long-acting insulin without seeing the patient. On September 1, 2024, the patient
was first seen for neck pain by a nurse and told he was sleeping wrong. He was seen by
nursing again on September 3 and 4, 2024 for ongoing neck pain and stiffness.
Each of these visits, conducted by a nurse practicing independently, were clear
violations of the Injunction (section 7.4.7) and caused harm, as his untreated infection had
now invaded the bones of his spine and required urgent management. An on-site
practitioner saw the patient on September 6, 2024, and gave him muscle relaxants, warm
compresses, and a referral to physical therapy. The practitioner noted needle marks on the
patient’s carotid veins, a sign he might still be using drugs intravenously, which increases
his risk of re-infection of his blood and the ongoing risk from his inadequately treated prior
blood infection. The practitioner should have, but did not, consider and evaluate the patient
for serious infection based on his clinical history (in violation of Injunction section 1.1.)
Nurses, acting independently, again saw the patient for ongoing head and neck pain on
September 17, 23, and 24, 2024, when he was finally referred back to a practitioner. He
eventually had blood tests drawn on September 26, 2024, which were reported back to
Defendants on September 28, 2024, but were not reviewed until October 7, 2024 (in
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violation of Injunction section 4.3.) On September 28, 2024 the patient was finally sent
emergently to the hospital due to headache, decreased level of consciousness, incontinence,
lethargy, rocking in pain, and shivering. His MRSA infection now involved his blood, heart
valve, heart tissue, brain, and spine. The infection was so severe at this point, that it
required not only intravenous antibiotics, but also antibiotics administered directly into the
fluid around the brain. A note on October 19, 2024 documented a call between the doctor
in the hospital and a practitioner at the prison in preparation for discharge that requested
weekly labs results be faxed to the hospital for review until the patient was predicted to be
off intravenous antibiotics (November 20, 2024) and follow-up with a heart specialist and
an infectious disease specialist around the time antibiotics were to be ending. None of these
necessary measures occurred as requested (in violation of Injunction section 1.1.)
Upon return from the hospital on October 22, 2024, Defendants placed the patient
in an IPC or SNU bed (the medical records contain contradicting statements.) The patient
had vital signs and nursing assessments conducted at haphazardly spaced intervals,
sometimes going days without any vital signs or a nursing assessment which was not
clinically appropriate based on the patient’s clinical acuity (in violation of Injunction
section 7.6.)
Given his condition, this lack of adequate nursing care
placed him at great risk for serious medical complications. In
light of the patient’s known serious heart, brain, and spine
infection in the setting of poorly controlled diabetes, he also
required daily examinations by a practitioner upon admission
back to [Defendants], if not more frequent examinations,
especially when he started complaining of worsening neck pain
and new urinary incontinence on November 6, 2024. Instead,
from the date of discharge from the hospital (October 22, 2024)
until December 7, 2024, practitioner care was provided only
via telehealth using remote personnel and only on the
following dates: October 22, 23, 25, November 6, 19, 21, 26,
29, and December 1, 2024. During this time period, he was
never once examined by a provider for changes in his heart,
brain, or spinal cord function, despite their highly vulnerable
status. His antibiotics were discontinued on November 20,
2024 without any clinical reassessment by an onsite provider
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or outside specialist to determine if this was still clinically
appropriate. This was extremely dangerous as it is important to
ensure a serious infection is improving based on clinical
signs/symptoms and laboratory tests before stopping a course
of intravenous antibiotics and to establish a long-term
treatment plan (in violation of section 1.1.) In fact, this patient
did not see an on-site provider until December 7, 2024, almost
six weeks after his hospitalization, and only after going back
to the hospital on December 1, 2024 for worsening symptoms.
Due to the seriousness of the infection, even after completing
a course of intravenous antibiotics, he was started on a year-
long course of oral antibiotics at the hospital. The patient was
not scheduled with a neurosurgical specialist until March 7,
despite discharge from the hospital on October 22, 2024 with
instructions to wear a cervical collar at all times due to concern
about the stability of the bones in his neck and compression of
his spinal cord. The cardiology consultation that was supposed
to occur in late November 2024 for his serious heart infection
was not scheduled to take place until February 10, and then was
rescheduled to April 17 due to insufficient ADCRR
transportation resources. The infectious disease consultation to
follow-up on the overall management his life-threatening
infection that was also supposed to occur in late November is
still not scheduled as of June 23.
(Id. at 53-57.)
Patient 50 is a 41-year-old male with a number of serious conditions, including heart
disease, was seen on February 19, 2025 complaining of intermittent chest pain and
experiencing a discharge of the internal defibrillator. The APP did not obtain further
essential history and examination and noted she was unable to conduct a physical exam
due to telemedicine, but made no effort to have a physical examination scheduled. Despite
that these symptoms required urgent or emergency referral to a cardiologist, the APP
ordered a routine referral. This was the first time this patient saw this APP and over the
course of six months since his arrival in early January 2025, Defendants assigned him a
new PCP 18 times, only 2 of those assignments were to physicians, and only for a total of
5 days; the rest were all APPs (or indeterminate.)
Patient 51 was found to have an abdominal aortic aneurysm during a hospitalization
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and incorrectly referred to a cardiologist rather than a cardiovascular surgeon. The
Monitors concluded that “in light of the great delays ADCRR is experiencing in getting
patients to the specialists they need to see on time due, in part, to caps on daily custody
transportations . . . such inappropriate referrals exacerbate those delays, indirectly leading
to a dangerous delay of more urgent and necessary consults.” (Id. at 58-59.)
Patient 52 was diagnosed with multiple myeloma, a serious blood cancer, during a
hospitalization, and upon discharge on February 20, 2025, hospital specialists
recommended that he receive the next dose of chemotherapy the following day, and then
see the oncologist two to three days later, but the patient did not have the chemotherapy
for 5 weeks, and did not see the oncologist until March 14, and Defendants did not provide
the oncologist the medical records. The Monitors opined that “[f]ailure to arrange timely
continuation of the chemotherapy to bring the cancer under control started in the hospital,
put the patient at significant risk of serious harm.” (Id. at 60.)
Patient 53 has Type 2 diabetes and is on insulin; the order to have his blood glucose
checked every morning expired on March 10, 2025 and, since then, he has received
inconsistent blood tests. The Monitors conclude “This above continuing error in nursing
care might have been noticed had the patient had a primary care practitioner and had been
receiving chronic care for his diabetes. Instead, he was last seen on March 5 by an APP
other than his assigned PCP (in violation of Injunction section 7.2) for diabetes. The APP’s
plan for management of the patient’s diabetes was for him to return to the clinic if the
patient felt it was necessary or had any concerns about diabetes. There was a chronic care
clinic appointment scheduled for June 16, but that date has come and gone without a visit
(in violation of Injunction section 1.22c.)” (Id. at 62-63.)
Patient 54 had an MRI ordered in response to a concern about a spinal cord mass on
February 25, 2025. Defendants did not schedule the MRI to be completed until April 4, in
part because of a failure to treat the situation with sufficient urgency and in part due to
transportation being unavailable, which risked irreparable harm because a mass on the
spinal cord could cause irreversible paralysis. The April 4, 2025 MRI did not occur;
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although this was not the fault of the Defendants, it was not rescheduled immediately and
was not completed until May 9, 2025. The Monitors opine that the 9-10 week delay posed
a serious risk of harm to Patient 54. (Id. at 64-65.)
Patient 58 has Hodgkin’s Lymphoma and was last seen by an oncologist in July
2024. Despite evidence of possible cancer spread and a recommendation from the
oncologist that the patient see an oncologist specializing in lymphoma, the appointment
was not made for more than 8 months, which caused “avoidable suffering due to inadequate
pain management.” (Doc. 4968 at 69-70.)51
Patient 59 has HCV-related liver cancer. On September 20, 2024, a surgeon
recommended that Defendants refer him to an interventional radiologist to ablate two
cancerous lesions in the liver and then obtain an MRI four months hence. The APP ordered
the referral as “routine,” i.e., within 2 months (in violation of the Injunction section 1.1.)
The patient’s assigned PCP was another APP (in violation of the Injunction, section 6.1-
6.2.) The first APP’s order was ignored (in violation of the Injunction, section 1.22) and he
was not seen. The referral to remove the cancer, which, if completed as ordered, should
have been completed by November 30, 2024 was not scheduled until January 3 (in violation
of the Injunction, section 1.22d), but the removal of the cancer did not occur on this date,
and instead, the patient was mistakenly sent for another MRI, which MRI showed the larger
of the two cancers had grown by more than 50% from 42 mm to 66 mm. On January 23,
an oncologist saw the patient and reiterated that the patient needed to be seen by the
interventional radiologist STAT sending back a hand-written note with the patient. Due to
his concern that the patient’s care was not being addressed, he also followed up with a
typed note containing the need for a STAT referral and stating “This was conveyed to the
prison via notes, as well as, a phone call to the prison coordinator.”
The handwritten note has been in the patient’s chart since January 23, 2025, and as
of July 2025 had not been reviewed by a clinician (in violation of Injunction section 4.4.2
requiring review within four days.) On April 28, 2025, an APP who was not the patient’s
51 This Patient had not yet been seen by the specialist at the time of the Monitor’s report.
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PCP saw the patient in a primary care visit (in violation of Injunction section 6.1/6.2 and
in violation of Injunction section 6.3), noted the need for an urgent visit with an
interventional radiologist to ablate the cancer lesion in the liver and ordered it with urgent
priority, but it was not scheduled to take place until June 5 (in violation of the Injunction,
section 1.22d.)
The Monitors opine that as a result of these numerous violations of the Injunction,
a patient with potentially curable liver cancer that was first identified on September 20,
2024, for whom removal of the cancer should have taken place by the end of September,
2024, did not have that treatment until June 5, 2025 more than nine months later, resulting
in progression of cancer, and decreased overall rate of survival. (Id. at 70-72.)
Patient 64 was seen for management of his diabetes on February 20, 2025. During
the visit, it was noted a diabetes-related test from December was mild to moderately
elevated; the practitioner ordered a repeat test, which was returned on February 22, 2025
showing that his diabetes was now much more poorly controlled. The practitioner did not
review the result in a timely manner (in violation of Injunction section 4.4.2.) As a result,
the patient had a very abnormal test result on February 22 that was not shared with the
patient until April 22, not treated in the interim, and for which there was an intentional plan
that the patient would not receive treatment until May 2, almost 3 months later (in violation
of Injunction section 1.1) placing the patient at risk of serious harm. (Id. at 79.)
Patient 70, a 21-year-old Spanish-speaking male, was initially seen by a nurse on
February 1, 2025 at approximately 9:30 a.m. without an interpreter (in violation of
Injunction section 3.1) for a complaint of constant right upper quadrant abdominal pain
with nausea and vomiting 15 times, starting that day. The patient was noted to be pale with
abdominal pain on exam in the right upper quadrant. A remote practitioner prescribed
fluids by vein and mouth and ordered anti-nausea medications, and directed the
practitioner be updated in one hour, but no one ever did any follow up. The patient returned
the next day with 9/10 abdominal pain and nausea. A nurse, practicing independently, cared
for the patient using a disallowed Abdominal Pain or Injuries Nursing Protocol. The patient
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was seen again by an RN on February 3, 2025 for continuing nausea and a loose stool, low-
grade fever of 100.9, and abdominal pain 10 out of 10. The patient was put on a bland diet
and full liquid diet simultaneously and told to drink fluids and rest, was given an
antidiarrheal even though he said he only had one stool in the past 24 hours, and the nurse
obtained an order for acetaminophen from a practitioner since it was not available in
commissary, but a provider still never saw the patient and there is no indication that the
nurse discussed the case with the practitioner beyond asking for permission to use stock
acetaminophen.
On February 5, 2025, the patient was seen by yet another nurse because he now had
fever, chills, headache, and dizziness. Although he had a fever, the nurse told him to come
back if “any other [symptoms] return.” On February 6, 2025, he was seen for the sixth time
with intermittent right upper quadrant abdominal with chills all night, pain when his
abdomen was pressed and a fever of 102. He was given acetaminophen and a practitioner
ordered laboratory tests and an abdominal ultrasound without seeing the patient or sending
the patient to the ER. The ultrasound was not done until the next day, February 7, resulting
in the patient being sent immediately to the hospital due to a finding of acute inflammation
of the gallbladder with a gallstone in the duct on ultrasound. He underwent urgent surgery.
During the operation, the degree of inflammation present made the surgery difficult. The
Monitors opine that the delay in care due to the repeated nurse visits could have led to
sepsis and death, and likely increased the patient’s risk of surgical complications due to the
amount of inflammation present. There were numerous violations of section 1.1 of the
Injunction throughout this patient’s care. (Id. at 91-92.)
Patient 78 is a 29-year-old male with Type 1 Diabetes on insulin and has suffered 4
episodes of low blood sugar, only receiving insulin once he becomes delirious or
unconscious, which could have been avoided by allowing him to have oral glucose in his
possession in violation of Injunction provision 10.5.5. Allowing low blood sugar to the
point of unconsciousness in Patient 78 presents a risk of permanent brain damage or death.
(Id. at 112.)
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All of the above examples identified by the Monitors in their report echo the same
unconstitutional care presented during the 2021 trial. And they reflect, despite Defendants’
promises to address them by strictly adhering to the requirements of the Injunction,
prisoners still remain exposed to an intolerable grave and immediate threat of continuing
harm and suffering because the systemic deficiencies pervade the administration of health
care.
Accordingly, the first factor supports the appointment of a receiver. See United
States v. Hinds Cnty., No. 3:16-CV-489-CWR-BWR, 2023 WL 1186925, at *12 (S.D.
Miss. Jan. 30, 2023) (first Plata factor favors the appointment of a receiver where “the
conditions have not improved, nor has the situation become any less unconstitutional since
[defendant] was last directed to remedy the problems.”) (internal quotations and citation
omitted); Nunez v. New York City Dep’t of Correction, 782 F. Supp. 3d 146, 161–62
(S.D.N.Y. 2025), reconsideration denied, No. 11-CV-5845-LTS-RWL, 2025 WL 2939046
(S.D.N.Y. Oct. 16, 2025) (same.)
2. Exhaustion or Futility of Less Extreme Measures
Since this litigation commenced, rather than imposing the most punitive sanctions,
the Court has painstakingly sought to and imposed the least restrictive measures and
requirements on Defendants to incentivize compliance with the Constitution. Magistrate
Judge David Duncan was devoted to tirelessly working with both parties to design an
agreement that created medical Performance Measures that Defendants unreservedly
agreed to fulfill.
But between 2016 and July 2021, Plaintiffs, frustrated with Defendants’ persistent
unconstitutional conduct, filed twelve motions to enforce the Stipulation, followed by
multiple evidentiary hearings and status conferences which resulted in dozens of orders
with detailed directions mandating Defendants comply with the 2014 Stipulation. What
followed was three Orders to Show Cause why Defendants should not be held in contempt,
which required the Court appoint experts, resulting in Defendants being held in contempt
twice. They were fined millions of dollars upheld on appeal. (See, e.g., Docs. 2898, 3861.)
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Finally, an exasperated Court found Defendants had blatantly refused to comply with the
Stipulation, having offered baseless legal and factual reasons. The substantial fines, and
threats of more, proved worthless as an attempt to bring Defendants into constitutional
compliance. (Doc. 4335 at 4.)
The Court appointed many experts and held a bench trial in 2021, which disclosed
even more shocking, unconstitutional healthcare, including what can only be described as
cruelty. One prisoner suffering extreme pain at the end of life was refused palliative care
by the private contractor, Centurion, because he had been designated “Do Not Resuscitate,”
which, as a matter of simple common sense, is irrelevant to palliative care. Consequently,
“his cachectic body was racked with pain, and he wasted away with no reasonable
assistance from medical science in the form of comfort or compassionate pain control.”
(Doc. 4335 at 53.)
The 200-page 2022 Order containing Findings of Fact identified with graphic detail
that if Defendants had ever intended to abide by the 2014 Joint Agreement, they abjectly
failed. Thus, the long and difficult history of Defendants’ noncompliance throughout the
litigation informed the Court that robust, stringent, firm barriers and requirements were
necessary to compel Defendants to constitutional compliance. Thus, the uniformly agreed
upon 2023 Injunction emphasized it was inspired by the many years of Defendants’
recalcitrance and resistance to change such that the Court would demand strict compliance.
The Court stated, “the changes necessary to redress the failures will be substantial.” (Doc.
4410 at 4.) And “significant detail regarding medical care [and] mental healthcare” will be
clearly articulated. (Id.)
Defendants offer the appropriate period for consideration for this motion is the time
since the April 2023 entry of the Injunction because the Injunction “dramatically altered
what the Department is required to do.” (Doc. 4818 at 18.) This reflects Defendants’
profound misunderstanding of the law and facts of this litigation. The alleged
unconstitutional violations by the Defendants in the complaint are the same
unconstitutional violations that have occurred throughout the long history of this litigation.
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From the beginning, Defendants were alleged to have failed to provide medical and mental
health care as required by the Constitution, and the Injunction, which Defendants helped
draft and to which they stipulated in 2023, reflects the exact same violations that have
persisted throughout this litigation. The preamble to the Injunction reads the “unusual
scope of this Injunction is informed by Defendants’ actions throughout the case . . . the
Court cannot impose an Injunction that is even minutely ambiguous because Defendants
have proven they will exploit any ambiguity to the maximum extent possible.” And the
breadth of the Injunction is not a “dramatic” alteration of Defendants’ obligations. Rather,
it is a comprehensive elucidation of what has always been required of the Defendants. And
the obligations of the Injunction are the same as those required of Defendants in the 2014
Joint Stipulation.
The 2023 Injunction—a much less extreme measure than receivership—was
ordered with the manifest goal of offering Defendants a hoped-for final opportunity to
remedy their constitutional violations. This less restrictive sanction designed to invite
Defendants’ compliance has failed again. (See Doc. 4410 at 2 n.1 (“The decision not 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.
. . . Any failure to act in good faith or to meaningfully comply with this Injunction will
revive consideration of appointing a receiver.”) (emphasis added).) The history of the
Injunction bears briefly repeating.
As noted above, since entry of the Injunction, Defendants’ paltry efforts to remedy
the constitutional violations in the provision of healthcare have been in substantial
conformity with their behavior throughout the litigation. Within three months of the
effective date of the Injunction, in July 2023, Defendants were in fundamental violation
because of serious lack of critical staffing. A series of lengthy hearings, attended by
Director Thornell, were held from August 2023 to May 2024 to prompt Defendants into
compliance. Plaintiffs and the Court refrained, at each of those hearings, from initiating
immediate contempt sanctions and Defendants were repeatedly urged by the Court to find
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ways to meet the requirements of the Injunction. Instead, Defendants, in violation of the
Injunction and law, repeatedly placed the entire blame on the contractor, NaphCare. The
Court emphasized to Director Thornell at the March 2024 hearing that compliance,
including increasing staff, was essential. The Court inquired what he planned to which he
responded: “[w]e discuss it” and he has “sent letters.”
Also of significance is Defendants’ startling response in 2024 to the Monitors’
opinions in which Defendants stated that the Monitors failed to provide a “how-to” plan to
achieve compliance, which was never contemplated by the Injunction. And Defendants
have repeatedly attempted to excuse their conduct by arguing funds are not available and
the legislative process to seek more funds is impractical, unworkable, and essentially
nonfunctioning. In particular, regarding attempted funding of the Pilot project, the
Defendants initially resisted and informed the Court the problem was not with Defendants
but because of the “NaphCare contract” and the “healthcare” generally. Defendants stated:
“Because for this fiscal year they’re already millions of dollars over budget because of the
Injunction and the healthcare and the NaphCare contract.” (Doc. 4634 at 112.) Defendants
added, “we don’t have the money . . . . It would require a new contract with NaphCare. It
would require approval of the JLBC.” The mutually agreed upon Pilot was ordered to assist
Defendants in shifting to the PCCM and to allow for a smaller initial implementation by
Defendants, rather than requiring implementation of the entire, much larger staffing plan
across all facilities. However, Defendants’ participation was so deficient that it completely
undermined any confidence in their ability to ever implement the PCCM and more widely.
Again, Defendants are non-compliant with 131 of 154 Quality Indicators of the
Injunction. (See endnote 1.) Defendants have failed to accept the feedback, instruction, and
coaching from the neutral Monitors. Although Defendants chose the Monitors, who “have
been providing such feedback, heavily, in formal reports, in informal documents, and—
over hundreds of hours—orally, since the inception of the Injunction (if not before), [and]
have also offered numerous additional meetings with the Health Services Division staff to
assist Defendants with reviewing and understanding the requirements of the Injunction and
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[the Monitors’] methodology,” Defendants “declined” “those offers.” (Doc. 5040 at 5.)
Defendants have nonsensically claimed that hiring “an individual or individuals with
significant health care management experience to help Defendants reform the current
system,” though less extreme than a receivership, would be duplicative and unnecessary
given their intent to receive recommendations from a consulting firm. (Docs. 4552 at 15;
4566 at 6-7.) Defendants never explained how this would accomplish something different
or better than what the Monitors have already provided. Moreover, the consulting firm’s
eventual report produced no discernible change.
Defendants suggest a special master would be preferable to a receiver, but “[a]
special master is primarily useful for conducting hearings and making recommended
findings of fact [and Defendants have] not raised any factual issues to be addressed in such
hearings, and [have] not asked for those hearings.” Plata, 603 F.3d at 1098. Moreover,
Defendants were already effectively provided a very well-qualified dedicated special
master that they proceeded to squander. Magistrate Judge David Duncan, for six years,
worked tirelessly, sometimes weekly, with Defendants and Plaintiffs to identify ways, and
to design an acceptable plan, to allow Defendants to remediate the unconstitutional
healthcare. It failed because Defendants chose to completely resist the terms and
requirements of the Stipulation. There is no justifiable basis for a special master that would
serve any purpose beyond that already fulfilled by the Court’s Rule 702 experts and
Monitors.
The Court’s efforts have proven to be an exercise in futility. To date, and despite
the repeated offers of assistance and advice from the Monitors, Defendants offer no
concrete plan to achieve compliance other than to limp along with their continuing failure
to comply with the Injunction. Accordingly, the second factor favors appointment of a
receiver. See Coleman v. Newsom, No. 2:90-CV- 0520 KJM SCR P, 2025 WL 2475040, at
*10 (E.D. Cal. Aug. 27, 2025) (“Notwithstanding the court’s substantial effort, . . . the
work is unfinished, the progress too slow and no end in sight if the current framework
remains in place.”); Nunez, 782 F. Supp. 3d at 162–63 (“The DOC has repeatedly failed to
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incorporate the Monitoring Team’s thoughtful recommendations, which are backed by
years of expertise, experience and research, and ‘has taken few concrete actions to adopt
these recommendations (or devise reasonable alternatives)’ to come into compliance with
the Contempt Provisions . . . .This pattern has been well documented by the Monitoring
Team for years . . . .There is no doubt that these less extreme measures have proven
futile.”.)
3. Effectiveness of Continued Insistence on Compliance
In issuing the Injunction, the Court stated:
Moreover, the unusual scope of this Injunction is informed
by Defendants’ actions throughout this case. Despite their
agreement and promise to the Court 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
subclass. Yet almost immediately Defendants failed to perform
those obligations and continued in that failure. Instead of
acknowledging their failures, Defendants kept inaccurate
records and unreasonably misread the settlement’s
requirements to their advantage. During trial, Defendants
presented arguments and witnesses that were manifestly
unreliable and unpersuasive. And on some aspects, Defendants
presented no meaningful defense at all…Most importantly,
trial established Defendants blatantly 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 ambiguous because
Defendants have proven they will exploit any ambiguity to
the maximum extent possible.
(Doc. 4410 at 4-5 (emphasis added).) Despite this finding of continuous resistance
throughout this litigation, Defendants appear oblivious to the ongoing harm caused by their
actions. Defendants persist in challenging the Injunction they approved. Many examples
of Defendants’ non-compliance with the Court’s Orders and the Injunction have been
mentioned, but some very recent instances particularly demonstrate the ineffectiveness of
continued insistence on compliance with the Injunction.
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During the staffing Pilot, Defendants’ Health Services Division (HSD) PCCM
Team, Pilot Front-Line Staff Teams, and Court Experts were required “to provide coaching
to the front-line Pilot clinical teams, identify emerging issues and needs, and to build the
HSD PCCM Team’s experience with coaching, distilling team experience and applying it
to other teams.” (Doc. 4761 at 9.) Although the meetings should have begun on October 8,
Defendants instructed the Monitors to not have any contact with the Pilot team staff without
HSD and were told to only schedule these meetings with HSD. (Id.) Despite numerous
requests from the Monitors, HSD ignored all of them with the exception of one meeting in
November. (Id.) As a result, at the end of the Pilot, front-line teams, “reported needing far
more hands-on support, especially during their early weeks of the Pilot,” and the failure to
schedule these meetings meant “the teams . . . did not receive support in using process
improvement cycles, developing open scheduling, developing RN roles, strengthening
daily huddles, . . . did not experience coaching and their skill set did not grow as intended,
[and] did not gain experience with many of the components of the PCCM and are therefore
not able at this time to serve as ‘ambassadors’ to other units and complexes on these
components during the statewide implementation of the PCCM.” (Id at 9-10.) This also
meant the Monitors were left to try to gain data necessary to evaluate the Pilot from other
sources. (Id. at 10.)
Again and throughout, Defendants repeatedly attempt to defend their behavior by
claiming lack of resources—money, space, and the NaphCare contract. And they have
repeatedly been reminded of binding authority52 that money and space is required to be
utilized to bring healthcare to prisoners into constitutional compliance.
The Pilot Program was designed to provide Defendants a significant opportunity to
demonstrate they could comply with the Injunction on a smaller scale. Despite the Court’s
clear, specific orders, Defendants “were not able to secure staffing for all positions needed
to fully implement the Pilot.” (Doc. 4814 at 7.) As noted above, Defendants did not run the
Pilot fully at either site, and it was terminated at one site after only eight days. The
52 See Peralta v. Dillard, 744 F.3d 1076 (9th Cir. 2014.)
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termination was attributed to insufficient space, even though Defendants had specifically
selected the pilot sites, and had been on notice of the inadequacy of space at that site since
at least July 2024.
Similarly, complex-wide communication about the Pilot was necessary “to build
anticipation about the PCCM and staffing plan, quell rumors, and give staff a venue for
asking questions.” (Doc. 4761 at 11.) Despite the Court’s instructions, the fact that
Defendants’ Facility Health Administrators welcomed and sought such communication as
they were barraged with questions and rumors, and the Monitors “described a number of
venues through which this could occur including newsletters, reports at staff meetings,
email blasts, FAQs, discussion groups, staff and patient testimonials, and more,”
Defendants did not comply. (Id.) Indeed, the Court “required communication across the
rest of the ADCRR complexes beginning in late September and continuing throughout
December to prepare the other seven complexes for the statewide rollout of the PCCM and
staffing plan.” (Id.) Defendants did not do any of it; instead they created an unmonitored
email address, which did not accomplish any goals. (Id.) Defendants did not implement
any of the communications and failed to inform health care and custody staff at the other
complexes of the PCCM or staffing plan. (Id.)
Defendants still have no plan to fully implement the PCCM and related staffing and
space provisions of the Injunction, even though the Monitors “have been providing such
feedback, heavily, in formal reports, in informal documents, and—over hundreds of
hours—orally, since the inception of the Injunction (if not before) [and] have also offered
numerous additional meetings with HSD staff to assist Defendants with reviewing and
understanding the requirements of the Injunction and [the Monitors’] methodology, but
have had those offers declined.” (Id. at 5.)
Defendants offer and exalt heavy reliance on some improvements and promises of
more as if they should be praised, not sanctioned. The Monitors readily credit Defendants
where appropriate, but find Defendants significantly overrepresent their success in
substance use treatment and HCV treatment. (Id.) In fact, the improvements are a small
fraction of the Injunction and “taking into account the nature, number, and speed of
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improvements, does not change [the] core findings” that non-compliance with the
Injunction persists and poses serious risks of harm to the prisoners. (Id. at 38.)
Of equal concern is the substantial undermining tension between Defendants and
NaphCare. Defendant Thornell, as Director, is tasked with providing constitutionally
adequate healthcare to those in his custody. As noted above, the Court has repeatedly
inquired of Director Thornell what provisions he has incorporated into the contract to
ensure NaphCare provides constitutionally adequate healthcare in compliance with the
Injunction and what sanctions have been implemented when NaphCare repeatedly breaches
the contract. Despite the many years this action has been pending, four years since the trial,
almost three years since the effective date of the Injunction, and the new leadership who
claim to be committed to achieving constitutionally adequate care, the answers to these
questions either do not exist or are unavailing. When the Court inquired, Defendants
blamed the “NaphCare contract,” the “cost of providing healthcare,” and “the Injunction”
as reasons they were unable to fully engage in the Pilot. (Doc. 4634.) Although the Court
has, pursuant to the express terms of the contract, often inquired of Defendants about
sanctioning their healthcare provider, Defendants have shown no cognizable interest in
imposing sanctions that would result in actual change. Based upon a list provided by
Defendants, as of September 22, 2025, Defendants have imposed $1,424,900 in sanctions
since the inception of the Injunction.53 Indeed, the CEO of NaphCare averred that
“sanctions . . . have not in any way incentivized or influenced NaphCare’s performance or
compliance.” (Doc. 4616-1 at 25 ¶ 10.) Although there is evidence in the record that
Defendants’ inability to directly control NaphCare interferes with implementation of the
Injunction, the Director has never contended that he is unable to comply with the Injunction
due to NaphCare’s involvement in prisoner healthcare and, as the Court has previously
53 “Of this, $645,000 was for 4 errors in patient care and 1 failure in a patient care process.
The remainder appears to be for vacancies in mental health staff and failed inventory audits.
Despite vacancies in mental health staff that existed consistently during the 28 months in
question, Defendants only sanctioned NaphCare for vacancies that existed during 9 of those
28 months. Defendants did not sanction NaphCare for vacancies in medical staff during
any month.” (Doc. 5040 at 2.)
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noted, Defendants have a non-delegable duty to provide constitutional healthcare to
prisoners. (See Doc. 2898 at 16.)
Moreover, the Monitors document Defendants’ unwillingness or inability to prepare
NaphCare for implementation of the Injunction. (See Doc. 4761 at 11 (the Monitors “do
not believe that any steps have been taken by [Defendants] to discuss the need to empanel
and assign patients with NaphCare, to teach NaphCare how to run the empanelment
program, or to otherwise plan to execute this first step in implementing the staffing model
statewide.”) Finally, as noted above and of substantial significance, Defendants did not
object, or much less, even respond to NaphCare’s Motion to Intervene despite NaphCare’s
bold assertion it had “significantly improved the healthcare system.” Although NaphCare
claimed it did not intend to relitigate the Injunction, NaphCare also stated in the Motion to
Intervene it fully intended, in violation of the contract, to “tinker” with the Injunction
provisions such as “staffing levels.” It is not surprising NaphCare would be concerned
about efforts to increase staff and raise their salaries because increasing staff might affect
profits negotiated in the contract.
It is indeed “resoundingly clear” that rather than genuinely attempting to comply
with the Court’s orders and the Injunction or set forth any concrete plan of compliance,
Defendants will continue to object to and fight each aspect of the Court orders, keep
inaccurate records, unreasonably misread the Injunction’s requirements to their advantage,
offer unacceptable excuses for violations, and exploit any ambiguity to the maximum
extent possible. Plata, 2005 WL 2932253 at *29; see supra at 37-38. It now falls to the
Court to ensure that the Constitution is upheld.
The third factor supports the appointment of a receiver. See Coleman, 2025 WL
2475040, at *10 (“Even if there are finally a few signs of progress with respect to staffing,
defendants do not appear close to achieving completion of the staffing remedy, let alone
durably. . . . And staffing is but one aspect of the remedy long unfulfilled. Particularly if
the court must continue to rely on contempt proceedings to obtain compliance with its
orders, there is no indication defendants’ reflexive practice of appealing the court’s orders
will cease.”); Nunez, 782 F. Supp. 3d at 163 (finding that a persistent pattern of slow
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compliance with Court Orders “despite support and guidance from the Monitoring Team
reinforces the Court’s conclusion that continued insistence on Defendants’ proactive
compliance with Court orders would only lead to further delay” and supports the third
factor of receivership.)
4. Lack of Leadership.
Defendants assert the Department’s leaders are committed to complying with the
Injunction and making progress toward that goal and contend they should be allowed to
continue these efforts, perhaps forever. However, the Monitors’ reports reveal a stark lack
of leadership able to effectively implement the requirements of the Injunction.
An additional, very recent example is instructive. In the wake of the staffing Pilot’s
abysmal conclusion, the Monitors opined that “[Defendants do] not have a plan for, nor the
leadership expertise to, implement patient empanelment beyond the Pilot sites.” (Doc. 4761
at 16.) HSD ignored the Monitor’s repeated emphatic recommendation to designate a
project manager, resulting in lack of organizational project management, revealing
“[Defendants do] not have the project management capacity to roll the PCCM out statewide
and implement the statewide staffing plan,” or the “capacity to manage the schedule,
marshal all assignments and deliverables, assign resources, track progress, effectively
engage other ADCRR resources, and effectively interface with NaphCare.” (Doc. 4761 at
13-14.) The Monitors further concluded that Defendants lack the technical expertise or
tools to calculate the staffing of patient primary care or mental health teams based on panels
and caseloads, or to modify staffing at some point in the future when patient complexity
changes and Defendants have no mental health or medical leaders who have experienced
or been trained in the PCCM model. (Doc. 4761 at 16.)
Defendants dismiss the grim performance of the staffing Pilot and its introduction
of the PCCM as insignificant and not indicative of their leadership or seriousness. But
Defendants either do not understand or have chosen to ignore the purposes of the Pilot and
the importance of the PCCM, which is fundamental to the Injunction. The Pilot was a vital
step toward constitutionally adequate care because adequately trained staffing is a
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prerequisite for “successful fulfillment of the health care-related requirements of the
Injunction” (Doc. 4539 at 16), and was, in many ways, the perfect opportunity for
Defendants to demonstrate their willingness and ability to comply with the requirements
of an Injunction. Defendants’ abject failure to implement it at only two sites they
themselves selected, comprising only 8% of ADCRR’s inmate population, is clearly
demonstrative of their inability to achieve full compliance.
Plaintiffs also point out that in March 2024, Defendants assured the Court that their
Medical Director would fix the broken mortality review process (Doc. 4795 at 21), but the
Medical Director position remained vacant from August 2024 until January 8, 2026, and,
as noted above, the experts amply support their opinion that the mortality review process
is still woefully insufficient. (See, e.g., Doc. 5040 at 13-17 (“none of this changes [the
Monitors’] conclusion that [Defendants’] Mortality Review process is flawed.”).)
Furthermore, Defendants have consistently demonstrated a marked imbalance of
priorities. (Doc. 4761 at 15-16 (finding that HSD leadership focused on “monitoring and
enforcing standards that are not applicable to the staffing plan and are inappropriate when
introducing large-scale clinical change.”).) At every hearing for the last almost three years,
Defendants have touted improvements with Hepatitis-C and opioid use disorder. As noted,
there is some evidence that Defendants overrepresent their successes in these areas. The
Monitors assert that Defendants present their treatment of opioid/substance use disorder as
a success story, but “Defendants are compliant with only 3 of 7 requirements of the
Injunction and have made little progress (and in fact may have regressed) in the treatment
of Alcohol Use Disorder” and there are “seven ways in which treatment of TB at ADCRR
remains unsafe and dangerous.” (Doc. 5040 at 4.)
While any improvements are desirable, the continual emphasis on these few
improvements presents two significant problems. First, simply improving in two areas does
not ensure constitutional health care and mental healthcare for a substantial portion of the
prison population. Additionally, it is extremely concerning that these are among the only
improvements the Department continues to emphasize after pointing to these
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improvements years ago. Indeed, the Court explained to the parties in its findings that “this
case is not about particular diseases. Rather the focus must be on the overall provision of
health and mental health care and whether there is a substantial risk of serious harm.”
Defendants tout their accomplishments with Hepatitis C and MOUD treatment but those
were included in the Permanent Injunction at Defendants’ behest and not because they
related to the Court’s findings. At the March 15, 2024 status conference, Director Thornell
extolled the “progress” Defendants had made by commenting on MOUD and Hepatitis C
treatments, unspecified progress in “the way that [Defendants are] approaching
accountability,” and a partnership with “external experts” at a consulting firm. (Doc. 4581.)
As the Monitors note in their supplemental October 4 Report, “most of the consultant’s
recommendations and attendant improvements, while worthwhile, do not relate to the
Court’s Injunction regarding health care, or do so in a very indirect manner.” (Doc. 5040.)
In contrast, the Monitors point to three areas with direct impacts on the prisoner
population that could have been implemented soon after the Injunction was issued, but still
have not been implemented. (Doc. 4968 at 25-26.) The Monitors demonstrate this in the
300-page report and, as reflected in the analysis of the mortality reports and many examples
of systemic healthcare failures identified in this Order, the Monitors also establish
Defendants have not discontinued the dangerous practice of having RNs independently
manage episodic patient problems and the practice has not only continued, but is supported,
by the EHR system that contains 45 protocols designed for independent practice by nurses,
demonstrating to the RNs that is still acceptable for them to provide primary care. (Id.)
Likewise, while the Injunction allowed RNs to independently manage a very small number
of approved conditions, LPNs were wholly barred by the Injunction from any independent
management, and yet the EHR still contains 35 protocols designed for independent practice
by LPNs. (Id.) The Monitors make clear after the Injunction issued, it would have been
relatively simple (and Defendants were advised and coached) to: (1) discontinue use of the
protocols within the EHR that allowed RNs and LPNs to manage patients independently
of provider involvement; (2) remove from the EHR the option of letting the nurse choose
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an option not to contact a provider; and (3) identify errors in care of a deceased patient
during mortality reviews. (Id.)
Defendants have demonstrated a pronounced tendency to actively avoid leadership
and responsibility. There is ample evidence in the record that Defendants deflect
responsibility to their vendor, “saying essentially, ‘not me,’” in an “exercise of
accountability hot potato.” Hinds County, 2023 WL 1186925, at *11-*12 (finding lack of
leadership in those circumstances.) This was consistent throughout the Pilot, when
Defendants “would imply that certain tasks were NaphCare’s responsibility, but did not
require that NaphCare act on them.” (Doc. 4761 at 13.) This behavior “contribut[ed] to the
failure to fully implement the Pilot.” (Id.) In the opinion of the Monitors, there is a “marked
lack of clarity” regarding the responsibilities of Defendants and NaphCare and although
the Monitors raised this as critical to the success of the Pilot, their entreaties were ignored
by Defendants implying “that certain tasks were NaphCare’s responsibility, but did not
require that NaphCare act on them.” (Id. at 13.) The Monitors assert “[a]s a result of these
vagaries, multiple steps in implementation were skipped or dropped, contributing to the
failure to fully implement the Pilot.” (Id.) Despite the Court’s emphasis at multiple hearings
and in orders that increasing salaries was critical to fill positions, Defendants repeatedly
contended “[Defendants are] currently paying wages over the average wages provided in
the contract to get staffing levels to the appropriate level,” but NaphCare “is not paying
these wages.” (Doc. 4566 at 3.)54 It bears repeating, Defendants were in violation of the
Injunction three months after it became effective, which begs the question of whether
Defendants negotiated the terms of the Injunction in good faith.55
54 See Doc. 4566 at 3 (“Defendants provide an example that the current contract requires
certain mid-level providers be paid approximately $106.33 per hour, but NaphCare is
paying these providers “between $80.00 and $95.51 per hour.”).
55 The Court expressly brought this to the attention of Director Thornell at many hearings
and, in March 2024, the Director promised to engage in solving it. But at the end of 2024,
100 contract positions still had not been filled. Amazingly, Defendants appeared to seek
praise in their subsequent filings for having only an additional 100 positions remaining.
This shows an abject lack of foresight because the staffing report approved by the Court
will require hiring significantly more staff.
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When the Monitors taught HSD to convert a patient panel into primary care and
mental health staffing using the staffing model tools, HSD indicated that “this should be
NaphCare’s responsibility,” but made no efforts to discuss this with NaphCare, to have the
Monitors work with NaphCare, or to otherwise “execute this first step in implementing the
staffing model statewide.” (Doc. 4761 at 12) Even when Defendants’ staff person
“developed an excellent program” for empanelment (assigning patients to providers),
Defendants “indicated that empanelment ‘should be NaphCare’s responsibility,’” but took
no steps “to discuss the need to empanel and assign patients with NaphCare, to teach
NaphCare how to run the empanelment program, or to otherwise plan to execute this first
step in implementing the staffing model statewide.” (Id.) All the while, Defendants persist
in using NaphCare as an excuse for delay. (See, e.g., Doc. 4553 at 7 (“[Defendants have]
moved as quickly as [they] could given the challenges associated with having to effect
changes through third-party vendors.”).)
Closely tied to Defendants’ tendency to shrug and insinuate the problem is their
private healthcare contractor is their apparent need for constant micromanagement. In fact,
as noted above, rather than proactively taking steps to enforce their contract with
NaphCare, Defendants insisted the Court “enter an order intended to get [NaphCare] to
increase health care salaries within the bounds of the current contract,” including ordering
Defendants to order NaphCare to comply with their contract obligations. (Doc. 4566 at 3-
4.) The Court was bewildered by such a suggestion, and at a March 15, 2024, status
conference informed Defendants their relationship with NaphCare “is a contractual matter.
If they have breached that contract, and you have made every effort to have them comply
with the contract, then you can take the actions. You don’t need the Court for that. This is
basic common law contract law, not something that I need to get involved with.” (Doc.
4581 at 61.) Despite Defendants’ averment that they have sanctioned NaphCare through
offsets from the contracted payment, as noted elsewhere in this Order, such efforts have
been tepid and obviously ineffectual, 56 and their proposal that the Court violate the law
56 The Monitors write that “the 5 errors for which Defendants have sanctioned NaphCare
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and intervene by ordering sanctions reflects a continued outsourcing of responsibility and
refusal to act independently.
It bears repeating that Defendants’ Response to the Monitors’ first Interim Report
complained the report did not provide “a ‘how-to-guide,’ much less a comprehensive plan,
on how [Defendants could] achieve compliance with the Injunction” and in particular, did
not provide “detailed guidance on how to achieve compliance.” (Doc. 4553 at 2.) Sadly,
this suggests that when Defendants agreed to the terms of the Injunction, they had no
knowledge of what was required. And the joint agreement was only reached after three
intense months of negotiation. It is apparent Defendants chose not to take any initiative to
independently maintain compliance with the Injunction. Rather, Defendants apparently
secretly hoped for guidance and instructions from the Court. Such an undertaking would
have required substantial briefing, additional work and effort by the Court and Court
Monitors, and numerous status conferences, resulting in nothing other than a waste of time
and resources rendering the implementation of the Injunction nearly impossible.
At Oral Argument on September 10, 2025, Defendants repeatedly asserted their
“progress” and “commitment.” (Doc. 4995.) But their focus on progress and commitment
disavows their substantial failures and pervasive violations that persisted nearly four years
after trial in 2021, and three-and-a-half years after the Court’s Findings in 2022, and almost
three years after entry of the Injunction. If the alleged progress had been made, prisoners
would not still be suffering the adverse outcomes reflected in the Monitors’ reports and the
Court’s Orders. If progress had truly been made, the PCCM would have been implemented
immediately after issuance of the Injunction and not remain “at its infancy” as it is today.
(Doc. 5040 at 2.) And the many additional hours to implement the staffing plan would be
in place.
amount to a small percentage of the errors for which monetary sanctions could have been
levied. As such, we estimate that the $1.4 million in monetary sanctions is a small fraction
of the monetary sanctions that ADCRR could have imposed on NaphCare for failures to
provide comprehensive healthcare services, misrepresentation or falsification of
information in the EHR, or other non-compliance with contractually required (and, by
extension, Injunction-required) performance.” (Doc. 5040 at 3.)
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In short, even if Defendants have some commitment to forthwith enforcing the
Injunction, the record is rife with examples of their willful inability to institute
constitutionally adequate healthcare in compliance with the Injunction. This factor favors
receivership. See Coleman, 2025 WL 2475040, at *11 (where receiver-nominee identified
multiple failures of leadership including not clearly identifying “who is ultimately
responsible for delivery of constitutionally adequate mental health services”; “poor
communication and lack of information” about what is required by the established
remedies in this action; and “no uniform . . . mechanism for sharing best practices and
lessons learned across institutions,” this factor weighed in favor of finding a receiver);
Nunez, 782 F. Supp. 3d at 163–65 (Although the Monitoring Team praised the relatively
new DOC commissioner for working actively with the Monitors and providing some basis
for hope of future sustained change, such change was not sufficient to tip this factor against
the appointment of a receiver because “even a strong Commissioner with sound intentions
can only make limited progress where, as here, the ‘dedicated team’ of competent senior
leadership required for reform has been lacking for years” and “dangerous and unsafe
conditions in the jails have persisted well into the second year of the Commissioner’s
tenure.”).
5. Bad Faith or Repeated Failure to Implement Changes
Defendants assert there is no bad faith displayed by their current leadership and
maintain they are committed to achieving compliance with the Injunction and delivery of
constitutionally adequate healthcare.
However, instead of actually engaging with the Monitors; embracing and
implementing their recommendations and complying with Court rulings, Defendants have
spent most of their time attacking the Monitors and their methodologies, with no
evidence—just a “difference of opinion”—to support their ad hominem attacks.57 Again, it
57 For example, when the Monitors requested the appointment of Ms. Donna Strugar-
Fritsch as a Monitor to assist in the implementation of the staffing plan, Defendants sought
to prevent her appointment and argued, in spite of her years of experience in health care,
corrections, government agencies, and the implementation of organizational changes in
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cannot be overstated that Monitor Dr. Marc Stern was the same expert who testified in
hearings before Magistrate Judge David Duncan with criticisms of Defendants’ healthcare,
but Defendants welcomed his appointment as an expert to help draft and monitor the
Injunction. Moreover, not until the Motion for Receiver was filed did Defendants officially
or unofficially provide the Monitors or the Court in writing, or otherwise, with specific,
detailed objections to the Monitors’ opinions and direction. Now, however, Defendants
have offered abundant disagreements, differences of medical opinions, and criticisms of
the Monitors. This is entirely inconsistent with the Court’s experiences with the Monitors,
who have consistently and patiently explained their methodologies and have shown ample
latitude and understanding in their recommendations, acknowledging the difficult hurdles
faced by Defendants in making the changes required by the Injunction. The experts, like
the Court, have without exception demonstrated that the main concern is that the prisoners
in the custody of the State of Arizona receive constitutional healthcare. It is alarming that
instead of sharing that concern and working with the Monitors, Defendants have engaged
in unproductive and distracting litigation tactics.
The Monitors’ purpose as defined by the parties and the Court was to monitor
Defendants’ compliance with the Injunction: the data and methodology that support their
opinions are consistent with that purpose. The parties agreed “reports from the experts will
help speed the remedial process by acknowledging areas of compliance with the Injunction
and by bringing attention to areas in need of improvement,” and “the experts’ opinions are
critical because they are independent, neutral, and are based on expertise that the parties
themselves lack.” (Doc. 4507 at 5-6.) Thus, Defendants’ arguments in opposition to the
Monitors’ comments, opinions, and direction, made for the most part for the first time and
after the Motion for Receiver was filed, reflect significantly their disagreement and
dissatisfaction with the requirements of the Injunction. Further, Defendants’ objections to
the staffing plan submitted by Ms. Strugar-Fritsch largely amount to objections to the
medical operations and her key role in developing the staffing plan, Ms. Strugar-Fritsch
lacked the “multi-faceted expertise . . . to play the most constructive role possible.” (Doc.
4976.)
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Injunction. After years of litigation, to quarrel so fixedly with the Injunction, which they
helped draft, and to which they steadfastly agreed casts serious doubt on Defendants’
averments of good faith. And it reflects a profound misunderstanding of the harm their
conduct has caused over the past decade.
The staffing Pilot provides a particularly salient example: The Court declared in the
Injunction “the core issue is that staffing levels are so inadequate that the provision of
constitutionally mandated care is impossible.” (Doc. 4335 at 21.) Despite Defendants’
acknowledgement that “the pilot is necessary to provide important refining information for
the staffing model and new model of care being developed” (Doc. 4686 at 2), their
participation in the Pilot vanished after it was approved. Throughout the Pilot, Defendants
argued with the requirements,58 failed to comply with the necessary staffing provisions,
provided minimal and inaccurate data, and implemented fewer than half of the enumerated
steps and activities necessary for the Pilot. (See generally Doc. 4761.)
As noted above, the Pilot was to be implemented at two sites, housing only 8% of
Defendants’ prisoner population, but Defendants unilaterally ended the pilot at one of the
two sites. Plaintiffs point out that “[t]he issue of space to accommodate new clinical staff
and their patients was raised at the very first pilot meeting on July 8,” and again in
September, “HSD reported that space modifications had been approved, budgeted, and
would be complete within 90 days,” but Defendants, in their response to a draft of the
report, disavowed knowledge of those comments and wrongly asserted “[t]he pilot never
contemplated building additional space and should not be contingent on building additional
space,” despite the Injunction’s requirement that Defendants “provide sufficient space” for
healthcare delivery. (Doc. 4410 at 11-12 §§ 1.6-1.7.)
The HSD PCCM Team did not hire the required psychology associate, and the HSD
Mental Health Director left during the Pilot. During three leadership meetings, the
Monitors conveyed an urgent need for the Monitors to teach HSD’s newly hired mental
58 (See, e.g., Doc. 4761 at 7 (“in its feedback to a draft of this report, with regard to
requirements about the use of registry staff for the pilot, Defendants noted, ‘These were
impractical requirements from the beginning.’”).)
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health director about the Primary Therapist model, new clinical expectations for mental
health care, and the staffing model for the mental health care Pilot, but they received no
response from HSD. (Doc. 4761 at 12.) The Monitors noted that “HSD leaders’
participation in Pilot activities waned throughout the pilot and [they] did not see any
evidence of HSD leaders’ attempting to invigorate the HSD PCCM Team to meet the work
plan objectives or hold them to any expectations or accountability for doing so.” (Doc.
4761 at 15-16.)
Despite the Injunction’s terms as ordered by the Court that the staffing plan be
implemented statewide after the Pilot, Defendants treated the Pilot as an incidental,
insignificant, optional activity and the subsequent implementation of the plan as an unlikely
potentiality. Although Defendants know that the PCCM must be implemented at all
complexes (in 45 units of 9 complexes) pursuant to the Injunction, Defendants’ HSD
refused to respond to the Monitors’ “numerous attempts to remind them that they must
begin this work in order to comply with the Injunction and the Court’s orders.” (Id. at 11.)
This failure is inexplicable and damning.
The Monitors reported that, in response to a draft of the Monitors’ first Interim
Report, Defendants suggested changing the phrase “experience from the pilot will inform
amendments to the final staffing plan that will improve the outcomes of the model as it is
implemented across ADCRR” with “experience from the pilot will inform amendments to
the final staffing plan that will improve the outcomes of the model if it is implemented
across ACDRR” and to adjust the statement that the Pilot is also intended to enable HSD
clinicians to “train and support other units throughout ADCRR complexes as they
implement the new model” to say that the pilot is intended to enable HSD clinicians to
“train and support other units . . . if they implement the new model in the future.” (Doc.
4681 at 1.) In short, Defendants were exclusively in control of implementing this vital part
of the Injunction and made no effort, or refused, to do so, causing significant repercussions,
not only in the implementation of the Pilot, but for a state-wide implementation of the Pilot.
Defendants’ regular overstatement of their “progress,” intransigence regarding key
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aspects of compliance, and reporting of inaccurate data59 reinforces the finding of bad faith
and repeated failure to implement changes. In their Response to the Monitor’s Third
Interim Report, Defendants assert “the Department has implemented the Patient Centered
Care Model (PCCM) at nine units across different complexes as part of the statewide roll
out.” This is flat wrong in that “at most units, that implementation is [in] its infancy,” and
critical components of the PCCM are not yet in place at all facilities, including assigning a
primary therapist and/or primary care provider to every patient on the caseload and having
the primary therapist or provider actually function as such. (Doc. 5040 at 2.) Defendants
emphasize some modest successes in disease-specific areas, such as substance use
disorders and treatment of tuberculosis, and yet “Defendants are compliant with only 3 of
7 requirements of the Injunction . . . in the treatment of Alcohol Use Disorder” and the
Monitors have identified seven “ways in which treatment of TB at ADCRR remains
unsafe”
Finally, as required by the Injunction and by the Court, and in countless other
instances, by the Monitors, Defendants have been urged, ordered, advised, and coached to
end the practice of nurse-driven care. (See, e.g. Doc. 4410 § 1.11, 7.4.7 (“LPNs and
Behavioral Health technicians shall not independently assess prisoners or initiate a plan of
care or treatment,” “The initial care provider shall be the prisoner’s primary care medical
provider,” “Pursuant to prisoner-specific direction provided by the medical practitioner,
RN may provide initial care for a limited number of conditions”)); (Doc. 4637 at 5 (“Let
the Court emphasize what is obvious, nurse-driven care is over.”)); (Doc. 4335 at 44
(“Using nurses as the first line, and often last line, for providing care is medically
unacceptable.”).) Despite this oft-repeated refrain, Defendants continue the practice.
Indeed, Defendants assert that this alarming, continued use of RNs to provide initial care
is acceptable because in the end “providers review and sign off on nursing protocols.”
(Doc. 4973-8 at 7.) This reads as if Defendants are bereft of an understanding of the
59 See supra note 44 (noting “Defendants report that they currently engage 15.3 FTE staff
physicians. In fact they only engage no more than 11 FTE.”)
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requirements of the Injunction, which they jointly drafted, requiring implementation of the
PCCM. And it does not reflect a good faith effort to reach the minimum requirements of
constitutionally adequate healthcare.
It is plain that conditions remain unconstitutional after “years of supervision and
support.” See Hinds County, 2023 WL 1186925 at *12. Regardless of assurances of good
faith, Defendants have repeatedly failed to implement necessary changes as directed by the
Court and the Monitors, both throughout the lengthy history of this case and since the
issuance of the Injunction. Accordingly, this factor favors receivership. See, e.g., Nunez,
782 F. Supp. 3d at 165 (the key question in deciding this factor is whether the
unconstitutional conditions fall below the constitutional minimum despite years of
supervision and support by the Monitor and his team.”) (internal quotation omitted.)
6. Waste of Resources
Plaintiffs assert, as the Court has previously observed, the amount spent on this
litigation is astronomical, and argue with a receiver, resources will be properly invested
into making changes needed to improve healthcare and, ultimately end this case.
In Response, Defendants assert that they are “devoting substantial resources to
complying with the Injunction and . . . achieving measurable success.” (Doc. 4818 at 21.)
Conversely, at the same time, for almost three years, they have complained they do not
have the resources to fully engage in complying with the Injunction. Defendants assert that
the appointment of a receiver will waste resources, pointing to the increase in the California
Department of Corrections’ spending and decline in prisoner population and the cost of the
Plata receivership.
Defendants’ argument is conclusory as Defendants do not proffer an estimated cost
of a receiver. There will be costs for improvements to the healthcare system, but the entire
point of almost 14 years of litigation and the remedy for many years of constitutional
violations is to improve the healthcare system. As such, Defendants cannot use the cost of
improvements already required under the Injunction to oppose the appointment of a
receiver on the grounds of expense.
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Moreover, Defendants’ arguments based on the California Department of
Corrections receivership are unavailing and ignore key facts: there, the Receiver has
delegated oversight of the medical program at 31 of 35 institutions back to the Secretary
as of August 2025, the decline in prisoner population was necessary for achievement of a
remedy, and healthcare has been significantly improved under the receiver. California
Correctional Healthcare Services Fact Sheet, at https://cchcs.ca.gov/factsheet/, permalink,
https://perma.cc/T7ED-ZPJY; Gabriel Petek, Legislative Analyst’s Office, Overview and
Update on the Prison Receivership (Nov. 2023), at
https://lao.ca.gov/Publications/Report/4813.
Defendants have not demonstrated that a receivership would be a waste of resources,
but there is certainly evidence that resources will continue to be wasted in the absence of a
receiver. Defendants spend more than $1 billion per year, and millions of dollars towards
inmate healthcare. Defendants have proven completely incapable of reaching constitutional
compliance, resulting in more than a decade of litigation without appreciable effect on the
provision of healthcare. Allowing this to continue would waste enormous sums of money
in compounded costs of ineffective care and litigation costs that do nothing to improve
healthcare conditions.60 And Defendants contract with NaphCare to provide healthcare to
inmates, paying upwards of $300 million a year, but it makes little effort to enforce
NaphCare’s obligations.61 As noted, the sanctions that have been imposed are sparse, in
the form of “offsets” from the contractual amount and have totaled approximately
60 Defendants have been ordered to pay $3,192,448.38 in attorneys’ fees and costs,
$2,545,000,00.00 in contempt sanctions, $4,186,940.00 in payments for the Monitors’
work, and $9,140.00 in appellate filing fees. (See, e.g., Docs. 2902, 3245, 3576, 3841,
2898, 3861, 537, 1817, 1932, 1953, 2444, 2838, 2935, 2936, 2937, 2944, 2957, 3106, 3272,
3338.) Moreover, the attorneys’ costs and fees of both Parties are in addition to the fees
and costs reflected on the Court’s docket and the Court’s time and resources. In short, the
cost to taxpayers has been enormous.
61 The contract provides for sanctions “including but not limited to monetary sanctions,
suspension, refusal to renew, or termination of the contract” and explicitly states
Defendants may impose immediate monetary sanctions, “cure notice” monetary sanctions,
and performance offsets for violations of contractual Performance Measures. (Doc. 4507-
1 at 41.)
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$1,424,900. Absent the drastic measure of imposing a receivership, Defendants will
continue to expend funds on inefficient and unconstitutional care.
The evidence before the Court shows that if the healthcare system is brought into
compliance with the Injunction, the healthcare system will run more efficiently and waste
less resources. Throughout this litigation, the Monitors have documented how denying
prisoners a constitutional level of care not only harms the prisoners but is ultimately a
massive waste of resources within the prison and to the State of Arizona. In discussing
deaths that were, at least, contributed to by violations of the Injunction, the Monitors
document numerous instances where appropriate healthcare would have saved practitioner
time and money. (See, e.g., Doc. 4968 at 6, 12 (proper diagnosis of a urinary tract infection
would have saved patient from emergency trip to the hospital; telehealth visits and nurse-
led triage led to dangerous treatment of patient with complicated medical history and
allowed his unstable heart condition to be seen as stable; urgent request for catheter ignored
for three months until patient was already hospitalized; sleep apnea evaluation delayed for
a year when the patient ultimately died; delay of review of specialist medical records for
months; patient never offered a flu shot in violation of Injunction and developed flu that
likely contributed to his death.).)
Defendants also do not take accountability for these failures, instead arguing that
certain parts of the Injunction were complied with, showing a deliberate misunderstanding
of the vision of the Injunction. (See, e.g., Doc. 4968 at 16 (Defendants argued that patient
who committed suicide was seen multiple times, but the Monitors note that those sessions
were conducted by different psychology associates, no primary therapist was assigned,
more than half occurred at cell-front, and despite clear signs of suicide risk, none of the
four psychology associates assessed dynamic suicide risk factors); id. at 18 (Defendants
argued that a 65-minute encounter constituted an adequate initial health assessment when
the encounter was actually an Intake Assessment for Max Custody Placement); id. at 18-
19 (Defendants’ arguments demonstrate confusion in difference between psychiatrist and
therapist.).)
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Additionally, in mid-2024, Plaintiffs requested the Court order Defendants to hire
an individual or individuals with significant health care management experience to assist
Defendants in reforming the current system, but Defendants claimed such an order would
be “duplicative and unnecessary” because Defendants “already engaged . . . a nationwide
correctional consulting and management firm” and anticipated the firm’s recommendations
for “system-wide improvement.” (Doc. 4998 at 4.) Director Thornell asserts that this report
was necessary “for a comprehensive, systemwide review of ADCRR’s programs and
systems as part of [his] vision for redefining and implementing modern correctional
policies and practices in Arizona, and also to address the constitutional deficiencies
identified in this Court’s 2022 order.” (Doc. 4998-3 at 17.) The Monitors opine that “most
of the consultant’s recommendations and attendant improvements, while worthwhile, do
not relate to the Court’s Injunction regarding health care, or do so in a very indirect
manner.” (Doc. 5040 at 4.) This undermines Defendants’ initial contention that providing
Defendants with help from an individual with significant health care management
experience to assist Defendants in reforming the current system was duplicative and
unnecessary. Indeed, the Monitors were already providing ample recommendations for
“system-wide improvement” to no avail, making engagement of the consulting firm itself
the “duplicative and unnecessary” expense. (Doc. 4998 at 4.)
In short, Defendants’ continued violations of the Injunction and their conduct
throughout this litigation are contributing to a waste of resources and there is no showing
that appointment of a receiver would result in waste of resources. See Coleman, 2025 WL
2475040, at *11–12 (“It cannot reasonably be disputed that the amount of money being
spent on the contentious litigation that has plagued remediation in this action for more than
a decade is a significant waste of public resources, given that the litigation has not effected
any material change in the court-ordered remedy but rather only served to delay
implementation and the end of federal court oversight.”).
7. Relatively Quick and Efficient Remedy
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Defendants argue that appointment of a receiver would not be quick and efficient
and would “dramatically increase the cost of compliance and cause further delay” (Doc.
4818 at 2.) Defendants also cite the appointment of a receiver in the California Department
of Corrections as an example of a receivership that was purportedly inappropriate and not
quick or efficient. However, as noted above, and in contrast to Defendants’ purported
efforts, the receivership in California has had marked success.62
This factor does not ask the Court to consider whether appointment of a receiver
would be quick and efficient, but whether appointment would be relatively quick and
efficient. This determination must be evaluated against the backdrop of this case. See, e.g.,
Plata, 2005 WL 2932253, at *31 (“the speed of reform must be judged relative to the scale
of the project.”.) Defendants first promised to achieve constitutional compliance in October
2014. As amply detailed in this Order, Defendants continue to argue about the underlying
requirements of the Injunction rather than bringing the medical and mental healthcare
systems into constitutional compliance.
Even since the issuance of the Injunction, Defendants have failed for more than two
years to implement relatively simple solutions.63 Here, given more than 11 years of delays
and the same arguments and non-compliance, the Court finds that appointing a receiver
that is willing to implement the recommendations of the neutral experts would be relatively
quick and efficient. See Coleman, 2025 WL 2475040, at *12 (finding “quick and efficient
remedy” factor favored receivership because estimated 5-7 year receivership must be
evaluated against “long-running remedial phase of th[e] case” “with some progress . . . but
62 Progress was initially slow under the receiver in California. In 2011, the Supreme Court
found that unless overcrowding was addressed, the receiver would be unable to achieve a
remedy. Once the CDCR reduced the state prison population to acceptable levels in 2015,
progress moved much more quickly. Between 2015 and 2017, the receiver returned
authority over 16 prisons to the state. See California Correctional Healthcare Services
Fact Sheet, (Aug. 2025), https://cchcs.ca.gov/factsheet/, permalink,
https://perma.cc/T7ED-ZPJY).
63 See generally supra (Noting relatively simple measures that could have been taken and
to resolve issues with the refusal process and to make the shift away from inappropriate
nurse-driven care, but were not).
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no durable end otherwise in sight.”); Nunez, 782 F. Supp. 3d at 165 (in evaluating quick
and efficient remedy, finding in favor of receivership because “steady and much more rapid
progress is possible under the guidance of a well-structured receivership.”).
8. Balance of Factors
It is an unavoidable conclusion that the balance of factors favors a receivership in
this action. The Court is cognizant that the appointment of a receiver is an extraordinary
remedy that should be reserved for the most extreme circumstances. From the evidence
compiled over the past decade, the Court is convinced the situation at ADCRR is such an
extremity.
In their opposition to the appointment of a receiver, Defendants emphasize District
of Columbia v. Jerry M., a case in which the District of Columbia Court of Appeals
reviewed the appointment of a receiver over the education system at the Oak Hill center
for detained and committed children. The court concluded that “while the District’s history
of compliance with the orders of the court leaves much to be desired, we are not persuaded
that the record reveals a sufficient basis for the imposition of this remedy of last resort
under the circumstances existing at the time of the entry of the order.”
Jerry M. presents a factual situation markedly different from that existing here.
There, a receiver was appointed “just eight weeks after” the newly appointed
superintendent of the District of Columbia Public Schools had agreed to take responsibility
for education at the Oak Hill School and just days into the new school year, with “no notice
that [the Court] intended to judge [the Superintendent] based on conditions during the first
week of school.” Jerry M. at 1212. DCPS had developed and presented a plan for running
the facility in compliance with requirements. Id. at 1210. A new governmental body, the
District of Columbia Financial Responsibility and Management Assistance Authority, had
been created and issued a Directive taking various steps to address problems with public
schools. Id. at 1210, 1213.
Here, Defendants argue that “the Department’s current leadership has been at the
helm for only a couple years” and, like the newly appointed Superintendent in Jerry M.,
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“must be given an opportunity to ‘turn the tide’ before additional relief could be warranted”
(Doc. 4818 at 17), but this opportunity has been given and proved fruitless. Here, the long
history of this case has made evident that ADCRR’s healthcare is deeply, systemically
flawed. New leadership already in place for two years has failed to make headway in
rooting out systemic issues or offer any concrete plan for achieving compliance.
Defendants are correct that alone, a historical failure to fully comply may not
warrant the extraordinary remedy of a receivership. In reversing the order granting a
receivership in Jerry M., the court explained “the trial court relied principally upon only
one of the factors essential for a reasonable exercise of its discretion” when it “focused
upon the history of the District’s failure to comply fully with the court’s requirements.”
Jerry M. at 1213. This historical failure was “a compelling consideration,” but could not
be “the only factor for consideration.” But here, the Court has not relied solely, or
predominantly, on any one factor, but rather has conducted a holistic review.
The Court has exercised restraint for much of this litigation, to the point that
anymore tolerance of unconstitutional healthcare becomes judicial indulgence.
Defendants’ healthcare delivery system continues to cause and threaten grave harm; the
Court has attempted to resolve the issues through less extreme measures; Defendants have
consistently dragged their feet, delayed, exploited ambiguity, and fought compliance at
every turn, making continued insistence on compliance ineffective; Defendants lack the
leadership capacity to complete the necessary systemic changes to achieve compliance;
Defendants’ repeated failures, repeated attacks upon the Injunction and the Monitors, and
need for constant micromanagement undermine their avowals of commitment and good
faith; resources are being wasted; and after fourteen years of litigation with little to change,
continuing to employ the same approach would be wildly inefficient with no indication
that improvement will accelerate. The Court finds no lesser measure will suffice to remedy
the pervasive constitutional violations present in Defendants’ healthcare delivery system.
III. NARROWNESS OF THE REMEDY
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As in its issuance of the Permanent Injunction in 2023, the Court embraces the rule
that the remedy imposed must be narrowly drawn, extend no further than necessary to
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.)
The Court finds the appointment of a receiver over Defendants’ healthcare and mental
healthcare system is such a remedy.
IV. SCOPE OF ORDER:
Plaintiffs request that the Court “assign to the receiver all authority granted to the
receiver in Plata, given the success of the receiver in that case.” (Doc. 4795 at 30.) In
Response, Defendants assert that the relief requested by Plaintiffs is too expansive
“particularly considering a lack of history of the Department’s current leadership being
unwilling to institute change.” (Doc. 4818 at 25-26.)
In determining the scope of a receiver’s powers, the Court should ensure that the
receiver’s powers “cover only the scope of the constitutional violations” and should give
necessary explanation and justification to support the scope of those powers. Hinds Cnty.,
128 F.4th at 639.
Although the Court is inclined to propose that the Receiver be given powers
consistent with the Receiver in Plata, the Court will allow the parties and the Monitors to
weigh in on the proposed powers before issuing a final order as to the powers of the
receiver. Both the parties and Monitors must address whether the proposed powers cover
only the scope of the constitutional violations
IT IS ORDERED Plaintiffs’ Motion for a Receiver (Doc. 4795) is GRANTED.
IT IS FURTHER ORDERED within 60 days of the date of this Order, the parties
and the Monitors shall submit a list of up to five candidates each to serve as the Receiver
over medical and mental health care in Arizona state prisons. Objections shall be filed no
more than fourteen days later, and responses shall be filed no later than seven days
thereafter.
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IT IS FURTHER ORDERED within thirty days of the date of this Order, the
Parties shall simultaneously file Motions setting forth the proposed duties, powers, and
authorities of the Receiver, addressing how each proposal will extend as far as but no
further than necessary to correct Defendants’ constitutional violations.
Dated this 19th day of February, 2026.
Honorable Roslyn O. Silver
Senior United States District Judge
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i
Section Provision Status Description Compliance
Medical
Services
Injunction
Provision 1.1
and 1.3
Non-
compliant
All care and the documentation supporting that care, delivered during a
medical encounter (primarily face-to-face encounters), in response to an
inquiry from a nurse or patient, during a chart review or chart-based triage
decision, or upon receipt of results from a test, report from a consultant,
other external health record, shall be clinically appropriate including
scheduled follow-up in an appropriate timeframe when applicable. Settings
include, but are not limited to, those described in the subsections of these
provisions below.
Medical
Services
Injunction
Subprovision
1.1a
Non-
compliant
Emergent care Doc. 4968 at 46 (Defendants
using flawed methodology even
though Monitors consistently
provide feedback since
November 2023 that data
collection is flawed.)
Medical
Services
Injunction
Subprovision
1.1b
Non-
compliant
Urgent care Doc. 4968 at 48 (Defendants
self-assess 96% compliance
with urgent care provision in sub
provisions 1.1b of Injunction,
but Monitors assess as closer to
33%);
Medical
Services
Injunction
Subprovision
1.1c
Non-
compliant
Non-urgent, episodic care Doc. 4968 at 49 (Defendants
self-assess 79% compliance
with non-urgent, episodic care
in subprovision 1.1c of
Injunction, but Monitors
calculate 35% compliance)
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Medical
Services
Injunction
Subprovision
1.1d
Non-
compliant
Chronic care Doc. 4968 at 52 (Defendants
self-assess 86% compliance
with chronic care provision in
section 1.1d of Injunction, but
Monitors assess closer to 35%)
Medical
Services
Injunction
Subprovision
1.1e
Non-
compliant
Inpatient care Doc. 4968 at 53-57 (Monitors
assess noncompliance with
inpatient care provision in 1.1e,
but find percentage is
inappropriate methodology)
Medical
Services
Injunction
Subprovision
1.1f
Non-
compliant
Off-site specialty referrals Doc. 4968 at 58-59 (Monitors
assess non-compliance with
off-site specialty referrals
provision in section 1.1f of
Injunction and that percentages
do not fully capture
methodology, Defendants self-
assess at 96% compliance, but
Monitors assess 65%
compliance.);
Medical
Services
Injunction
Subprovision
1.1g
Non-
compliant
(Additional reference 9.1) Action taken on post-hospital, post-emergency
room, or specialist recommendations. This includes that the practitioner
shall adopt and perform recommendations from outside providers unless a
clinically appropriate basis exists to alter or forgo the off-site
recommendations.
Doc. 4968 at 60 (Defendants
self-assess 84% compliance
with 1.1g of Injunction regarding
action taken on post-hospital,
post-emergency room, or
specialist recommendations
and that percentages do not
fully capture methodology,
Defendants self-assess at 96%
compliance, but Monitors
assess 10% compliance.)
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Medical
Services
Injunction
Provision
1.22
(see
individual
sub-
provisions
below)
Orders from health care staff in the outpatient and inpatient arenas shall be
completed within the timeframe ordered. This includes, but is not limited to,
those orders described in the subsections of this provision below.
Medical
Services
Injunction
Subprovision
1.22a
Non-
compliant
On-site diagnostic tests See Doc. 4968 at 62-63
(Monitors find non-compliance
with on-site diagnostic tests
provisions in section 1.22a of
the Injunction and that
Defendants use improper
methodology regarding
compliance)
Medical
Services
Injunction
Subprovision
1.22b
Non-
compliant
Off-site diagnostic tests Doc. 4968 at 64-65 (Monitors
find non-compliance with off-
site diagnostic tests provisions
in section 1.22b of the
Injunction)
Medical
Services
Injunction
Subprovision
1.22c
Non-
compliant
On-site follow-up visits with nurses or practitioners Doc. 4968 at 66-67 (Monitors
find non-compliance with on-
site follow-up visits with nurses
or practitioners provision in
section 1.22c of the Injunction
and include backlog chart
showing extremely back-logged
appointments)
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Medical
Services
Injunction
Subprovision
1.22d
Non-
compliant
(Additional reference 8.1) Off-site visits with specialist Doc. 4968 at 68-72 (Defendants
self-assess 28% compliance
with 1.22d of Injunction
regarding offsite visits with
specialists, but Monitors assess
probably much worse given
certain data manipulation.
Monitors also address
substantive issues outside of
percentages)
Medical
Services
Injunction
Provision
1.21a (a.k.a.
“1.21”)
Non-
compliant
All cancellations of patient-initiated visits shall be made directly to a health
care professional by telephone, tablet, video, face-to-face, or in writing by the
patient. If a patient will not voluntarily displace, health care staff will go to the
patient’s location.
Doc. 4968 at 73-74 (Defendants
self-assess 76% compliance
with 1.21a of the Injunction
regarding cancellation of
patient-initiated, but Monitors
assess 60% compliance)
Medical
Services
Injunction
Provision
1.21b (a.k.a.
“1.1,1.21a")
Non-
compliant
All refusals of provider-initiated on-site medical visits are made by telephone,
video, or face-to-face with an RN or practitioner, within three days after the
appointment. If a patient will not voluntarily displace, health care staff will go
to the patient’s location.
Doc. 4968 at 75 (Monitors find
non-compliance with refusals of
provider-initiated on-site
medical visits in section 1.21b of
the Injunction)
Medical
Services
Injunction
Provision
1.21c (a.k.a.
“1.1,1.21b)
Non-
compliant
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 patient will not
voluntarily displace, health care staff will go to the patient’s location.
Doc. 4968 at 76-77 (Monitors
find non-compliance with off-
site health visits in section 1.21c
of the Injunction)
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Medical
Services
Injunction
Provision
1.23
Non-
compliant
Patients shall be informed in a timely manner of diagnostic test results. Doc. 4968 at 78-79 (Defendants
self-assess 88% compliance
with 1.23 of the Injunction
regarding timely conveyance of
diagnostic test results, but
Monitors assess 76%
compliance)
Medical
Services
Injunction
Provision 5.1
Non-
compliant
For patients with any medical conditions and identified treatment providers
in the community, if the patient consents, health care staff shall send each
provider relevant health care information prior to the patient’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. The
patient’s health record shall contain documentation of the above information
that was provided, when, and to whom.
Doc. 4968 at 80-81 (Defendants
self-assess 96% compliance
with 5.1 of the Injunction
regarding healthcare
information, but Monitors
assess 20% compliance)
Medical
Services
Injunction
Provision
7.4.1
Compliant Patients shall be given on a daily basis an opportunity to indicate their need
to be seen for a medicalclinic appointment at the next available clinic by one
of the following mechanisms, depending on theirliving situation, freedom of
movement, and access to electronics: affixing their name to a time slot on
apaper list maintained on the living unit or in the medical unit; affixing their
name to a time slot on anelectronic list via tablet or kiosk; informing the nurse
who conducts daily (or more frequent) welfarechecks on that unit; an
effective paper-based system in the event of temporary non-functioning of
theelectronic system.
Medical
Services
Injunction
Provision
7.4.2
Unable to
determine
compliance
A reminder of the following rule is communicated via the medium the patients
use to make requests (e.g., a statement placed on the paper or electronic
sign-up list): Patients should only use the non-urgent system if they have a
non-urgent need. Patients with urgent or emergent needs should notify a staff
member.
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 88 of 128

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Medical
Services
Injunction
Provision 7.1
Non-
compliant
An RN or higher credentialed professional shall conduct an intake screening
within four hours of a patient’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 patient 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.)
Doc. 4968 at 84-85 (Monitors
find non-compliance with timely
intake screening in section 7.1
of the Injunction)
Medical
Services
Injunction
Provision 7.2
Non-
compliant
A medical practitioner shall complete a history and physical examination of
each patient by the end of the second full day after a new patient arrives in
ADCRR.
Doc. 4968 at 86 (although
Monitors agree with 96%
compliance with 7.2 of the
Injunction regarding complete
history and physical exam, not
achieving full compliance is
dangerous and may be errors in
data)
Medical
Services
Injunction
Provision
7.4.6
Non-
compliant
All non-urgent/non-emergent care at the request of a patient shall be
completed in a reasonable time.
Doc. 4968 at 87-88 (Monitors
find non-compliance with all
timely non-urgent/non-
emergent in section 7.4.6 of the
Injunction noting that the data is
erroneous, and Defendants are
not performing this part of the
Injunction properly)
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Medical
Services
Injunction
Provision
7.4.7a/b
Non-
compliant
The initial care for non-urgent/non-emergent care and chronic care shall be
provided by the patient's primary care provider (PCP) with the exceptions
noted below. (1) The care may be provided by another medical practitioner or
health care practitioner as directed by the PCP as clinically appropriate. (2) If
the PCP is not on the premises or conducting telehealth visits at the time, the
care may be provided by another medical practitioner of the same or higher
credential. (3) Pursuant to patient-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.
Doc. 4968 at 89-92 (Monitors
find non-compliance with PCP
initial care in section 7.4.7a/b
due to three systemic problems)
Medical
Services
Injunction
Provision 1.5
Non-
compliant
Emergency response and care provided by custody staff shall be appropriate
given the skill level and knowledge expected of custody staff.
Doc. 4968 at 93 (Defendants
self-assess 85% compliance
with 1.5 of the Injunction
regarding emergency response
and care by custody staff, but
Monitors assess 50%
compliance)
Medical
Services
Injunction
Provision
1.8a
Non-
compliant
Emergency response equipment (Emergency Response Bag, Automated
External Defibrillators (“AEDs”), oxygen) shall contain all items required by
policy, all equipment shall be in working order, and all medications shall be
unexpired.
Doc. 4968 at 94 (Defendants
self-assess 86% compliance
with 1.8a of the Injunction
regarding emergency response
equipment, but Monitors say
there is no meaningful way to
calculate a percentage
performance, and there is
evidence of non-compliance in
13 units)
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Medical
Services
Injunction
Provision
1.8b
Non-
compliant
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.
Doc. 4968 at 95 (Defendants
self-assess 79% compliance
with 1.8b of the Injunction
regarding emergency response
bag checklists, but Monitors say
there is no meaningful way to
calculate a percentage
performance, but Monitors
found that checklists were
inaccurate and therefore non-
compliant)
Medical
Services
Injunction
Provision
1.8c
Non-
compliant
Staff shall complete and document all AED manufacturer recommended
checks (e.g., daily, monthly, annual.)
Doc. 4968 at 96 (Defendants
self-assess 94% compliance
with 1.8c of the Injunction
regarding AED manufacturer
checks, but Monitors found that
they were 94% compliant only
where a few units actually have
AED)
Medical
Services
Injunction
Provision
1.8d
Compliant Naloxone (Narcan®) is required to be kept on every living unit or with every
AED.
Medical
Services
Injunction
Provision 7.5
Compliant Build (or modify existing) living units to accommodate all patients requiring
SNU housing, build theunits with per-patient floor space consistent with
Arizona’s Medicaid agency (AHCCCS) requirementsfor similar populations,
equip and staff the units to meet the assisted living needs of the SNU patients
atthe appropriate custody levels, and transfer all these patients to those
beds. (Definition of SNU: elderly,physically disabled, or developmentally
disabled, generally guided by the health/functional/physicalneeds criteria
established by AHCCCS – see Pre-Admission Screening Tool)
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Medical
Services
Injunction
Provision
7.6.1
Non-
compliant
A medical practitioner shall be contacted and collaborate on the creation of
a care plan immediately upon a patient being admitted to the IPC.
Doc. 4968 at 100-01
(Defendants self-assess 75%
compliance with 7.6.1 of the
Injunction regarding
collaboration of medical
provider for IPC patients, but
Monitors assess 30%
compliance)
Medical
Services
Injunction
Provision
7.6.2
Non-
compliant
An RN shall complete an admission nursing assessment immediately upon a
patient arriving in the IPC.
Doc. 4968 at 102 (Defendants
self-assess 75% compliance
with 7.6.2 of the Injunction
regarding nursing assessment
upon arrival in IPC, but Monitors
assess 65% compliance)
Medical
Services
Injunction
Provision
7.6.3
Non-
compliant
A medical practitioner shall complete an admission history and physical
within one calendar day of admission to the IPC for patients who are going to
remain beyond 24 hours.
Doc. 4968 at 103 (Monitors
assert no more than occasional
compliance with 7.6.3 of the
Injunction regarding completion
of admission history and
physical within one day of IPC
admission)
Medical
Services
Injunction
Provision
7.6.4
Non-
compliant
An RN shall complete an assessment in the IPC at the frequency ordered. The
spacing of the assessments shall be clinically appropriate.
Doc. 4968 at 104 (Monitors
assert non-compliance with
7.6.4 of the Injunction regarding
RN completing an assessment
in the IPC at the frequency
ordered)
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Medical
Services
Injunction
Provision
7.6.5
Non-
compliant
The call buttons of all patients 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.
Doc. 4968 at 105-06
(Defendants self-assess 88%
compliance with 7.6.5 of the
Injunction regarding working call
buttons on IPC beds, but
Monitors could not perform
assessment based on
“frequency of careless or
erroneous nursing
documentation”)
Medical
Services
Injunction
Provision 8.4
Non-
compliant
If Defendants or their healthcare vendor utilize categorical referral
timeframes, e.g., “emergency,” “urgent,” “routine,” for which it 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.
Doc. 4968 at 107 (Monitors
assert that Defendants added a
category of referral time frames,
but never notified the Court of
this change or its meaning, even
though this provision of the
Injunction requires notification
to the Court)
Medical
Services
Injunction
Provision 8.7
Non-
compliant
If a practitioner orders, or informs a patient there will be an order for an off-
site test or referral, but circumstances change and the order is modified or
rescinded, the patient shall be informed within one month of the change.
Doc. 4968 at 108 (Monitors
assess non-compliance with 8.7
of the Injunction requiring that
patient be informed within one
month of change to order for an
off-site test or referral because
form does not tell patients what
was cancelled); Defendants
self-assessed 94% compliance,
but Monitors assessed 50%
compliance)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 93 of 128

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Medical
Services
Injunction
Provision 9.2
Non-
compliant
Patients 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.
Doc. 4968 at 109-10
(Defendants self-assess 80%
compliance with 9.2 of the
Injunction with requirements for
patients returning from ER and
Monitors agree Monitors
suggest tools to remedy ongoing
violations)
Medical
Services
Injunction
Provision
10.5.4
Non-
compliant
Patients 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 patients living in
a unit with 24-hour nursing and access to an emergency call button.
Exceptions may also be made for patients where the practitioner can
document a significant and serious penological need to prohibit a particular
patient from having such an inhaler. This exception must be patient-specific.
Doc. 4968 at 111 (Monitors find
Defendants non-compliance
with 10.5.4 of the Injunction
requiring rescue inhalers)
Medical
Services
Injunction
Provision
10.5.5
Non-
compliant
Patients with diabetes who are at significant risk of hypoglycemia shall be
provided a source of glucose KOP. Exceptions may be made for patients living
in a unit with 24-hour nursing and access to an emergency call button.
Doc. 4968 at 112 (Monitors find
Defendants non-compliant with
10.5.5 of the Injunction requiring
KOP glucose for hypoglycemic
prisoners)
Medical
Services
Injunction
Provision
10.5.6
Non-
compliant
Patients prescribed rapid-delivery nitroglycerin for cardiac disease shall be
provided the medication KOP. Exceptions may be made for patients living in
a unit with 24-hour nursing and access to an emergency call button.
Doc. 4968 at 113 (Defendants
self-assess 86% compliance
with 10.5.6 of the Injunction
regarding KOP nitroglycerin for
patients with cardiac disease,
but Monitors assess 83%
compliance)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 94 of 128

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Medical
Services
Injunction
Provisions
11.1.1.1 &
11.1.8
Non-
compliant
All patients are offered a screening blood test for HCV under opt-out
conditions within a month of arrival.
Doc. 4968 at 114-15
(Defendants self-assess 100%
compliance with HCV testing
and opt-out in 11.1.1.1 & 11.1.8,
but Monitors found that opt-out
is not being enforced)
Medical
Services
Injunction
Provision
11.1.4
Non-
compliant
All patients 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.
Doc. 4968 at 116-18
(Defendants self-assess 100%
compliance with 11.1.4
regarding prioritized list for HCV
infections, but Monitors find that
list is not being maintained in
accordance with Injunction “in
significant ways” and this
continues despite that Monitors
have identified these problems
previously)
Medical
Services
Injunction
Provision
11.1.7
Non-
compliant
All patients with HCV shall be offered education about HCV, whether they
receive treatment or not.
Doc. 4968 at 119 (Monitors find
non-compliance with 11.1.7
requiring HCV education for
prisoners with HCV; Defendants
self-assess 87% compliance)
Medical
Services
Injunction
Provision
11.1.5a
Non-
compliant
All patients with newly diagnosed HCV are tested to determine if they have
more advanced hepatic disease
Doc. 4968 at 120-21 (Monitors
found greater compliance (96%)
with 11.1.5a, requiring that HCV
patients be tested for more
advance hepatic disease, than
Defendants self-assessed 88%
compliance, but noted ongoing
issues with informed consent for
denial of treatment)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 95 of 128

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Medical
Services
Injunction
Provision
11.1.5b
Non-
compliant
All patients with fibrosis scores of F3 or F4 will be offered treatment for HCV. Doc. 4968 at 122-23
(Defendants self-assess 100%
compliance with 11.1.5b
requiring that patients with F3 or
F4 fibrosis scores be offered
treatment for HCV, but Monitors
assess 91% compliance)
Medical
Services
Injunction
Provision
11.1.5c
Compliant At least the following number of patients will begin treatment for HCV
monthly using the current standard of care medications: 110 patients plus
70% of the number of newly admitted patients who tested positive for HCV
during the previous month.
Medical
Services
Injunction
Provision
11.1.6
Non-
compliant
No patient 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 except for those patients with markedly
reduced life expectancy who would not be expected to benefit from
treatment, or patients 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 or there is a
documented informed refusal.
Doc. 4968 at 124 (Defendants
self-assess 79% compliance
with 11.1.6 regarding treatment
for prisoners with HCV released
during ongoing treatment, but
there are significant, recognized
errors in methodology)
Medical
Services
Injunction
Provision
11.2
Compliant All newly admitted patients shall have a completed test for tuberculosis (skin
test, blood test, or chest x-ray) by the end of the seventh full day after
admission into the ADCRR system, unless the patient refuses.
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 96 of 128

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Medical
Services
Injunction
Provision
11.3.1
Non-
compliant
All newly admitted patients shall be screened for, and if indicated then
evaluated for, substance use disorder. Screening shall include assessment
as to a history of opioid overdose.
Doc. 4968 at 127-29 (regarding
11.3.1 clinically appropriate
evaluation after intake
screening for substance use
disorder (OUD), Monitors and
Defendants agree on 100%
compliance for screening, but
Defendants self-assess 100%
compliance with evaluations
while Monitors assess 70%
compliance due to five errors)
Medical
Services
Injunction
Provision
11.3.2
Compliant All newly admitted patients shall be offered to have current Medication for
Opioid Use Disorder (“MOUD”) (buprenorphine, naltrexone) continued.
Medical
Services
Injunction
Provision
11.3.3
Non-
compliant
All pregnant or post-partum patients with diagnosed Opioid Use Disorder
(“OUD”) shall be offered to have current MOUD (buprenorphine, naltrexone,
methadone) continued, or if not currently on MOUD, shall be offered to
initiate treatment with buprenorphine or naltrexone.
Doc. 4968 at 131 (Monitors
found Defendants non-
compliant with 11.3.3 regarding
treatment for pregnant or post-
partem patients with OUD)
Medical
Services
Injunction
Provision
11.3.4
Compliant All patients who have a documented history of opioid overdose or who upon
assessment are determined to be at imminent risk of an opioid overdose,
shall be offered MOUD with methadone, buprenorphine or naltrexone.
Medical
Services
Injunction
Provision
11.3.5
Compliant All patients offered treatment for HCV shall be evaluated for OUD and if found
to have OUD, shall be offered MOUD with methadone, buprenorphine or
naltrexone.
Medical
Services
Injunction
Provision
11.3.6a/b
Non-
compliant
Patients with OUD will be offered MOUD, including counseling, if appropriate.
The Department will take the necessary steps to ensure that any patient
transferring to another facility will not experience an interruption in MOUD,
counseling, or alcohol treatment.
Doc. 4968 at 134-38 (Monitors
find noncompliance with
11.3.6a/b requiring medication
for patients with OUD and detail
lack of leadership in roll-out)
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Medical
Services
Injunction
Provision
11.3.6c/d
Non-
compliant
Patients with Alcohol Use Disorder will be offered medication treatment and
counseling if appropriate. The Department will take the necessary steps to
ensure that any patient transferring to another facility will not experience an
interruption in medication or counseling.
Doc. 4968 at 139 (Monitors find
non-compliance with 11.3.6c/d
requiring medication and
counseling for patients with
alcohol use disorder)
Medical
Services
Injunction
Provision
11.4
Non-
compliant
Patients shall be offered all immunizations recommended by the CDC's
Advisory Committee on Immunization Practices.
Doc. 4968 at 140 (Monitors find
non-compliance with 11.4
requiring offering vaccinations)
Medical
Services
Injunction
Provision
2.1.3
Non-
compliant
Following a medical-related death, 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.
Doc. 4968 at 141 (Monitors find
non-compliance with 2.1.3
requiring follow-up after deaths)
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Medical
Services
Injunction
Provision
2.4.1
Non-
compliant
There needs to be a robust continuous quality improvement program to
monitor the quality of clinicalcare. As part of this program, staff monitor the
absolute number and trend of various parameters on amonthly basis. Where
metrics or trends in metrics show room for improvement, staff make
appropriateefforts to understand the underlying reason for deviation, take
reasonable steps to effectuateimprovement, evaluate the effectiveness of
these steps in a reasonable time, and make adjustments to itsimprovement
efforts as needed. At a minimum, ADCRR will monitor the following
parameters: • percentage of individuals (regardless of whether diagnosed
with hypertension) whosesystolic blood pressure exceeds 140 mmHg or
diastolic blood pressure exceeds 90mmHg; • 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 receivingtimely cervical
cancer screening; • percentage of pregnant women who have the results of
routine prenatal laboratory testsresults as recommended in current national
guidelines (e.g., Guidelines for Prenatal Care,8th Edition, American Academy
of Pediatrics and American College of Obstetricians andGynecologist, Table
6-2) documented within one month of diagnosis of pregnancy; • percentage
of health care grievances which are appealed; percentage of health
caregrievance appeal replies that are appropriate; • percentage of prisoners
on antipsychotic medications receiving timely AIMS (abnormalinvoluntary
movement scale) assessments; • percentage of prisoners on antipsychotic
medications receiving appropriate and timelymetabolic assessments; •
percentage of prisoners receiving punishment for a rule violation, for whom a
mental health intervention would have been more clinically appropriate than
punishment; andpercentage of prisoners arriving at ADCRR for whom intake
screening by an RN (orhigher credentialed professional) is completed more
than four hours after arrival.
Doc. 4968 at 142-43 (Monitors
find that Defendants have
“completely failed to meet the
requirements of any of the 12
domains listed” in 2.4.1
regarding a quality improvement
plan and “and has failed to do so
consistently for the past two
years,” which “increases the
risk of harm to patients”)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 99 of 128

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Medical
Services
Injunction
Provision
2.4.2
Non-
compliant
In addition to the parameters prescribed in 2.4.1, ADCRR will monitor other
parameters as reasonably dictated by the other self-improvement activities
described in the Injunction.
Doc. 4968 at 144-46 (Monitors
find noncompliance with 2.4.2
regarding monitoring other
parameters and “with regarding
to systemic dangers to which
patients are exposed and which
have caused serious harm,
Defendants are unable to
identify, examine, remediate in a
manner that is lasting, and
monitor the effectiveness of its
remediation of these dangers”)
Medical
Services
Injunction
Provision
6.2a/7.3
Non-
compliant
All patients are assigned a Primary Care Practitioner (PCP.) Patients are
appropriately assigned to a physician or APP based on the patient's medical
complexity.
Doc. 4968 at 147-49 (Monitors
find that “Defendants’ practice
regarding [6.2a/7.3 requiring
that patients be assigned a
primary care practitioner] has
changed little since trial,
causing a “significant risk of
serious harm and causing
serious harm”)
Medical
Services
Injunction
Provision
6.2c
Non-
compliant
Facility Medical Directors (FMD) at high intensity facilities shall be assigned
up to 100 patients as the primary care provider and shall have no other
scheduled patient care assignments including supervision of APPs or as the
scheduled provider for specialized units such as Inpatient Component
(“IPC”) or Special Needs Unit (“SNU”.) This does not limit FMDs from
occasional unscheduled clinical supervision and care activities.
Doc. 4968 at 150 (Monitors find
Defendants’ non-compliance
with 6.2c requiring that Facility
Medical Directors (FMD) at high
intensity facilities be assigned
up to 100 patients and have no
other scheduled patient care
assignment, finding that one
FMD has over 600 patients)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 100 of 128

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Medical
Services
Injunction
Provision 6.4
Non-
compliant
All medical physicians–at hiring and during employment–shall be board
certified in Internal Medicineor Family Practice, or board eligible if within 7
years of their completion of an ACGME approvedresidency in one of these 2
specialties, with the following exceptions: medical directors, shall be
boardcertified at hiring and during employment; physicians providing
obstetric and gynecologic services shallbe board certified or board eligible if
within seven years of their completion of an ACGME approvedresidency in
obstetrics and gynecology; and physicians who are currently employed and
are not boardeligible may remain employed for no longer than one year after
issuance of this Order. They may alsonot possess a restricted license if the
restriction is related to clinical competency or is restricted topractice in a
correctional facility. (Notify Court Monitors if there is a request for an
exception)
Doc. 4968 at 151 (Defendants
and Monitors agree with 64%
compliance with 6.4 requiring
certain qualifications for
medical physicians, and
Monitors note that NaphCare
disagrees with the necessary
qualifications set forth in the
Injunction)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 101 of 128

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Medical
Services
Injunction
Provision
1.11
Non-
compliant
Licensed Practical Nurse (“LPNs”) shall practice within their scope of
practice set forth in Arizona Administrative Code § 4-19-401 (not
independently assess patients or initiate a plan of care or treatment.)
Doc. 4968 at 152-54 (although
Defendants self-assess at 100%
compliance with 1.11 regarding
practice limitations for LPNs
consistent with Arizona law,
Monitors find that Defendants
are non-compliant finding that
ADCRR allows LPNs to see
patients independently and the
EHR encourages this practice,
while Defendants “make[s] a
critical logic error in its analysis
[of its compliance with this
factor] despite repeated oral
and written feedback”)
Medical
Services
Injunction
Provision
1.12
Compliant No one 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.
Medical
Services
Injunction
Provision 1.9
Non-
compliant
Directors of Nursing (DON) at each complex may not spend more than 15%
of their time providing scheduled or unscheduled patient care.
Doc. 4968 at 156 (although
Defendants assert 71%
compliance with 1.9 regarding
Directors of Nursing spending
no more than 15% of their time
providing scheduled or
unscheduled patient care,
Monitors assert that Defendants
remain non-compliant due to
understaffing and a percentage
is not an effective way of
determining compliance)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 102 of 128

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Medical
Services
Injunction
Provision 1.4
Non-
compliant
Telehealth for medical care may be used only when clinically appropriate. Doc. 4968 at 157-58 (Monitors
find Defendants noncompliant
with 1.4 regarding telehealth
when clinically appropriate
because Defendants use
telehealth “well beyond its safe
limits and without the
availability of other proxies”)
Medical
Services
Injunction
Provision 1.6
Non-
compliant
There is sufficient space, equipment (e.g., otoscopes, ophthalmoscopes),
and supplies (e.g., dressings) to deliver medical care services appropriate to
the location.
Doc. 4968 at 159-61
(Defendants self-assessed 83%
compliance with 1.6 requiring
sufficient space, equipment,
and supplies to deliver medical
care services appropriate to the
location, but Monitors assert
“performance . . . cannot
logically be described by
percentage” and noting that
Defendants notes in its own
monthly report that several
facilities do not have enough
space to adequately see
patients)
Medical
Services
Injunction
Provision 3.5
Compliant The equipment used for interpretation shall allow for confidential
communication in all medical health care circumstances (e.g., dual hand- or
head-set device in locations where a speaker phone or computer can be seen
or overheard by other patients or custody staff.)(As explained in more detail
below in provision 1.7, the Injunction looks separately at whether, for this
provision, ADCRR has the proper equipment to allow for confidential
communication when interpretive services are needed. Whether or not that
equipment is actually used to benefit is captured in provision 1.7.)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 103 of 128

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Medical
Services
Injunction
Provision 1.7
Non-
compliant
There is auditory and visual confidentiality during medical encounters or
encounters that are not strictly medical or MH (confidentiality during MH
encounters is addressed in section 16.7.) 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.
Doc. 4968 at 162-63
(Defendants self-assessed its
compliance with 1.7 regarding
auditory and visual
confidentiality during medical
encounters or encounters that
are not strictly medical or MH as
73-100%, but Monitors
assessed noncompliance and
systemic failure)
Medical
Services
Injunction
Provision
1.10
Compliant All staff hired in clinical medical supervising positions must have at least two
years clinical experience.
Medical
Services
Injunction
Provision
1.13
Non-
compliant
Health care staff (Medical and Mental Health) responsible for direct patient
care shall not be mandated to work beyond the following limits: more than 12
hours in any 24-hour period; less than 8 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. Time spent on-call is not included in the time limits.)
Doc. 4968 at 164 (Monitors
assess non-compliance with
1.13 limiting hours for
healthcare staff)
Mental
Health
Injunction
Provision 1.1
See
subprovisions
below
All care and the documentation supporting that care, delivered to patients
during: a MH (primarily face-to-face encounters), in response to an inquiry
from a nurse or patient, during a chart review or chart-based triage decision,
or upon receipt of results from a test, other external health record, shall be
clinically appropriate. Settings include, but are not limited to those described
in the subprovisions of these provisions below.
Doc. 4968 at 165 (Monitors
assess noncompliance with 1.1
requiring clinically appropriate
care for mental health
encounters despite Monitors
repeatedly highlighting the
deficiencies)
Mental
Health
Injunction
Subprovision
1.1a
Non-
compliant
Emergent care Doc. 4968 at 168 (Defendants
self-assess 80% compliance
with 1.1a regarding emergent
care, but Monitors assess 28%
compliance)
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Mental
Health
Injunction
Subprovision
1.1b
Non-
compliant
Urgent care
Mental
Health
Injunction
Subprovision
1.1c
Non-
compliant
Non-urgent Doc. 4968 at 170 (Monitors
assess non-compliance with
1.1c regarding non-urgent care)
Mental
Health
Injunction
Subprovision
1.1d
Non-
compliant
Care provided by psychology associates or psychologists in an outpatient
setting (MH-3)
Doc. 4968 at 171 (Monitors
assess noncompliance with
1.1d regarding care provided by
psychology associates or
psychologists in outpatient
setting)
Mental
Health
Injunction
Subprovision
1.1e
Non-
compliant
Care provided by psychiatric practitioners in an outpatient setting (MH-3) Doc. 4968 at 172 (Defendants
assess 100% compliance with
1,1e regarding care provided by
psychiatric practitioners in
outpatient setting, but Monitors
assess only 94% compliance
when using Defendants’ dataset
and noting that dataset is only
one element in determining
compliance)
Mental
Health
Injunction
Subprovision
1.1g
Non-
compliant
Care provided by a psychology associate or psychologist in a MH Residential
Unit (MH-4)
Doc. 4968 at 173-75 (Monitors
assess Defendants
noncompliant with 1.1g
regarding care provided by
psychology associate or
psychologist in Mental Health
Residential Unit)
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Mental
Health
Injunction
Subprovision
1.1h
Non-
compliant
Care provided by a psychiatric practitioner in a MH Residential Unit (MH-4.)
This includes the requirements in 16.4.5 that the encounters are as often as
clinically indicated, but no less often than every 14 days.
Doc. 4968 at 176-77
(Defendants self-assessed 93%
compliance with 1.1h regarding
care provided by psychiatric
practitioner in Mental Health
Residential Unit, Monitors found
50% compliance when using
Defendants’ dataset and noting
that dataset is only one element
in determining compliance)
Mental
Health
Injunction
Subprovision
1.1i
Non-
compliant
Care provided by a psychology associate or psychologist in MH Inpatient Unit
(MH-5)
Doc. 4968 at 178-79 (Monitors
assess noncompliance with 1.1i
regarding care provided by
psychology associate or
psychologist in mental health in
patient unit)
Mental
Health
Injunction
Subprovision
1.1j
Non-
compliant
Care provided by a psychiatric practitioner in a MH Inpatient Unit (MH-5.) This
includes the requirement in 16.5.4 that a psychiatric practitioner shall
conduct a clinical encounter as often as clinically indicated, but no less than
once per week.
Doc. 4968 at 180-81 (Monitors
assess noncompliance with 1.1j
regarding care provided by
psychiatric practitioner in
mental health inpatient unit,
noting that in 2/3rds of reviewed
cases, psychiatric practitioner
“failed to provide minimally
necessary care.” Defendants
assess 88% compliance, but
using the same dataset, the
Monitors assessed 36%
compliance “despite ongoing
feedback and coaching from the
Monitors”)
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Mental
Health
Injunction
Provision 1.3
Non-
compliant
All patients with mental illness who require regular follow-up shall be
designated on the mental health caseload.
(Doc. 4968 at 182 (Defendants
self-assess compliance with 1.3
regarding follow-up for patients
with mental illness as 100%, but
experts assess 88% using the
same dataset and noting that
dataset is only one element in
determining compliance)
Mental
Health
Injunction
Provision
1.22
Non-
compliant
Follow-up visits with MH professionals are completed within the timeframe
ordered.
Doc. 4968 at 183 (Monitors
assert Defendants
noncompliant with 1.22
regarding timely follow-up with
mental health professionals)
Mental
Health
Injunction
Provision
1.21a
Unable to
determine
compliance
All refusals of patient-initiated visits shall be made directly to a health care
professional by telephone, video, or face-to-face. If a patient will not
voluntarily displace health care staff go to the patient’s location.
Doc. 4968 at 184 (Defendants
self-assess 80% compliance
with 1.21a regarding handling of
refusals of patient-initiated
visits, but Monitors unable to
assess due to flawed dataset)
Mental
Health
Injunction
Provision
1.21b
Non-
compliant
All refusals of a MH professional-initiated 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 psychiatric practitioner
(psychiatrist, psychiatric nurse practitioner, psychiatric physician assistant)
for mental health visits, within three days after the appointment. If a patient
will not voluntarily displace health care staff go to the patient’s location.
Doc. 4968 at 185-86
(Defendants self-assess 80%
compliance with 1.21b
regarding handling of refusals
for mental health professional-
initiated health visits, but
Monitors assess 60%
compliance using same dataset
and point to overuse of BHTs)
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Mental
Health
Injunction
Provision 5.1
Non-
compliant
For patients on the MH caseload with identified treatment providers in the
community, if the patient consents, health care staff shall send each provider
relevant health care information prior to the patient’srelease. 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, name and
contact information of the primary therapist, an aftercare plan that reflects
progress in treatment, and a current treatment plan. The patient’s health
record shall contain documentation of the above information that was
provided, when, and to whom.
Doc. 4968 at 187-88
(Defendants self-assess
compliance at 88% with 5.1
regarding sending community
provider relevant mental health
information with patient
consent, but Monitors estimate
20% and note two errors in
assessment of performance)
Mental
Health
Injunction
Provision
16.1
Non-
compliant
A psychology associate or psychologist conducts a mental health
assessment of each patient within one business day of that patient first
entering the ADCRR system. The intake mental health 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; medications;
suicide risk; behavioral observations of staff; and a preliminary designation of
level of care.
Doc. 4968 at 189-90 (Monitors
find Defendants noncompliant
with 16.1 regarding psychology
associate or psychologist
conducting intake assessments
because in one-third of patients,
assessments are clinically
inadequate)
Mental
Health
Injunction
Provision
15.8
Non-
compliant
For patients admitted to ADCRR on a psychotropic which is not on ADCRR’s
formulary, the medication shall be continued if, based on the patient’s
history, there is significant risk of worsening of the condition if a different
medication is prescribed. If no such risk exists, the medication shall be
continued long enough to allow a safe transition to a different medication or
medications.
Doc. 4968 at 191 (Defendants
self-assess compliance with
15.8 regarding non-formulary
psychotropics as 96% and
Monitors assert it may be 96%,
but could be lower and
Defendants will not produce
formulary despite Monitors’
request for it)
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Mental
Health
Injunction
Provision
15.3
Non-
compliant
Patients on the mental health caseload who believe they need mental health
care shall submit HNRs. Theprimary therapist or, if necessary, another
psychology associate shall triage HNRs within 24 hours ofreceipt. “Triage” in
this context means determining whether the request requires immediate
attention andresolution 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 theHNR within
three business days of its submission. “Address” means evaluating the
request, determiningthe clinical need, and if an action is required (e.g., face-
to-face visit), planning that action to occur in aclinically appropriate
timeframe. When the primary therapist is absent, another psychology
associate ora psychologist completes these tasks in their stead within the
same time.
Doc. 4968 at 192-95
(Defendants self-assess
compliance with 15.3 regarding
handling of mental health HNRs
at 80%, but Monitors assess it at
50% using same data and
Monitors identify issues with
data)
Mental
Health
Injunction
Provision
15.4
Non-
compliant
If a patient’s PT determines a visit is clinically appropriate following
submission of an HNR, the patient shall be seen by the PT or referred to
another professional as directed by the PT.
Doc. 4968 at 196-
97(Defendants self-assess 80%
compliance with 15.4 regarding
PT visits after submission of
HNR, but using same data,
Monitors assess 50%
compliance)
Mental
Health
Injunction
Provision
15.5
Non-
compliant
Patients 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.
Doc. 4968 at 198 (Defendants
self-assessed compliance with
15.5 regarding seeking initial
mental health treatment as
100%, but using same data,
Monitors found 25%
compliance)
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Mental
Health
Injunction
Provision
15.6
Non-
compliant
When custody staff, families, or any other concerned party refers a patient for
mental health assessment, there is a timely response to the concern by
mental health staff.
Doc. 4968 at 199-200 (Monitors
find non-compliance with 15.6
regarding responses of mental
health staff to reports made by
parties other than patient and
that Defendants’ methodology
is flawed)
Mental
Health
Injunction
Provision
16.3.1.1
Non-
compliant
An MH-3 patient’s assigned PT shall conduct an initial comprehensive mental
health evaluation within one month of arriving at the assigned facility if not
already completed when the patient first entered the prison system.
Doc. 4968 at 201-203
(Defendants self-assess
compliance with 16.3.1.1
regarding initial comprehensive
mental health evaluation for
MH-3 as 100%, Monitors found
performance level to be close to
0%)
Mental
Health
Injunction
Provision
16.3.1.2
Non-
compliant
An MH-3 patient’s assigned PT shall conduct an evaluation whenever there is
a change in MH level of care designation.
Doc. 4968 at 204 (Monitors find
Defendants noncompliant with
16.3.1.2 regarding PT
assessment of MH-3 when there
is a change in MH level)
Mental
Health
Injunction
Provision
16.3.1.3
Non-
compliant
An MH-3 patient’s assigned PT shall conduct an evaluation at least once per
year.
Doc. 4968 at 205-206 (Monitors
find Defendants noncompliant
with 16.3.1.3 regarding MH-3 PT
evaluation once per year)
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- 111 -
Mental
Health
Injunction
Provision
16.3.3
Non-
compliant
A treatment plan meeting shall be conducted with MH-3 patients and their
assigned PT. The treatment plan meeting shall occur at least once per year. A
psychologist or psychiatric practitioner shall also be present for complex
cases and in all other cases shall provide input to the PT prior to the treatment
plan meeting. At that meeting, the patient’s treatment plan shall be reviewed
and updated to determine adherence to treatment, efficacy of interventions,
evaluation of the level of care needs, diagnostic impressions, progress to
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 adate 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.
Doc. 4968 at 207-208 (Monitors
find Defendants noncompliant
with 16.3.3 regarding treatment
plan meetings with MH-3
patients focusing on low-quality
of treatment plans)
Mental
Health
Injunction
Provision
16.3.2
Non-
compliant
A psychiatric practitioner shall conduct an appropriate clinical encounter
with all patients in anoutpatient level of care (i.e., MH-3) on psychotropic
medications as often as clinically required, no less often than every three
months.
Doc. 4968 at 209 (Defendants
self-assess compliance with
16.3.2 regarding outpatient-
care patients on psychotropic
medications encounters with
psychiatric practitioners as
100%, but Monitors find
methodology to be flawed and
that Defendants’ failure to make
a risk-benefit analysis “posed a
significant risk to the patient of
the potential side effects of his
medications without
commensurate benefits)
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- 112 -
Mental
Health
Injunction
Provision
16.4.1.1
Non-
compliant
An MH-4 patient’s assigned PT shall conduct an evaluation whenever there is
a significant change in the course of treatment, e.g., new type of treatment
including medication, significant decompensation.
Doc. 4968 at 212-14
(Defendants self-assess
compliance with 16.4.1.1
regarding PT evaluation when
significant change in course of
treatment for MH-4 patient as
91%, but Monitors assess at
30% with same dataset and note
percentage is only element in
measuring Injunction
compliance)
Mental
Health
Injunction
Provision
16.4.1.2
Non-
compliant
An MH-4 patient’s assigned PT shall conduct an evaluation at least annually,
documenting the patient’s need for residential level of care.
Doc. 4968 at 215-16 (Monitors
find Defendants noncompliant
with 16.4.1.2 regarding mental
health evaluations, and noting
that treatment can fall well
below standard of care without
compliance)
Mental
Health
Injunction
Provision
16.4.2
Non-
compliant
Patients in residential level of care shall have face-to-face encounters with
their assigned PTs as determined by the treatment plan.
Doc. 4968 at 217-18 (Monitors
assess that “Defendants
continue to fail to provide
clinically meaningful treatment
to mentally ill patients” and are
non-compliant with 16.4.2
regarding face-to-face
encounters with PTs for patients
in residential level of care)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 112 of 128

- 113 -
Mental
Health
Injunction
Provision
16.4.3
Non-
compliant
Patients 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.
Doc. 4968 at 219-20 (Monitors
find two deficiencies prevent
compliance with 16.4.3
regarding review of treatment
plans for patients in residential
level of care)
Mental
Health
Injunction
Provision
16.4.4
Non-
compliant
A full Treatment Team meeting shall be conducted at least every 3 months by
the primary therapist,psychologist, psychiatric practitioner, and any other
staff as necessary. Patients shall be included in themeeting unless there is a
clinical or legitimate and substantial safety and security concern
documented inthe custody record. The meeting discussion shall include
determination of adherence to treatment,efficacy of interventions,
evaluation of their level of care needs, rationale for the need for
residentialcare, diagnostic impressions, progress to date in treatment, and
steps taken toward moving to a lessrestrictive environment.
Doc. 4968 at 221-22
(Defendants self-assess 91%
compliance with 16.4.4.
regarding full treatment team
meetings for mental health
patients, but Monitors note 33%
compliance and that
compliance is not fully reflected
by percentage; experts note
“risk of significant harm from
inadequate Treatment Plans)
Mental
Health
Injunction
Provision
16.5.1.1
Non-
compliant
The PT assigned to a patient in MH Inpatient care (MH-5) (or, if not already on
the mental health caseload, the mental health provider assigned to the
inpatient unit) shall conduct at least annually a comprehensive mental health
evaluation reflecting the rationale for inpatient placement including but not
limited to current symptoms and functional impairment, timing and pattern
of 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.
Doc. 4968 at 223-24 (Monitors
find Defendants noncompliant
with 16.5.1.1 regarding annual
comprehensive mental health
evaluation for MH-5 patients)
Mental
Health
Injunction
Provision
16.5.1.2
Non-
compliant
The PT assigned to a patient in MH Inpatient care (MH-5) (or, if not already on
the mental health caseload, the mental health provider assigned to the
inpatient unit) shall upon discharge from inpatient care, prepare a discharge
summary.
Doc. 4968 at 225 (Monitors find
Defendants noncompliant with
16.5.1.2 regarding PT
assignment to MH-5 patients)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 113 of 128

- 114 -
Mental
Health
Injunction
Provision
16.5.2
Non-
compliant
Patients in MH Inpatient care (MH-5) shall have a daily face-to-face
encounter with their PT unless such an encounter would be clinically
contraindicated. If the patient participates in the weekly treatment progress
meeting described in Section 16.5.3, it may be counted as a daily face-to-face
encounter.
Doc. 4968 at 226 (Monitors find
Defendants noncompliant with
16.5.2 regarding MH-5 daily
face-to-face encounters with
PT)
Mental
Health
Injunction
Provision
16.5.3
Non-
compliant
Patients in MH Inpatient care (MH-5) 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. Patients 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 patient progress, the type and efficacy of interventions used,
treatment adherence, potential obstacles to recovery, and rationale for
continued placement in the inpatient unit.
Doc. 4968 at 227 (Monitors find
Defendants noncompliant with
16.5.3 regarding treatment
teams for MH-5 patients)
Mental
Health
Injunction
Provision
16.6.1
Non-
compliant
If a patient’s treatment team changes due to a change in the patient’s mental
health level of care 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.
Doc. 4968 at 228 (Defendants
self-assess 76% compliance
with 16.6.1 regarding changes in
treatment team, but Monitors
assess 50% and that
compliance is not fully reflected
in percentage)
Mental
Health
Injunction
Provision
16.6.2
Non-
compliant
If a patient’s treatment team changes due to a change in the patient’s mental
health level of care, if the transition is to anything other than to residential or
inpatient, the “new” PT meets with the patient within seven calendar days;
Doc. 4968 at 229 (Monitors find
Defendants noncompliant with
16.6.2 regarding timing of new
PT after treatment plan change)
Mental
Health
Injunction
Provision
16.6.3
Non-
compliant
If a patient’s treatment team changes due to a change in the patient’s mental
health level of care, if the transition is to residential or inpatient level of care,
the PT meets with the patient as soon as possible, but no more than one
business day after arrival, and the psychiatric practitioner is contacted and
collaborates on the immediate care plan as soon as a patient is admitted.
Doc. 4968 at 230 (Monitors find
Defendants noncompliant with
16.6.3 regarding timing of new
PT and psychiatric practitioner
with treatment team change)
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- 115 -
Mental
Health
Injunction
Provision
16.6.4.1
Non-
compliant
If a patient’s PT changes without a change in mental health level of care, if the
transition is to anything other than to residential or inpatient, the “new” PT
meets with the patient within seven calendar days.
Doc. 4968 at 231 (Monitors find
Defendants noncompliant with
16.6.4.1 regarding timing of PT
when PT changes without a
change in mental health level of
care)
Mental
Health
Injunction
Provision
16.6.4.2
Non-
compliant
If a patient’s PT changes without a change in mental health level of care,
because the patient is being moved but is remaining in residential or inpatient
level of care, the “new” PT meets with the patient within one business day.
Doc. 4968 at 232 (Monitors find
Defendants noncompliant with
16.6.4.2 regarding timing of new
PT after transitions in mental
healthcare)
Mental
Health
Injunction
Provision
18.1
Non-
compliant
Prior to release of any patient designated as Seriously Mental Ill (“SMI”), MH-
4, or MH-5 who shall bereleased and who is presumptively eligible for federal
or state assistance by virtue of their mental illness,ADCRR: (a) develops and
documents an aftercare plan that reflects the patient’s current symptoms
andfunctional impairments, progress in treatment, and treatment plan; (b)
facilitates evaluation for SMIdesignation and placement in the community, as
clinically indicated; and (c) arranges follow-up carewith an appropriate
community provider where possible.
Doc. 4968 at 233-35
(Defendants self-assess
compliance with 18.1 regarding
procedures for release of MH-4
and MH-5 patients as 94%, but
Monitors assess as close to 0%
using same dataset)
Mental
Health
Injunction
Provision
16.8.1
Non-
compliant
During normal business hours a patient who presents as a suicide risk shall
have a formal in-person suicide risk assessment completed by a licensed
psychology associate, psychologist, or psychiatric practitioner to determine
the acute suicidal risk and the level of protection that is needed (e.g., return
to current housing, placement in one-on-one observation, etc.) 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
patient (which may or may not include constant observation.) If the patient 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.
Doc. 4968 at 236-37
(Defendants self-assess
compliance with 16.8.1
regarding suicide risk
assessments as 78%, and
Monitors assess at 72% using
same dataset)
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Mental
Health
Injunction
Provision
16.8.3
Non-
compliant
Upon recommendation from a psychologist or psychiatric practitioner that
housing a patient on suicide watch (a.k.a. MH Watch) in the same room with
other suicide watch patients (“cohorting”) would be clinically safer than
housing each patient in isolation, Defendants shall cohort such patients,
provided that based on the patients’ custody classification (determined
based on factors other than the fact that the individual is on suicide watch)
such cohorting would not be contraindicated.
Doc. 4968 at 238-39
(Defendants self-assess
compliance with 16.8.3
regarding cohorting of suicide
risk patients as 82%, while
Monitors assess compliance
using same dataset as close to
0% identifying two flaws in
ADCRR assessment)
Mental
Health
Injunction
Provision
16.9.2
Non-
compliant
Continued treatment in a crisis stabilization bed requires review and approval
by a psychologist initially at seven days and every three days thereafter.
Starting at ten days following placement in a Crisis Stabilization bed, the
psychologist and or psychiatric prescriber shall document the justification for
their continued assignment to the Crisis Stabilization bed rather than a
Residential or Inpatient bed. (Additional reference 16.9.1)
Doc. 4968 at 240-43 (Monitors
find Defendants noncompliant
with 16.9.2 regarding continued
treatment in Crisis Stabilization
bed)
Mental
Health
Injunction
Provision
16.9.3
Non-
compliant
Patients in a crisis stabilization bed shall be evaluated at least daily in person
by their PT (or another psychology 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 patient
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.
Doc. 4968 at 241-43 (Monitors
find Defendants noncompliant
with 16.9.3 regarding daily
evaluation by PT and treatment
plans for patients in Crisis
Stabilization beds)
Mental
Health
Injunction
Provision
16.9.4
Non-
compliant
The patient shall be assessed by a psychiatric practitioner as soon after
admission to a crisis stabilization bed 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.
Doc. 4968 at 244 (Defendants
self-assess compliance with
16.9.4 regarding assessment by
psychiatric practitioner when
placed in Crisis Stabilization bed
at 79%, but Monitors assess
compliance at 55%)
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Mental
Health
Injunction
Provision
16.9.5
Non-
compliant
For patients placed in a crisis stabilization bed for suicidal concerns, a
suicide risk assessment (SRA) 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.
Doc. 4968 at 245-46 (Monitors
find Defendants noncompliant
with 16.9.5 regarding suicide
risk assessments for patients in
Crisis Stabilization beds)
Mental
Health
Injunction
Provision
16.9.6
Non-
compliant
A clinical note shall be entered whenever the level of suicide watch is
changed.
Doc. 4968 at 247-48
(Defendants self-assess
compliance with 16.9.6
regarding clinical notes when
level of suicide watch changed
as 96%, but Monitors assess
17% compliance using same
dataset and note that they have
explained to ADCRR the error in
the procedure)
Mental
Health
Injunction
Provision
16.9.7
Non-
compliant
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 patient’s
identified protective factors; and plans for follow-up treatment, and aftercare
including a safety plan developed in collaboration between the patient and
treatment providers.
Doc. 4968 at 249 (Monitors find
Defendants noncompliant with
16.9.7 regarding discharge
suicide risk assessment on
release from Crisis Stabilization
bed)
Mental
Health
Injunction
Provision
16.9.8
Compliant “Safety contracts” (forms signed by patients, agreeing not to hurt
themselves) shall not be used.
Mental
Health
Injunction
Provision
16.9.9
Non-
compliant
When possible and safe, attempt to provide stabilization at the complex at
which the patient has been housed unless there is documented clinical
justification for transfer based on the low likelihood of stabilization and/or
clinical danger if the patient is maintained at the complex.
Doc. 4968 at 251-52
(Defendants self-assess
compliance with 16.9.9
regarding stabilization at
complex where patient is
housed as 100%, but Monitors
calculate 80% compliance with
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same dataset)
Mental
Health
Injunction
Provision
16.10
Compliant Restraints used by mental health clinicians for clinical purposes shall comply
with the following 8 requirements: 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 patients. They shall not be used for
punishment. 2) Restraints shall be ordered and reviewed only by a psychiatric
practitioner or psychologist. 3) Restraints shall only be applied for the
minimum amount of time necessary to accomplish the stated need (e.g.,
patient and
staff safety, requisite transports, etc..) 4) Soft restraints shall be used
whenever possible. 5) 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. 6) Renewal of restraints beyond four hours shall be approved by
the Facility Medical Director/designee and must be renewed at intervals no
longer than four hours. If the Medical Director/designee are not available, a
licensed mental health provider may approve continued use. The
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justification for continued use shall be documented in the patient’s medical
records. Renewals occurring after hours shall be done in collaboration with
the Facility Medical Director/designee, a psychiatric practitioner, or a
psychologist. 7) Patients 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 patient’s medical records. 8) Patients 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.
Mental
Health
Injunction
Provision
13.2
Compliant 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 psychology
associate, psychologist, or psychiatric practitioner.
Mental
Health
Injunction
Provision
14.1
Compliant 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; they may also not possess a restricted license if the restriction is
related to clinical competency or is restricted to practice in a correctional
facility. (Notify Court Monitors if there is a request for an exception.)
Mental
Health
Injunction
Provision
14.2
Compliant All psychologists and psychiatric practitioners shall have the appropriate
state licenses. All psychology associates shall be licensed or become
licensed within one year of hiring or within one year of this Order, whichever
is later, and may not possess a restricted license if the restriction is related
to clinical competency or is restricted to practice in a correctional facility.
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Mental
Health
Injunction
Provision
1.10
Compliant All staff hired in clinical MH supervising positions must have at least two years
clinical experience.
Mental
Health
Injunction
Provision
1.11
Compliant Behavioral Health Technicians shall not independently assess patients or
initiate a plan of care or treatment.
Mental
Health
Injunction
Provision
1.12
Compliant No one 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.
Mental
Health
Injunction
Provision
13.1
Compliant Outpatient psychologists supervise no more than eight psychology
associates, and inpatient psychologists supervise no more than six
psychology associates.
Mental
Health
Injunction
Provision
15.1
Non-
compliant
Each patient on the mental health caseload, i.e., all patients in MH Levels 3,
4, and 5, are assigned aprimary therapist (PT; psychology associate or
psychologist) who serves as the single point of contactand coordination for
providing care to all patients designated MH-3 and above. When a
patient’sassigned PT is unavailable, another psychology associate or
psychologist acts on their behalf.
Doc. 4968 at 261-62 (Monitors
state “[w]ith the current reports
generated by Defendants, it is
not yet possible to calculate an
accurate count of the number of
patients for whom [15.1
regarding assignment of PT to
patients on mental health
caseload] has been met,” but
that current conditions make it
“impossible to provide
meaningful safe MH care,”
which “underscores the need for
immediate implementation of
the PCCM and staffing plan.”)
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Mental
Health
Injunction
Provision
15.2
Non-
compliant
A psychologist shall review the records of each patient who is added to, or
discharged from, the mental health caseload after intake. The psychologist
shall approve or deny the level of care assignment and take appropriate
action.
Doc. 4968 at 263-64
(Defendants self-assess 92%
compliance with 15.2 regarding
psychologist review of records
after mental health intake, but
Monitors assess approximately
30% compliance with same
dataset)
Mental
Health
Injunction
Provision 1.4
Non-
compliant
Telehealth (video encounter with remotely located clinicians; TH) for mental
health care may be used only when clinically appropriate.
Doc. 4968 at 264 (Defendants’
compliance with 1.4 regarding
telehealth for mental healthcare
as 88%, but Monitors assert that
“[d]espite our strong
recommendations to the
contrary, Defendants continue
to rely heavily on, if not has
increased its reliance on,
remote mental health clinicians
providing chronic care in mental
health via video.”)
Mental
Health
Injunction
Provision
15.9
Non-
compliant
There is sufficient space, equipment (e.g., computer, furniture), and supplies
(e.g., assessment and treatment materials) to deliver mental health care
services. This includes, but is not limited to, areas for mentally ill patients to
be housed, engage in programming, and receive treatment (both individual
and group) in an environment commensurate with that unit/facility’s
designated level of care. There is auditory and visual confidentiality during
MH encounters.
Doc. 4968 at 266 (With regard to
15.9 regarding sufficient space,
equipment, and supplies to
deliver mental health services,
Monitors state “Defendants
cannot possibly comply with
almost any of the requirements
of the Injunction in the absence
of sufficient space, equipment,
and supplies.”)
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Mental
Health
Injunction
Provision
16.7
Non-
compliant
All mental health encounters with all patients shall occur in a confidential,
therapeutically appropriate setting unless there is a clinical or legitimate and
substantial safety and security concern that is documented.
Doc. 4968 at 267-68 (Monitors
find Defendants noncompliant
with 16.7 regarding conducting
MH encounters in confidentially,
therapeutically appropriate
setting despite Monitors’
previous documentation of
these issues in their Second
Interim Monitors’ Report)
Mental
Health
Injunction
Provision
1.15
Non-
compliant
There is a sufficient number of custody staff to support the functioning of the
health care operation, including but not limited to: transporting patients 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 a declared emergency (e.g., prison riot, natural
disaster.)
Doc. 4968 at 270-71 (Monitors
find non-compliance with 1.15
regarding sufficient number of
custody staff to support
healthcare due to insufficient
number of custody staff while
noting that existing custody staff
attempts to comply)
Mental
Health
Injunction
Provision
1.16a
Non-
compliant
(Additional reference: Any Court orders related to staffing levels) All positions
required by the current contract with the health care vendor including any
modifications, addenda, or updates are filled. A filled position is one in which
there is an incumbent receiving a salary for the full intended time
commitment of the position and is not on long term leave, e.g., Family
Medical Leave Act. An individual may not fill more than 1.0 FTE.
Doc. 4968 (Monitors find that
“Defendants cannot possible
fulfill the requirements of” 1.16a
regarding staffing levels under
current contract due to
inadequate number of staff with
proper credentials working at
Defendants on a daily basis, and
noting errors in staffing numbers
and competitive salary
compensation calculations)
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Mental
Health
Injunction
Provision
1.16b
Compliant Up to 15% of staff described in 1.16a may be filled with registry staff.
Mental
Health
Injunction
Provision
10.1
Non-
compliant
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.
Doc. 4968 at 275-79 (Monitors
find Defendants noncompliant
with 10.1 regarding prescribed
medications for direct
observation therapy (DOT))
Mental
Health
Injunction
Provision
10.2a
Non-
compliant
For a patient 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.
Doc. 4968 at 280 (Monitors find
Defendants noncompliant
10.2a regarding medication
administration for newly
admitted patients)
Mental
Health
Injunction
Provision
10.2b
Non-
compliant
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.
Doc. 4968 at 281 (Monitors find
Defendants noncompliant with
10.2b regarding administration
of newly ordered medications)
Mental
Health
Injunction
Provision
10.4.1
Non-
compliant
KOP medications shall be delivered to the patient before the medication runs
out (based on the date of the previous fill.) A KOP medication shall be
delivered either by providing the patient 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 patient is so informed.
Doc. 4968 at 282 (Defendants
self-assess its compliance with
10.4.1 regarding refills of KOP
medications at 96% and
Monitors agree, but note a high
degree of harm from any
deficiency in this area)
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Mental
Health
Injunction
Provision
10.3
Non-
compliant
When a patient 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 thecase to a higher
authority and within a specified amount of time (which may differ by
medication or class.) The decision rules described above should be
incorporated into the medication administrationsoftware of the EHR such
that the EHR automatically alerts the medication administrator when action
isneeded and what action is needed. When medication refusals require
escalation, an RN or higher willobtain an INFORMED refusal.
Doc. 4968 at 283-84 (Monitors
find Defendants non-compliant
with 10.3 regarding procedures
for medication refusals due to
uninformed refusals)
Mental
Health
Injunction
Provision
1.20a/b
Non-
compliant
When a patient notifies a correctional officer that he/she has a need for health
care (medical or mental health), the officer may not inquire as to the nature
of the need or symptoms. The officer’s inquiry is limited to asking whether the
need is immediate, if the patient can wait to sign up for the next scheduled
clinic, or if the patient is thinking of harming themselves. (If the patient is
thinking of harming themself,the officer shall immediately ensure the
patient’s safety and contact health care staff in accordance with Section
16.8.1.) For other needs that are immediate, the officer shall contact health
care staff immediately. An RN shall then immediately triage the patient, either
by seeing the patient, or talking to the patient directly over the phone. Based
on triage results, the RN shall discuss the patient with a medical practitioner
(i.e., physician or APP) or, if the patient is already on the mental health
caseload (i.e., MH-3, 4, or 5), a mental health professional in a clinically
appropriate timeframe, not to exceed four hours. In this context, the mental
health professional shall be a psychology associate, psychologist, or
psychiatric prescriber. Based on that interaction the professional who was
contacted shall: see and treat the patient the same day; or instruct the RN on
treatment to provide, and, if necessary, schedule the patient for further
evaluation or treatment in a clinically appropriate timeframe; or determine
the health care need is not urgent and that a reasonable patient would not
have considered the health care need to be urgent, defer treatment, and
instruct the patient to access non-urgent/non-emergent care for treatment.
Doc. 4968 at 285 (Monitors find
Defendants noncompliant with
1.20a/b regarding correctional
officer information regarding
healthcare needs noting that
correctional officers “are still
attempting to triage episodic
complaints brought to them by
patients,” resulting in
dangerous conditions)
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Mental
Health
Injunction
Provision
2.1.1
Non-
compliant
Following any death or suicide attempt, identify all significant health care and
custody errors (i.e., near misses as well as preventable adverse events.)
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 crafted and implemented within one month of the
death. A sustainable plan is one which outlives staff memory from a single
training after the review or staff turnover. Monitor the
Doc. 4968 at 286 (Monitors find
that “despite extensive
feedback and coaching we have
provided to Defendants’ staff,
both orally and in writing, little
progress has been made by
Defendants to comply” with
2.1.1 regarding identification of
significant healthcare and
custody errors following any
death or suicide attempt)
remedial plan for effectiveness and make appropriate and timely
modifications to the plan based on the monitoring. [2.1.3.] For each death,
the plan in this section shall be crafted and implemented within one month
whether or not the medical examiner’s report is available.
Mental
Health
Injunction
Provision
2.5.1
Non-
compliant
Staff capture 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 patients, grievances, the Court-appointed Monitors, staff
reports, continuous quality improvement, etc. Staff maintain an active log of
all such errors and problems to assist in deciding which issues to address,
when, and at what level (complex and/or statewide), 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 remedial plan shall be monitored for
effectiveness. Appropriate and timely modifications shall be made to the plan
based on the monitoring.
Doc. 4968 at 287-89 (Monitors
find Defendants noncompliant
with 2.5.1 regarding staff
capture of errors and problems
stating that “[i]t is extremely
difficult for us to describe in
clear prose Defendants’ non-
compliance because of the
chaotic nature of their work,
documentation, and lack
thereof.”)
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Mental
Health
Injunction
Provision
4.4a/b
Compliant Imported or scanned documents (including but not limited to diagnostic test
results, consultation reports,and hospital discharge summaries) in the EHR:
shall be filed in a clear and usable manner, areaccurately labeled with
meaningful titles/file names, are scanned right-side up, and are filed with
anappropriate document date according to the following rules: Scanned
documents are dated (and appearin any programmed or ad hoc list according
to this date) based on the clinically relevant date of thedocument, not the
date scanned. For example, the clinically relevant date of a lab test is the date
the testwas 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; documents are scanned in the correctorientation and
labeled with the correct date. (This provision only addresses whether a
relevantdocument is eventually scanned into the EHR in some form,
regardless of the timeliness, accuracy oflabeling, or readability.)
Mental
Health
Injunction
Provision
4.4c
Compliant Fewer than 1% of files are labeled/titled with names beginning with
“Miscellaneous” or “Other.”
Mental
Health
Injunction
Provision
4.4d/e
Non-
compliant
Documents (including but not limited to diagnostic tests, consultation
reports, and hospital discharge summaries) which are supposed to be
manually scanned into, or electronically attached to (after receipt via email)
the EHR have this completed within 2 business days of receipt. All imported
documents are reviewed by the medical provider (for medical documents), or
primary therapist or psychiatric prescriber (for MH documents) within 4
business days of receipt.
Doc. 4968 at 292-93
(Defendants self-assess its
compliance with 4.4d/e
regarding documents scanned
or electronically attached to
EHR 97%, but Monitors find
errors in the samples, and that
performance would be well
below 97%, but even at 97%
presents a considerable risk of
harm)
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Mental
Health
Injunction
Provision 4.5
Non-
compliant
Staff provide patients access to their own medical records as follows, unless
a practitioner documents in the patient’s EHR how disclosure of such
information would jeopardize the health, safety, security, custody or
rehabilitation of the patient 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 patient: (a) read-only access to patients wishing to read a
copy of their health record; (b) orally sharing with a patient information
regarding their diagnosis or any other information about their health care; (c)
providing paper copies at a fee consistent with the updated policy; or (d) as
an alternative to a paper copy, if the patient agrees, staff may provide the
requested records, free of charge, in an electronic medium that the patient is
able to access.
Doc. 4968 at 294 (Defendants
self-assess compliance with 4.5
regarding providing patients
access to their own medical
records as 66-89%, and using
same dataset Monitors assess
at 60%)
Mental
Health
Injunction
Provision 4.3
Non-
compliant
The Problem List in a patient’s health record shall have the following qualities:
(1) It shall be accurate, complete, and easily usable. (2) Resolved or historical
conditions or diagnoses are separated from current conditions. (3) The date
of onset or resolution of resolved or historical conditions or diagnoses is
indicated, if known. (4) Similar or identical diagnoses of current conditions
are listed only once. For example, a Problem List should not simultaneously
list “heart disease,” “heart failure,” and “congestive heart failure, not
otherwise specified.”
Doc. 4968 at 295-302 (finding
noncompliance with 4.3
regarding problem lists in health
record and stating “In a half a
year, and despite our detailed
feedback to Defendants,
nothing has changed – the
patient Problem Lists are still
horrible, continuing to pose a
significant risk to patient safety,
compounded by the fact that the
majority of patient visits are still
with practitioners who do not
already know the patient well,
making an accurate, usable
Problem List that much more
invaluable.”)
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Mental
Health
Injunction
Provision 3.1
Non-
compliant
(Additional references: 3.2, 3.3, 3.4) The patient's preferred language is
known, shown in all relevant screens of the EHR, and care is delivered in the
language in which the patient is fluent at all times. For all individual and group
health care encounters in all settings involving patients who are not fluent in
English, interpretation shall be provided via: 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 patient; or in-person or via video interpretation service (for sign
language) or audio language interpretation service that is compliant with
federal law and uses licensed interpreters, where required by state law.
Exception is made when use of the above methods is not feasible due to
emergency circumstances.
Doc. 4968 at 303-305
(Defendants self-assess
compliance with 3.1 regarding
care and records in patient’s
preferred language as 99.5%,
but Monitors note significant
errors)
Mental
Health
Injunction
Provision 3.6
Non-
compliant
Written available notification (such as a poster) shall be hung in all housing
units and medical clinics inall prisons advising prisoners, in the ten most
common languages in Arizona, of the availability ofinterpretation 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 alreadydocumented in their electronic health record.
Doc. 4968 at 306 (Defendants
self-assessed compliance with
3.6 regarding posting of
availability of interpretation
services in ten most common
languages as 89%) Monitors
note that 5/43 living areas and
6/55 medical areas were
missing the poster.)
Case 2:12-cv-00601-ROS Document 5123 Filed 02/19/26 Page 128 of 128