Health care workers hold signs at a rally to keep the beds at the Adult Residential Facility for permanent residents on the Zuckerberg SF General Hospital campus on Thursday, Aug. 22, 2019. (Kevin N. Hume/S.F. Examiner)

Health care workers hold signs at a rally to keep the beds at the Adult Residential Facility for permanent residents on the Zuckerberg SF General Hospital campus on Thursday, Aug. 22, 2019. (Kevin N. Hume/S.F. Examiner)

SF Public Defender demands answers over mentally ill inmates languishing in jail

San Francisco’s shortage of mental health beds could be leaving some mentally ill jail inmates who have been ordered into treatment waiting behind bars months longer than necessary.

The San Francisco Examiner has learned that the Public Defender’s Office last week subpoenaed Department of Public Health officials seeking information on the cases of eight conserved and incarcerated clients.

In at least one case, an incarcerated person represented by the Public Defender’s Office has been waiting nine months since ordered into conservatorship to be placed in an appropriate care setting. Kara Chien, Managing Attorney of the Mental Health Unit at the Public Defender’s Office, said that while conserved clients should ideally be placed “immediately after they have been conserved,” a 90-day wait is “not unheard of for processing.”

“Our office is representing 11 conserved clients who are currently incarcerated. We recently issued several subpoenas to the Department of Public Health on behalf of eight of those clients who have been waiting in jail for placement between three to nine months since their date of conservatorship,” said Chien.

Health department spokesperson Jenna Lane confirmed the subpoenas but said that they only concern three clients.

A total of seven employees received subpoenas last week, Lane confirmed Wednesday. Sources have told the Examiner that the group includes two administrators and nurses in the Transitions Division at the Zuckerberg San Francisco General Hospital, which is responsible for making final assessments in determining the appropriate level of care for conserved individuals, and for finding them placements.

The Lanterman-Petris-Short (LPS) Conservatorship Act of 1967 helped to establish due process rights for mental health clients ordered into conservatorship and called for least restrictive placement, according to the Public Defender’s Office.

“LPS supports our efforts to serve our conserved clients in maintaining their psychiatric stability and medication compliance, while decreasing their cycles of relapse,” Chien said. “Jails cannot provide appropriate treatment, which is why we utilize all the legal tools we can to get our clients properly placed and treated for their conditions.”

The subpoenaed health department employees were asked to testify on resources available to the department and why it has taken so long to place the incarcerated individuals. Hearings are scheduled for later this month.

In the week since the subpoenas have been issued, however, those clients and others waiting in jail have suddenly received placements, according to the Public Defender’s Office.

Chien said that the Public Defender’s Office “has been informed by the DPH that these eight clients, among several others, will be placed prior to the hearings.”

Lane said that efforts to “find an appropriate placement” for each of the clients “were underway before receipt of the subpoena.”

“Without talking specifically about these three people, we can say that in general, DPH always tries to find the least restrictive and most appropriate level of care for a client, based on clinical needs,” Lane said.

But Jennifer Esteen, a nurse who works in the Transitions Division, said that the sudden placements “sound like [DPH] is hoarding resources and forcing people to stay in jail beyond medical necessity.”

“If we can come up with resources in a week for [more than eight] people, that means we have these resources all along,” said Esteen.

Backed up system leaves many mental health patients at ‘wrong level of care’

The Public Defender’s inquiry into what resources are available to treat some of The City’s sickest residents cuts into the heart of recent efforts to block DPH from converting 41 long-term residential treatment beds at Zuckerberg San Francisco General Hospital into short-term beds. The long-term beds are for patients who are unable to live independently.

Last month, at least 18 patients received 60-day relocation notices informing them that they will soon have to vacate the hospital’s Adult Residential Facility (ARF) — a unit in the hospital’s Behavioral Health Center where some patients have been living for more than a decade — and move to another part of the facility.

The patients were asked to move because the health department plans to close down 41 out of the 55 ARF beds to allow for a 27-bed expansion at the hospital’s Hummingbird Place, a psychiatric respite where patients stay an average of 19 days.

Outrage over the move grew after it was revealed that 32 of the 55 ARF beds have gone unfilled for nearly a year.

Health department officials have said that the beds were underutilized and cited staffing issues as a reason for repurposing them into shelter beds, which the department said are urgently needed. But supervisors Hillary Ronen and Rafael Mandelman have announced that they plan to reverse the decision with separate pieces of legislation.

“Holding beds open for a year is arbitrary,” said Esteen in reference to the ARF beds. “That is my biggest fear, that we are holding these clients for inordinate amount of time unnecessarily, based on arbitrary placement reasons.”

Esteen, who was angered by the planned ARF bed redistribution and helped to shine light on the issue, said that staffers in her division periodically appear at court hearings for conserved clients “to figure out what’s happening with their placement” and justify potential delays.

Esteen said that sometimes the reason is simple — a client ordered into treatment isn’t ready to move to the next level of care. But complications arise when a client who is ready to be placed isn’t getting the treatment they need because “placements do not exist or [treatment] isn’t available to meet the client’s need,” and so languishes in jail, Esteen said.

The planned redistribution of the permanent ARF beds, however, further impacts a system that is already backlogged with few residential facilities to send patients to, she said.

The 55 ARF beds, with residential beds serving seniors in the same building, are the only permanent residential beds operated by The City, which also contracts with independent board and care providers to house elderly patients and those with mental illness.

However, board and cares are dwindling at alarming rates, said Esteen, who estimates that the number of board and care beds in the city has decreased by 40 percent since 2013.

“In an ideal world everyone would be able to move to the level of care they need when they need it. If you need a higher level of care you should be able to access it. If a lower level, you should be able to access it,” said Michele Giardina, an LPS conservator for The City, at a recent planning meeting of her union.

She added that because the system is backed up, “we have a lot of people at the wrong level of care.”

Giardina said that the “flow is backed up to the street level.” Referrals to higher levels of care are made through ZSFGH’s Psychiatric Emergency Services (PES), but the backlog prevents PES from “admitting people because they have no space in the inpatient unit because people in there are waiting for locked [placements] or board and cares.”

“There are people in [BHC’s locked facility] who are ready to be in board and cares. They could leave that level of care and go to lower level, which opens up a bed in locked facility that a person in jail could move into,” said Giardina. “When the lower level of care stops you can’t move people down — you can’t clear out beds.”

Ronen, who has called for a public hearing on the ARF bed redistribution and announced plans to introduce legislation to reverse the plan, on Thursday called revelations about conserved individuals languishing in jail “a scandal.”

“San Francisco has turned into One Flew over the Cuckoo’s Nest,” said Ronen. “We have people trapped in jail cells … and women locked in a hospital ward with judges and doctors begging for them to be set free, and every other day someone with mental illness or addiction is dying on our streets. And all of this has been covered up by the Department of Public Health. This is a scandal.”

This story has been updated.

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