Mental Health Services in Denver's Jail System

Silver Star Sculpture Outside Denver County. Jail

Objective

To determine whether the Denver Sheriff Department’s mental health services and programs are effective in providing support for people in jail as well as employees of the Denver jail system.

Background

The Sheriff Department provides mental health services, both internally and through contractors, to individuals housed in its jail system.

All individuals receive a mental health assessment when entering jail to help identify issues, such as drug and alcohol addiction or behavioral conditions. Individuals are then able to receive the necessary care both while in jail and when returning to the community.

Why this matters

If the Sheriff Department’s mental health programs and operations are not effectively helping individuals in need or those who are at high risk, these people may not successfully return to the community and might instead cycle back through the jail system.

Findings

Finding 1 - The Denver Sheriff Department Does Not Have a Strategy for Its Mental Health Programs
 

The department’s decentralized mental health programs lack an overarching strategy, and it has not clearly defined what success means for all programs. The programs also lack oversight. Meanwhile, one program appears inequitable because it is offered only to men.

Finding 2 - The Denver Sheriff Department’s Data Processes Should Be Improved

The department needs to improve its data tracking for evaluating mental health programs and services. Also, it is not reliably tracking and evaluating individuals’ requests and complaints while in custody. Meanwhile, the department uses paper medical charts and manual data entry, which may complicate both mental health services and continuity of care.

Finding 3 - The Denver Sheriff Department Is Not Sufficiently Monitoring Mental Health Contracts and Invoices

The department should establish oversight of contracts and invoices to ensure terms are met and that payments are allowed. Additionally, without sufficient monitoring, the department cannot determine the quality of mental health services contractors provide.

Finding 4 - The Denver Sheriff Department Could Not Demonstrate All Individuals Identifying as Transgender Were Assessed and Housed According to Their Preference

The department could not provide evidence to show it met with all individuals identifying as transgender in line with policy and that they were not housed for longer than 72 hours in separate housing before receiving an initial assessment.

Finding 5 - The Denver Sheriff Department Could Not Demonstrate Compliance with Training Requirements

The department could not provide adequate documentation to show it was following training requirements, which include mental health classes for staff.

Recommendations

1.1 Develop a Strategy for Mental Health Programs – The Denver Sheriff Department should use leading practices — such as the “Standards for Internal Control” and “Designing Evaluations” guidance from the U.S. Government Accountability Office — to develop an overarching strategy for its mental health programs.

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

1.2 Identify Measures of Success – The Denver Sheriff Department should use leading practices — such as the “Designing Evaluations” guidance from the U.S. Government Accountability Office or “Program Design: A Literature of Best Practices” — to identify and document measures of success for each mental health program. Success should be specific and measurable. In instances where a contractor or other service provider is providing mental health services through a contract, the department should work with the contractor to amend the contract to include specific and measurable definitions of program success.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

1.3 Conduct Program Needs Assessments – The Denver Sheriff Department should formalize, document the process for, and identify the needs of all its mental health programs. The assessments should include identifying resources, such as funding and staff, required to meet program objectives. As part of the assessment, the department should consider equitable access to all mental health programs to align with the mayor’s priority.

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

1.4 Conduct a Workforce Analysis – The Denver Sheriff Department should conduct a formal workforce analysis based on the results of the needs assessments to identify gaps in its workforce to help the department achieve program objectives and success.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

1.5 Develop, Document, and Implement Program Policies and Procedures – The Denver Sheriff Department should develop, document, and implement policies and procedures for each of its mental health programs. For the department to meet its objectives and measure its success, policies and procedures should include, at a minimum:

  • Criteria for program entry.
  • Clear definitions of program success.
  • Data monitoring.
  • Details of the roles and responsibilities for various program tasks.

Agency Response: Agree, Implementation Date –Oct. 14, 2022

 

2.1 Identify and Track Performance Data – The Denver Sheriff Department should identify the data and information necessary for it to monitor progress toward meeting the objectives of its mental health programs, both individually and holistically. The data should be consistent across all programs to allow for monitoring across programs (e.g., demographic data such as race and gender).

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

2.2 Document Data-Entry Policies and Procedures – The Denver Sheriff Department should document policies and procedures for data entry related to its mental health programs.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

2.3 Create and Document Quality Assurance Reviews – The Denver Sheriff Department should create and document quality assurance processes for program data entry to ensure the data is reliable and accurate so it can make informed decisions.

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

2.4 Monitor Program Performance Data – The Denver Sheriff Department should periodically monitor the data and information it collects on its mental health programs to ensure performance measures and program objectives are being met, that programs are offered equitably, and to make decisions related to programmatic changes.

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

2.5 Establish a Consistent Way to Track Data for Requests and Complaints – The Denver Sheriff Department should work with Denver Health to develop a way to track information related to general and mental health requests and complaints. The data should be populated consistently and completely to allow the department to track and monitor data to identify trends.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

2.6 Track General Requests – The Denver Sheriff Department should use the mechanism established in Recommendation 2.5 to track general requests.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

2.7 Review Existing Policies and Procedures –  The Denver Sheriff Department should work with Denver Health to review and update existing policies and procedures for tracking and analyzing data related to general and mental health requests and complaints based on the mechanism established in Recommendation 2.5.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

2.8 Create and Document Quality Assurance Reviews – The Denver Sheriff Department should work with Denver Health to create and document quality assurance processes for data entry to ensure data is reliable and accurate to allow management to make informed program decisions.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

2.9 Monitor Data about Requests and Complaints – The Denver Sheriff Department should periodically monitor its and Denver Health’s data for general and mental health requests and complaints to identify trends, address personnel issues in a timely manner, and make adjustments to processes.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

2.10 Assess System Controls – The Denver Sheriff Department and Denver Health’s Continuous Quality Improvement Committee should assess internal controls within their electronic information systems to ensure health care providers’ and patients’ data is accurate and reliable. Where system controls cannot be implemented, the department should develop and document policies and procedures for reviewing providers’ and patients’ data to ensure accuracy and reliability.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

2.11 Implement an Electronic Medical Chart System – The Denver Sheriff Department should continue working with the City Council and Denver Health to implement an electronic medical chart system to better allow for continuity of care for people while they are in Denver’s jail system and after they are released.

Agency Response: Agree, Implementation Date – Jan. 13, 2022

 

2.12 Assess Fees for Medical Records – The Denver Sheriff Department should assess whether it should waive the fee for individuals leaving jail and after an individual has already been released so they have access to their medical and mental health records to better allow for continuity of care after their release from Denver’s jail system. The department should document their decision-making process for choosing whether to charge fees for medical records.

Additionally, the department should communicate its fee policy with Denver Health staff to ensure consistent understanding and application.

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

3.1 Establish Contract Oversight – The Denver Sheriff Department should identify an individual or individuals primarily responsible for monitoring contract compliance and the performance of contractors and subrecipients for all mental health services contracts and subcontracts.

Agency Response: Agree, Implementation Date – June 7, 2022

 

3.2 Document Contract Monitoring Policies and Procedures – The Denver Sheriff Department should establish and document policies and procedures for ensuring contract compliance as well as monitoring of contractors’ performance.

Agency Response: Agree, Implementation Date – Aug. 31, 2022

 

3.3 Establish Oversight of Invoices – The Denver Sheriff Department should identify an individual or individuals primarily responsible for reviewing and approving invoices — as well as reviewing associated supporting documentation related to its mental health programs — to ensure all expenses are allowable and aligned with contractual requirements.

Agency Response: Agree, Implementation Date – June 7, 2022

 

3.4 Document Policies and Procedures for Invoices – The Denver Sheriff Department should establish and document policies and procedures for requesting, reviewing, and maintaining supporting documentation for invoice payments to ensure invoices are paid according to the contract.

Agency Response: Agree, Implementation Date – Aug. 31, 2022

 

3.5 Follow the City’s General Records Retention Policy – The Denver Sheriff Department should follow the City and County of Denver’s general records retention policy for invoice supporting documentation.

Agency Response: Agree, Implementation Date – Aug. 31, 2022

 

3.6 Amend Contracts – The Denver Sheriff Department should ensure salaries of employees paid through a contract are allowable according to a contract’s budget either by enforcing the contracted amount, amending the contract to adjust for an increase to the budgeted salaries, or identifying another source of funds to account for the difference.

Agency Response: Agree, Implementation Date – June 7, 2022

4.1 Review Transgender Review Board Documentation Process – The Denver Sheriff Department should review and revise existing policies and procedures related to the Transgender Review Board to include how and where board meeting discussions should be documented as well as decisions made related to housing. The department should consider, as part of this process, identifying a central repository to house decisions related to the Transgender Review Board.

Agency Response: Agree, Implementation Date – Aug. 15, 2022

 

5.1 Clarify and Document Staff Roles and Responsibilities – The Denver Sheriff Department should identify a division and individual responsible for tracking training documentation, including hours and topics, for department staff. Where multiple departments or individuals are involved, the roles and responsibilities for maintaining records should be clearly documented.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

5.2 Establish a Consistent Way to Track Data for Training – Information The Denver Sheriff Department should develop a way to track information related to training, including hours and topics. The data should be populated consistently and completely to allow the department to track and monitor compliance with accreditation standards and internal policy.

Agency Response: Agree, Implementation Date – Oct. 14, 2022

 

5.3 Document Policies and Procedures for Training Records – The Denver Sheriff Department should document policies and procedures for tracking training information and storing training records. These policies and procedures should include a process for ensuring data quality.

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

5.4 Monitor Compliance – The Denver Sheriff Department should regularly monitor compliance with training requirements to ensure all staff meet requirements and are trained appropriately. If compliance issues arise, the department should implement consequences for staff who do not meet training requirements.

Agency Response: Agree, Implementation Date – Sept. 16, 2022

 

5.5 Retain Documentation for Staff Training – The Denver Sheriff Department should follow the City and County of Denver’s general records retention policy for personnel training records.

Agency Response: Agree, Implementation Date – Aug. 15, 2022

Auditor's Letter

June 16, 2022

The objective of our audit of mental health services in Denver’s jail system was to determine the extent to which the Denver Sheriff Department’s mental health programs are effective in providing support for people in jail. I am pleased to present the results of this audit.

The audit found the Sheriff Department needs to develop a strategy and needs to define what success looks like for its mental health programs. The department also needs to improve how it handles data when monitoring programs and tracking requests and complaints. Relatedly, the department could not provide sufficient documentation to support its assessment of contractor performance and could not show that invoices were paid appropriately. Furthermore, the department did not have adequate documentation to show that individuals identifying as transgender were promptly met with and were not being held in separate housing longer than necessary. Finally, the department’s inadequate training documentation prevented auditors from verifying the department’s compliance with requirements.

By implementing recommendations for stronger policies and procedures, the Denver Sheriff Department will be better able to track and monitor program and operational data, housing decisions related to individuals identifying as transgender, and employee training. Furthermore, once the department identifies a strategy and success measures for its programs, it will be able to use data to monitor progress toward meeting program goals. With stronger contract monitoring, the department will be better able to ensure expenses are allowed and that contractors provide quality mental health services for those in jail.

This performance audit is authorized pursuant to the City and County of Denver Charter, Article V, Part 2, Section 1, “General Powers and Duties of Auditor.” We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

We extend our appreciation to the personnel in the Sheriff Department as well as at Denver Health who assisted and cooperated with us during the audit. For any questions, please feel free to contact me at 720-913-5000.

Denver Auditor,

Auditor's Signature
Timothy O'Brien, CPA

Follow-up report

A follow-up report is forthcoming. 


 

 

 

 


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AUDITOR TIMOTHY O'BRIEN, CPA
Denver Auditor



Denver Auditor´s Office

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