SLO County fails to provide adequate mental health services, Grand Jury finds

August 3, 2022

By KAREN VELIE

A resent Grand Jury investigation determined San Luis Obispo County has failed to create and maintain a safe, orderly, effective and efficient means for ensuring that people suffering from mental health issues receive the care they need, according to a July 26 report.

In SLO County, people on mental health holds are kept in local hospitals rather than mental health facilities, resulting in inadequate care for the mentally ill as the hospitals are not staffed with mental health professional. In addition, requiring hospital staff to oversee mentally ill patients reduces the quality of emergency care.

The Grand Jury also discovered that the county does not provide mental health services to juveniles or adults who do not fit the criteria for treatment at the County Psychiatric Health Facility. Most mentally ill patients are transported to out of county facilities.

About four years ago, the county contracted with a private company, Sierra Mental Wellness Group (SMWG), to operate a four-bed Crisis Support Unit, located near the Psychiatric Health Facility in San Luis Obispo. The facility is supposed to offer mental health care to those not under a mental health hold.

The contract initially required SMWG to provide a full-time registered nurse. SMWG, however, failed to meet the requirement.

The county amended the contract in 2021 to only require either a registered nurse, a psychiatric technician or other psychiatric service provider at the facility when clients are present.

Staff at the county Psychiatric Health Facility regularly ask staffers at the Crisis Support Unit to admit patients from their facility. On multiple occasion, SMWG staffers claimed they were at their four-patient capacity, even though they had no clients, according to surveillance cameras located in the facility.

“Unaware that any clients were in the Crisis Support Unit at that time, Psychiatric Health Facility staff checked the cameras and saw that the Crisis Support Unit was empty except for SMWG staff members,” according to the Grand Jury report. “When questioned about the situation, Crisis Support Unit staff responded by taping sheets of paper over the cameras, rendering them useless.”

The Grand Jury is asking the county to relieve the hospitals of the responsibility to warehouse mentally ill individuals by integrating and improving county services.

“SLO County should commit to creating a single, integrated and unified mental health services center that houses the Psychiatric Health Facility, the Crisis Support Unit, the Mental Health Evaluation Team, outpatient coordination, juvenile mental health services, and that includes a medical health triage and screening facility where all held persons, regardless of age, categorization or insurance status, can be medically cleared prior to placement in an appropriate section of the mental health facility.

Abiding by the recommendations will likely be difficult for the county, as it is currently working to further outsource and divide county mental health services. In June, SLO County administrators announced plans to outsource inpatient mental health services at the Psychiatric Health Facility to a private entity.

During the past decade, administrators at the Psychiatric Health Facility have been under fire for alleged mistreatment of the mentally ill. The allegation has led to a federal investigation and continuous turnover of staff.

The doctor in charge of the unit, the Behavioral Health Department’s Medical Director Daisey Ilano, is under investigation for her actions in the treatment and death of Andrew Holland.

Holland, a 36-year-old a mentally ill man, died in Jan. 2017 after jail guards left him strapped in a restraint chair, also known as the “Devil’s Chair,” for more than 46 hours.

The county mental health facility had refused to admit Holland. Ilano claimed at the time that the county facility was full and could not admit any inmates, while allegedly storing boxes in some patient rooms.

San Luis Obispo County officials are required by law to respond to the Grand Jury recommendations.