New York Attorney General Eric Schneiderman has sued Armor Correctional Health Medical Services Of New York, which is under contract to provide medical services to inmates at the Nassau County Correctional Center (NCCC).

In a 50 page complaint [PDF], the attorney general catalogs Armor’s inadequate medical services, which have contributed to numerous deaths and injuries since the company took over in 2011. In addition to money damages, his office calls for an independent monitor to oversee Armor’s compliance with its contract and to prohibit Armor from bidding on future contracts in New York.

Between 2011 and the present day, fourteen people have died at NCCC and the Niagara County jail (also under contract with Armor). The New York Commission of Correction’s Medical Review Board found “egregious lapses in medical care” in seven of the fourteen deaths.

Four deaths from this year are still under review, but the attorney general believes they “also raise serious concerns about the care being delivered by Armor.” One of these deaths occurred just days before the lawsuit was filed.

Armor is a for-profit, physician-owned correctional healthcare company based in Miami, Florida, providing services to jails in 29 counties, across eight states.

Since its contract began in 2011, Armor has been paid around $11 million per year by Nassau County to provide comprehensive services to an average of 1,188 pretrial and sentenced inmates.

As the attorney general notes, “Due to high incidence of disease in correctional settings, ensuring appropriate and adequate medical care for those in custody is essential.” Yet Armor’s “many failures appear to have resulted in avoidable harm to incarcerated persons at NCCC, who rely on Armor for medical care.”

Just a few months after Armor’s contract was initially approved, a lawsuit [PDF] filed by the New York Civil Liberties Union noted that, since the company had taken over correctional medical care in Nassau County, the “volume of complaints received by the Nassau Chapter office of the NYCLU has increased dramatically.”

Such warnings and failures went ignored or unnoticed by the county, in large part because their contract absolved them of legal responsibility for the quality of their care and placed Armor in charge of monitoring its own compliance with the contract. The contract was subsequently renewed in 2013 and again in 2015, for periods of two years at a time, without ever going up for a second bidding.

Sick Call

Armor did not provide inmates with meaningful access to sick call—a failure which the attorney general said “goes to the very heart of providing adequate medical care.”

There is no evidence of a process to triage inmate medical requests so that inmates receive a response within 24 hours. Self-audits, as well as medical records and testimony from former inmates, show the company’s medical personnel failed to evaluate sick call patients within 72 hours of their request.

The attorney general found 37 percent of sick call requests in January 2016 and 28 percent in February did not receive responses in a timely manner. Over 150 sick call requests during those months were not fulfilled because patient charts were “simply not available.”

In 2015, sick call slips “were not picked up for many days because the key to the collection box was missing.”

An inmate with a history of cardiac disease, referred to as “JA,” filed numerous, weekly sick call requests about chest pain and numbness in his arm and hand, but his requests went unheeded. After Armor staff ignored his requests for a year, he filed a lawsuit. He was then given a stress test, “the results of which were so serious that he was taken immediately to Long Island Jewish Medical Center for an emergency angioplasty procedure.”

An inmate identified as “JG,” who died at the facility on July 14, 2014, filed a sick call request to obtain his prescription medications. He filed another request the next day, complaining of swelling in his arm. He was not examined for a total of six days, at which point “he presented with difficulty breathing and swelling of his shoulder, neck and throat.”

There is no record the company ever conducted regular reviews of the sick call system—only that it had performed two self-audits since 2011. The attorney general estimated the total reduction Armor should have made in its fee for its failures to uphold this provision of the contract “would equal some $3.7 million.”

Diagnosis and Treatment

Armor is required to “maintain a stock of approved medications and arrange for a back-up pharmacy so that new medications and orders” are fulfilled in a timely manner. Inmates are to receive medication within 24 hours of a written prescription.

Seventy three percent of the company’s medication self-audits received failing grades. Armor failed to document the time and date at which tests and X-rays occurred. They failed to collect lab specimens in a timely fashion. They failed to ensure the services performed matched those ordered by the doctor. In some cases, the diagnostic services ordered by Armor’s doctors were never performed at all.

One deceased inmate identified as “WS” had a history of hypertension, for which he was taking a daily prescription medication. His medical records show he did not receive any medication at all for three days after his incarceration, whereupon he was “unresponsive to verbal stimuli; a blood pressure reading could not be obtained and his respirations were noted as shallow.”

Medical staff called 911, but “for reasons not explained in WS medical record,” he was not taken to the hospital, but instead placed in the infirmary.” At this point, a urinalysis screen and blood work found WS was diabetic—a finding that should have been made upon intake, days earlier—and he was given insulin.

Three days after being admitted to the infirmary, WS was found to be unresponsive again. This time he was transferred to Nassau University Medical Center, where he died the next day from cardio-pulminary arrest.

The attorney general argues that, had Armor conducted a urinalysis screen upon WS’ entrance to the jail, the test would have “likely revealed that the inmate was diabetic and should have prompted a more thorough physical examination with diagnostic laboratory tests.” But it took five days for this to be discovered, after he was found unresponsive in his cell.

The testimony of a former inmate referred to as “WH” is particularly illustrative with regard to Armor’s near-total disregard for tests, screenings, and prescription medications.

Despite bringing his multiple prescriptions with him to the jail, Armor denied WH access to his drugs. Eight days after his incarceration, Armor’s medical director at NCCC, Dr. Morcos, “told him that he had been prescribed too many medications by his community providers and would not be getting the same medications” while in jail.

WH recounted another incident in March 2015, when he fell in the shower and lost consciousness. He cracked his tooth, had cuts on his head and arm and complained of pain in his head and ear. He also reported sensitivity to light.

Armor refused to send him to the hospital at first, and he was instead placed in the infirmary overnight, where he vomited three times. But they sent him to the hospital the following day, where he was diagnosed with a concussion. Doctors at the hospital gave him multiple prescriptions, but Dr. Morcos told WH he would only get the multivitamin they ordered, saying “just because it is written on the hospital discharge doesn’t mean that you will get it.”

One corrective action plan was devised to correct this specific niche of failure, but there is no indication the plan was ever carried out or evaluated again. Armor never reduced its fees for failing to comply with the contract.

Mental Health and Staffing

Despite a 2002 settlement between Nassau County and the Department of Justice, which ordered the county to develop and implement treatment plans for inmates with special needs, mental health care was deemed inadequate from top-to-bottom by the attorney general’s investigation.

Armor “repeatedly represented that it would provide treatment planning to guide mental health treatment and care” in its contract proposal, yet the company’s few audits found it failed to appropriately refer inmates for mental health evaluations and complete mental health treatment plans.

One inmate, known as “BR,” was an Iraq War veteran with post-traumatic stress disorder, bipolar disorder and a history of opioid abuse. The complaint states that “Armor’s psychiatrist overlooked or otherwise neglected to document” his full medical history, noting only his opioid addiction. This information was used to deny BR access to mental health housing. Hours after this decision was made, he hanged himself in his cell.

Armor failed to adequately staff mental health professionals at the jail, leaving the positions for the Mental Health Clinical Coordinator and Mental Health Psychiatric Advanced RNP/PA vacant for over a year. Other key jail medicine positions, such as the director of nursing and continuous quality improvement and nurse educator, were left vacant “for significant periods of time.”

The county estimated it overpaid Armor $484,795 for these and other staffing vacancies, which do not include further instances of inadequate staffing identified by the attorney general.

Off-Site Referrals

Armor staff did not refer and follow-up with inmates for whom off-site care was ordered by Armor’s doctors.

As Shadowproof has previously reported, Armor has been sued in other states for failing to refer inmates for emergency and speciality care. But the attorney general’s lawsuit brings to light a new bureaucratic obstacle to fulfilling such orders, which companies like Armor claim they can “better manage” in marketing their services as a way to control costs in jails.

Armor’s audits show that referrals for inmates in New  York were subject to a ‘utilization review,’ to be conducted by officials at Armor’s corporate headquarters in Florida. Armor “frequently simply failed to render a utilization decision to deny or approve the specialty referral request.”

When deferring referrals, Armor did not provide an alternative plan for the inmates’ care. Such failures led to preventable deaths:

Decedent S.L., who was detained at NCCC on October 3, 2015 until his death on March 7, 2016, filed frequent sick call requests throughout his incarceration relating to pain in association with his non-reducible inguinal hernia. In October 2015, Armor’s Medical Director denied Armor’s health care provider’s request that an inmate be sent off-site for a surgical evaluation because the hernia was non-reducible. Whenever he presented with a complaint about his hernia, the Armor clinician noted that the surgical consult was deferred. The inmate was found unresponsive in his cell on March 7, 2016.

Even when an inmate did get to see an off-site specialist, there was evidence that Armor “failed to review the off-site specialists recommendations and establish a plan of patient care based on the specialists’ directives” in many instances.

Like other aspects of its care, Armor was supposed to perform multiple audits of its off-site referral process each month, but performed just five between 2011 and 2015.

Self-Audits And Vouchers

Armor was to be it’s own judge, jury, and executioner with regards to its contract—and it failed to live up to the task.

Each two-year contract established a process by which the company would be paid through monthly vouchers (each for 1/12th of the agreed upon annual cost), which they submit to the county.

The vouchers include a written certification stating the company had fulfilled its contractual obligations delineated as specific performance benchmarks. Armor is supposed to file reports along with its vouchers, which include relevant data to substantiate the certification.

Importantly, the benchmarks are to be monitored through “self-audits,” which are annual, semi-annual, and monthly reviews conducted by Armor itself. If and when problems arise, Armor alone is required to identify, develop, and implement corrective action plans to provide remedies.

Where Armor fails to do so, the company is supposed to voluntarily reduce the amount it bills the county.

This is information the county was supposed to use to make sure it was paying Armor only for the services it was receiving. It is information that would verify that inmates received adequate care.

The lawsuit states, however, that “no fee reductions have ever been assessed or imposed on Armor, despite Armor’s serial failings.”

Armor’s monthly reports only included about half of the 24 required contract compliance indicators they are supposed to use. Armor has not reported basic, critical information, such as the number of inmates who get health screens at intake, or the percentage of inmates transferred to acute care.

The attorney general found no record Armor performed annual reviews or submitted studies to examine the effectiveness of its healthcare delivery or expected patient outcomes.

Since 2011, Armor conducted less than half the audits they were contractually obligated to perform.  Armor was required to design corrective action plans “within 30 days of the date of documentation of the deficiency,” but rarely did. Even when corrective action plans were developed, they were not consistently maintained or executed.

Armor was to reduce its fee by $100 for each day a corrective action plan was not completed, within 45 days of identifying a problem. The attorney general calculated that the contractor should have reduced it’s fee by at least $528,000, if not by “much more.”

Medical Records and Equipment

Despite having been paid $159,724 by taxpayers to implement an electronic inmate medical record system, Armor never did so, and the company never deducted the money it didn’t spend on the project from the vouchers it submitted to the county.

Armor failed to keep complete and legible medical charts and sick logs, “such that subsequent treating clinicians would not be able to read the medical history nor know the clinician who had treated the inmate.”

Armor conducted only one equipment self-audit between 2011 and 2015. That single audit found Armor didn’t check its AED defibrillator and failed to check the emergency crash cart (which is used to transport various emergency medical supplies to an incident) every shift.

Despite the serious deficiencies in this lone audit, and an acknowledgement that documentation of its equipment checks “was missing,” Armor gave itself a grade of 94 percent.

Blank Checks And Impunity

The Nassau County Interim Financing Authority (NIFA) approved Armor’s contract during a meeting on May 2, 2015, in which directors carefully stated on the record that they were relying on the county’s vetting “as to whether the company is competent or able to deliver the services it is asked to do.”

Still, directors warned, “the County cannot just sign the contract and walk away and expect to have savings,” stating “it will require active management by the County and the vendor to realize cost savings. ”

NIFA Chairman Stack was to “monitor this contract and it if does not save money then it would then be out of compliance with the financial plan and NIFA would take other actions.” The agreement was expected to save Nassau County $7,000,000.

By 2013, seven inmates had died, five of whom committed suicide. Two months before the renewal in July of 2013, the NYCLU filed its lawsuit, specifically citing the lack of adequate medical and mental health care as a factor in each death.

The contract was passed unanimously, again.

Shadowproof obtained a copy of a New York Commission of Correction investigation [PDF] into the case of inmate Kevin Brown, who died at NCCC in 2014. The commission’s findings matched those of the NYCLU and the attorney general.

The commission wrote, “Medical and mental health care provided to Brown at NCCC by Armor Inc. was deficient resulting in a mismanaged mental health diagnosis, inadequate psychiatric care in response to deteriorating behavior, undiagnosed or managed hypertensive cardiovascular disease, and inadequate medical management of a seizure disorder […] compounded by a health record that was unorganized, incomplete, and in selected sections, illegible.”

That report came out a few months after Nassau County renewed Armor’s contract for a second time, in 2015.

In Armor’s contracts [example: PDF], the company is required to purchase insurance and, most importantly, indemnify the county from “claims, actions, lawsuits, damages, judgments or liabilities arising out of the health care delivery system provided by Armor.”

Armor’s website specifically markets its ability to control costs related to lawsuits brought by inmates—a major selling point for county governments. They boast the company “has been highly successful at preventing and combating litigation resulting in a low number of active cases with the vast majority of claims dismissed. We have never had a judgment against us.”

In other words, while the Finance Authority noted Nassau County couldn’t “just sign the contract and walk away and expect to have savings,” the contract they approved on multiple occasions was more or less written so the county could do just that.