Mental Healthcare In The BOP – Is This Your Client?

Serious Mental Illness In The BOP 

The BOP provides Medical and Mental Healthcare (MH), through their 4 CARE LEVELS.

The BOP’s Psychology Data System (Page 2) Is Filled Out For All MH Levels.

The Designation and Sentence Computation Center places inmates into Care Levels 1 and 2

CARE LEVEL 1 MH

  • No Significant Need.
  • No history of serious functional impairment due to mental illness
  • No need for regular mental health visits
  • No hospitalization in the last 5 years
  • Defendant on their own has sought help
  • Controlled with 2 psychotropic meds (Not MH I if taking antipsychotic)
  1. Psychotropic medications:
    • anti-anxiety agents
    • mood stabilizers
    • stimulants
  2. Antipsychotic medicines, 
    • delusions (false, fixed beliefs) or
    • hallucinations (hearing or seeing things that are not really there).
    • schizophrenia, bipolar disorder, or
    • very severe depression (also known as “psychotic depression”).
  • Clinical visits q 6 mo

CARE LEVEL 2 MH

  • He/she has a mental illness requiring:
  • Routine Ongoing Outpatient visits
    • Medication controlled,
    • Medical visits q 1-6 months
    • Group Therapy, interventions every other week
  • Crisis Oriented, BRIEF MH Care, g., placement on suicide watch
  • Psychiatric Hospitalizations within the last 5 yrs
  • On Antipsychotic or 2 psychotropic meds

CARE LEVEL III & IV designation is made by the BOP’s Office of Medical Designations and Transportation

 CARE LEVEL 3 MH

  • Not In-patient
  • Enhanced Outpatient (Requires outpatient contacts with a prescribing doc > than monthly [at least weekly]); or
  • Housed in A Residential Treatment Program.
  • 2+ Psychiatric Hospitalizations within the last 3 yrs
  • 3+ anti-psychotic meds [Or > 5 meds for multiple Dx]

If you have a client with an MH CARE LEVEL of III, and a Medical CARE LEVEL of II,
The MH placement takes precedence.

Care Level 4 MH

  • Inpatient
    • gravely disabled and
    • cannot function in the general population, as in CARE3-MH
    • medical care 24/7/365
  • Tx plan reviewed every 90 days

Healthy Steps for Older Adults 2022

FSA, Productive Activities (PA)
Healthy Steps for Older Adults 2022

Program Description Healthy Steps for Older Adults is an evidence-based falls prevention program designed to raise participants’ knowledge and awareness of steps to take to reduce falls and improve health and well-being. The goal of the program is to prevent falls, promote health, and ensure that
older adults remain as independent as possible for as long as possible.
Hours 3
Location(s) All institutions
Needs Addressed Medical/Recreation/Leisure/Fitness
Program Delivery Contractors
Health Services
Recreation
Unit Team
Volunteers

Schizophrenia in Federal Prison

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Schizophrenia in Federal Prison

 

In federal prison, Schizophrenia is a mix of symptoms that varies from person to person and affects the mind. When severe, people have trouble staying in touch with reality. It’s hard for someone to think clearly, make good judgments, respond emotionally, communicate effectively, understand reality, and behave appropriately. There is no cure, and treatment requires a psychiatrist-guided team approach, which includes a psychologist, social worker, psychiatric nurse, and possibly a case manager to coordinate care.

Anxiety may present as a component, along with Posttraumatic stress disorder, as a symptom of a co-occurring disorder. While Schizophrenia is a serious brain illness, there is no test for it. Diagnosis requires eliminating what it’s not occurring, in order to identify the symptoms that are present.

There are three types of symptoms:

  1. Psychotic symptoms may distort thinking, including hallucinations, delusions (beliefs that are not true), and organizing thoughts.
  2. Negative symptoms: where you’re not able to show emotions – leaving you to present yourself as depressed and withdrawn.
  3. Cognitive symptoms: Trouble making decisions and paying attention.

There is no cure. Different medications may have to be tried to see which are effective because medications affect each person individually. Once you find the medication(s) that work, stay on them daily, keep your doctor’s appointments and follow their recommendations.

Schizophrenia

Changes in behavior;

Includes delusions and hallucinations – which may last a lifetime.

Delusions; False beliefs, not based on reality, such as another person is in love with you, or a major catastrophe is about to occur.

Hallucinations involve seeing or hearing things that don’t exist. They can be in any of the senses, hearing voices is the most common hallucination.

Disorganized thinking and speech may include putting together meaningless words that can’t be understood, sometimes known as word salad. Extremely disorganized or abnormal motor behavior can include resistance to instructions, inappropriate or bizarre posture, a complete lack of response, or useless and excessive movement. All of these behaviors can result in less than optimal interactions between other inmates or with correction staff. The result may be a trip to the hospital or the SHU (isolation), neither is acceptable, and both are preventable.

Negative symptoms can be expressed as, neglecting personal hygiene, appearing to lack emotion, (not; making eye contact, changing facial expressions, or speaking in a monotone), and losing interest in everyday activities, including socially withdrawing.

Treatment is accomplished under the psychiatrist-guided treatment team approach with a case manager coordinating care. The full-team approach may be available in clinics with expertise in schizophrenia treatment. These delusions and hallucinations — may last your lifetime.

First-generation older antipsychotics, introduced in the 1950s – As a class, these provided treatment for acute agitation, bipolar mania, and other psychiatric conditions.

On- Formulary Medications: Haloperidol (Haldol), Perphenazine (Trilafon), Loxapine, Trifluoperazine(Stelazine), and Fluphenazine

Not AvailableFlupentixol, Zuclopentixol, Sulpiride, Pimozide, Molindone, Prochlorperazine, Thioridazine, and Thiothixene

Second-generation or atypical antipsychotics,

Some associated side effects; “Schizophrenia in adults“Bipolar mania and hypomania in adults“,  “Unipolar major depression with psychotic features“,  “Delusional disorder”,   “Brief psychotic disorder”, and  “Treatment of postpartum psychosis”

On Formulary: Clozapine (Clozaril) “Clozapine remains the only antipsychotic that has been FDA-approved for treatment-resistant schizophrenia, “and it provides effective treatment even when patients do not respond to other second-generation antipsychotics. No existing first- or second-generation antipsychotic is as effective as clozapine monotherapy in treatment-resistant patients. Deanna Kelly, Pharm.D., of the Maryland Psychiatric Research Center (MPRC)” Other Medications: Olanzapine (Zyprexa), and Risperidone (Risperdal).

Medications Non-Formulary: Quetiapine (Seroquel)

Some of the more recent atypical antipsychotics:

Medications Not AvailableAsenapine (Saphris), Iloperidone (Fanapt), and Lurasidone (Latuda).

Schizophreniform

Symptoms of schizophreniform

Schizophreniform is a similar disorder that affects how you act, think, relate to others, express emotions, and perceive reality.

Unlike schizophrenia, it lasts one to six months.

A mental condition that can distort the way you:

  • Think.
  • Act.
  • Expresses emotions.
  • Perceive reality.
  • Relate to others.

Medication and Psychotherapy —to help the patient manage everyday problems related to the disorder.

Medications On Formulary: Click here for the article…

Brief psychotic disorder

Involves a sudden, short period of psychotic behavior, often in response to a very stressful event, such as a death in the family. Recovery is often quick — usually less than a month.

The first line of treatment may include atypical antipsychotics.

Medications On Formulary: Click here for the article…

Medications Non-Formulary:   Click here for the article…

For those that have an increased risk of having depression, medications that address this symptom can be an important part of their treatment.

Delusion disorder

The key symptom is having a delusion (a false, fixed belief) involving a real-life situation that could be true but isn’t, such as being followed, being plotted against, or having a disease. The delusion lasts for at least 1 month.

The exact cause is not yet known, but researchers are looking at genetic, biological, environmental, or psychological factors.

A cold, detached manner with the inability to express emotion

  • …has an over-inflated sense of worth, power, knowledge, or identity.
  • Jealous
  • …that someone is spying on them or planning to harm them.
  • …believes that he or she has a physical defect or medical problem.
  • …have two or more of the types of delusions listed above.

Symptoms that are ‘non-bizarre’:

  • An irritable, angry, or low mood
  • Hallucinations

Diagnosis: There are no laboratory tests to yield positive results, they are only good to rule out what it is not.

Treatment:

  • Psychotherapy is primary
  • Conventional antipsychotics

First-generation older antipsychotics, introduced in the 1950s – 

1st Generation, Medications On- Formulary for available medications: Click here for the article…

2nd Generation, Medications On- Formulary for available medications: Click here for the article…

Medications Non-Formulary medications require pre-authorization; click here for the article…

Other types of medications:

  1. Antidepressants might be used to treat depression, which often happens in people with delusional disorder
  2. Psychotherapy can also be helpful, along with medications, as a way to help people better manage and cope with the stresses related to their delusional beliefs and their impact on their lives.
  3. Sedatives and antidepressants might also be used to treat anxiety or mood symptoms if they happen with delusional disorder.
  4. Tranquilizers might be used if the person has a very high level of anxiety or problems sleeping.

Shared psychotic disorder (also called folie à deux)

Here one person in a relationship has a delusion and the other person in the relationship adopts that same delusion.

Diagnosing is difficult, possibly with an MRI.

Treatment: Psychotherapy aims to ease emotional distress, with medication to ease the symptoms of anxiety.

It cannot be prevented, and the key is to diagnose and treat them as soon as possible.

Substance-induced psychotic disorder

Substance-related disorders involve drugs that directly activate the brain’s reward system which typically causes feelings of pleasure.

The classes of drugs include

·       Alcohol

·       Caffeine

·       Cannabis and synthetic cannabinoids

·       Hallucinogens (eg, LSD, phencyclidine, psilocybin)

·       Inhalants (volatile hydrocarbons [eg, paint thinner, certain glues])

·       Opioids (eg, fentanylmorphineoxycodone)

·       Sedatives, hypnotics, and anxiolytics (eg, lorazepamsecobarbital)

·       Stimulants (eg, amphetaminescocaine)

·       Tobacco

·       Other (eg, anabolic steroids)

Treatment/Management

Clinical judgment, with a proper history, creates a safe environment during the withdrawal period. Due to the relative safety of most antidepressants in the setting of depressive symptomatology, and manic episode guidelines, second-generation antipsychotics, such as Quetiapine (Non-Formulary) or Olanzapine (On Formulary), may also be beneficial as they are faster-acting than mood stabilizers.

Psychotic disorder; due to other medical conditions;

Hallucinations, delusions, or other symptoms may happen because of another illness that affects brain function, such as a head injury or brain tumor.

Paraphrenia: symptoms similar to schizophrenia.

It starts late in life in the elderly,

  • Generally has a much better prognosis than other psychotic disorders.
  • Antipsychotic medication can be helpful,
  • Paraphrenia sometimes co-occurs with depression and anxiety

I) BOP Placement Based On Security Level Alone – Without Multiple Medication Needs

The Challenge Program – an EBBR FSA Evidence-based Recidivism Reduction Program for male inmates in Penitentiary (High Security) facilities. Treats those with substance abuse and/or mental illness disorders (psychotic, mood, anxiety, or personality).

II) BOP Placement- With Multiple Medication Needs v Prior Hospitalizations

Here, it depends;

  • the number of types of psychiatric hospitalizations, not related to substance abuse, and
  • the number of multiple diagnoses treated with antipsychotic and/or different psychotropic medications

Influences Mental Healthcare (MH) CARE LEVEL I-IV facility placement.

Post-COVID Virus Causes Lingering or Ongoing Symptoms

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The complicated care required for Post-COVID Long-Haulers is likely beyond the mission of most (if not all) prisons, jails, and detention centers.

According to researchers, this is still an active area of investigation. As we are approaching spring/fall 2022/2023, the Post-COVID Pandemic may be becoming an Endemic. Still, with that in mind, treating Post-COVID Long-Haulers and the amount and variety of staff, equipment, finances, and time needed, may just not be available to those incarcerated.

COVID is a true roller coaster of symptoms and severities, with each new day offering many unknowns.”

 “The difficulty is sorting out long-term consequences,” says Joseph Brennan, a cardiologist at the Yale School of Medicine.

While some patients may fully recover, he and other experts worry others will suffer long-term damage, including lung scarring, heart damage, and neurological and mental health effects.

Long after the fire of a Covid-19 infection, mental and neurological effects can still smolder[1]. ‘Long-Haulers’ after the initial COVID-19 hospitalization: fall into 3 categories (Dr. Sanghavi)

1st) The COVID virus causes lingering or ongoing symptoms, meaning that “ symptoms do not recover completely and are ongoing because of direct cell damage from the virus,”

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2nd) involves chronic ICU hospitalization for weeks. This causes:

  • muscle weakness,
  • cognitive brain dysfunction,
  • psychosocial stress-causing post-traumatic stress disorder (from chronic hospitalization).

3rd) symptoms appearing after recovery. “Interplay with the immune system of a person, and then the impact that both those things have on the body.”

“We are still trying to understand exactly how this interplay between the immune system and inflammatory markers work, but there’s no doubt that that is a group of symptoms because of ramped up immunity or ramped up inflammatory system,” Dr. Sanghavi added.

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Peripheral nerve issues, such as Guillain-Barré Syndrome, can lead to paralysis and respiratory failure.

Post-COVID Stress Disorder is another emerging consequence of the global pandemic.

Although most cases of COVID-19 appear to be mild with a recovery time of a few weeks, health experts are seeing more patients who suffer symptoms for months or get better, and then relapse down the road.

Isolation Is Not the Answer, Precautions for Adults with COVID-19[ii]

For more…

POST – COVID A PHYSICIAN’S JOURNEY

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POST – COVID, A PHYSICIAN’S JOURNEY

Post – COVID a physician’s journey in the summer of 2020 working on both general medical and COVID-positive wards. But by November of that year, the U.K. was in its second wave and second lockdown, with COVID deaths and hospital admissions rising.

“Like being on a treadmill I could not get off”

Being given only basic personal protective equipment (PPE), Dr. Fearnley and her newly graduated doctors were sent onto medical and COVID wards. While on a COVID ward, and after not feeling well, a PCR Test returned positive for COVID, and what comes next follows the phases she went through:

  • “The acute phase lasted 2 weeks – comparable to a case of mild-to-moderate flu.”
  • “As a fit and healthy 35-year-old with no comorbidities, she naively expected to recover quickly,”
  • “By week 3, she still had a lingering fever,”
  • By week 4, Dr. Fearnley wanted to return to work, but being lightheaded and jelly-legged, just made it home.

Thus began the start of her long Post-COVID Long-Hauler (as it was later defined) Journey.

Getting slightly graphic, these attacks “were associated with an unquenchable thirst, with or without an urgent need to open to my bowels, vomiting, or increased shortness of breath. These came in daily cycles lasting up to 14 hours at a time. I would frequently shake through the entire night”.

For more…

Federal Sentencing: From PSR Preparation To Drafting The BOP Placement Request

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Preparing for the Sentencing Hearing, in some cases should start as soon as possible.
Why?
a) Depending on if it’s a state or federal case, there may only be only weeks (or months) after the guilty verdict to start.
b) Getting all medical records via the HIPPA release can take a long time as some physicians and hospitals have been busy, especially in the age of COVID. HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508.
c) Coordinating character references, expert witnesses, and documentation for their PSR all takes time.
d) Developing the PSR along with recommendations for placement takes time.

I- The Presentence Report is used by;
1st) Judges
To establish the length of the sentence, along with they have the option to make a placement request.

2nd) The BOP, For Use It For Facility Placement.

3rd) Probation Uses it during Supervised Release.

4th) It then becomes a permanent part of the defendant’s record.

5th) Lastly, for inmates, it’s referred to as the ‘Inmates Bible’.

II) Sentence Length Determined By The Court based on;
USSC Sentencing Table (Point Based), [2018, CHAPTER 5: SENTENCING TABLE]
Offense Level (0-43+): *24+ categories.

Vs
Criminal History (0-13+)
Points for each prior sentence > 1 Year + 1 Month.
Points for each prior sentence > 60 days, not counted above.
Point for each prior sentence, <= 60 days not counted above; for up to a maximum of 4 points in this category.
Points for each revocation that has a new charge or occurs under federal supervision.
Point for each prior sentence resulting from a conviction of a crime of violence that did not receive any points as noted above because such sentence was treated as a single sentence, up to a total of 3 points for this subsection.

III) BOP Determines Placement Designation
1st) Healthcare: provided based on a CARE LEVEL I-IV Structure
Applies to Medical and Mental Healthcare CARE LEVELs.
Psychology and Life Skills National Programs have now been embedded into the First Step Act, with its limited availability and associated security requirements.
There are approximately 3500 Medications in the BOP, which fall into 3 tiers. PPRS Prison Match™ has all of these drugs categorized by tier level should this applies to your client.
Is there a special diet request?
Allergies: all need to be documented in the PSR.

2nd) Non-Medical Placement is based on;
Bed Space Availability. 
Aspirational: placement within 500 driving miles of legal residence.
Population Management; some inmates, for specified reasons, need to be monitored or separated from others.

2a) Public Safety Factors (PSF) & Management Variables [P5100.08, CN-I, 9/4/2019, Tables: Chapter 5, pages 12-13]
Could a Public Safety Factor (PSF: Chapter 4, pages 5-13) warrant a reduced security level?
Accepting Responsibility (may get point reductions).
Voluntary Surrender (gets point reductions).
Drug / Alcohol Abuse may allow RDAP.
RDAP; Required usage is within 1 year prior to date arrested (illegal or legal medications or drugs).
AGE: 55+ (0Pts), 36-54 (2pts), 25-35 (4pts), <25 (8pts), Unknown (8pts).
Education Level: High School (0pts), GED Progress (1pt), No degree (2pts).

Sentence Length
>10 years – Low
>20 yrs – Medium, (Females: High)
>30 yrs – High

Disruptive Group
Male inmates will be housed in a High-security level institution unless the PSF has been waived.

Greatest Severity Offense
Male will be housed in at least a Low-security level institution unless the PSF has been waived.

Threat to Government Official
Male or female will be housed in at least a Low.

Deportable Alien: (male inmate who is not a citizen will be housed in at least a Low).

History Violent Behavior
A female inmate whose current term of confinement or history involves two convictions or findings – Low.

Serious Escape
A female, serious escape with the last 10 yrs. designated to Carswell Adm. Unit, unless the PSF has been waived.
A male inmate with or without the threat of violence or escapes housed in at least a Medium.

Juvenile Violence
A male or female who has any documented:
a) Violent behavior, past or present, which resulted in a conviction, delinquency adjudication, or finding of guilt.
b) Violence: aggressive behavior causing bodily harm, death, or behavior likely to cause serious bodily harm. 

Serious Phone Abuse
a) A male or female who utilizes the telephone to further criminal activities or Promote Illicit Organizations.
b) Conviction is Not Required, housed at least in a Low.
c) The PSF should be entered regarding any one of the following, if applicable.

Criminal acts conducted by telephone
-Leader/Organizer or primary motivator; or
a) communicate threats of bodily injury, death, assaults, or homicides.
b) conducts Fraudulent activity (actual or attempted) in an institution.
-Leader / Organizer who used the telephone to conduct fraudulent activity (actual or attempted)…
a) Smuggled narcotics or alcohol into a prison.
-Federal Law Enforcement notifies the BOP of concern and needs to monitor an inmate’s telephone calls…
a) The inmate has been found guilty of a 100 or 200-level offense code for telephone abuse.
b) A Bureau of Prisons official has reasonable suspicion and/or documented intelligence supporting telephone abuse.

Prison Disturbance
A male or female inmate who was involved in a serious incident of violence; Engaging / Encouraging a Riot:
a) Males will be housed in at least a HIGH-security level institution and
b) Females will be assigned to the Carswell Adm. Unit.

2b) Plus
a) Judicial Recommendations
b) Options For Work Cadre Participation (at secure facilities without satellite camps), where the inmate is allowed to work outside the perimeter of the institution.
c) PSF Waved: An inmate may receive up to three Public Safety Factors (PSFs) wavers.
d) Long Term Detainee transfers for positive or negative behavior may cause placement in a facility different from scored security or custody level.

IV) Making The Placement Request
In recommending a facility placement, it’s helpful to provide a reason, for example:
To facilitate regular family visitation, or
To permit participation in a specific:
a) Medical CARE LEVEL
b) Mental Healthcare CARE LEVEL
c) Psychology has limited in availability and has associated security requirements.
d) Vocational Training Program
e) UNICOR job availability

V) Military: Is your client a Veteran?
If possible, connect your client with a facility that caters to veterans.
FCI Morgantown started a Veterans to Veterans Service Dog Training Program in 2016.
The Participants are federally imprisoned military veterans who are housed in a special wing that is responsible for training service guide dogs, for veterans who have mobility impairments, Post Traumatic Stress Disorders (PTSD), or other military service missions.

If you’d like to discuss this, I look forward to speaking with you.

Dr. Blatstein                                                                                                                            Physician Presentence Report Service                                                      info@PPRSUS.com, 240.888.7778

COVID-19; as we approach the Holidays and 2022, there are signs of hope!

Photo Credit, CDC, 8-24-2021

This is just an opinion of the author. While COVID-19 and its variants appear here to stay, the unvaccinated are the most likely to be facing its more serious side.

While it is true, that even with being vaccinated you may develop symptoms and test positive for COVID, it is not likely that you will be facing hospitalization and fatal disease.

For years, when we have had the flu, if it was bad enough and caught early, Tamiflu, an oral pill started within 48 hours of symptoms, shortened its duration. Reviewing my previous newsletter,

  1. A New Classification Of COVID Drugs are about to see the light of day and “Are a Bigger Deal Than People Realize”; Antivirals (“holy grail”):

Available in oral pill form, like Tamiflu, these antivirals can be taken within days of a positive COVID diagnosis. They could be made easily available to both those incarcerated as well as in the general population. Taken at home over approximately 7 days, they work to shorten the course of the disease, obviating the need for hospitalizations. A very big deal for the vaccinated and unvaccinated alike, but they do not take the place of vaccines.

Pfizer’s COVID-19 antiviral oral pil‘Paxlovid’, Near 90% protective against hospitalization, and death and retains its effectiveness against Omicron, December 14, 2021 (Reuters). Pfizer said it would grant a license for their antiviral pill to the Geneva-based Medicines Patent Pool, which would let generic drug companies produce the pill for use in 95 countries.

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Merck’Molnupiravir, while < 50% effective, is allowing generic drug makers royalty-free license to manufacture its oral COVID-19 antiviral pill. The FDA advisory committee narrowly voted in favor of a EUA, 13-10, but even those who voted yes acknowledged the modest efficacy and safety concerns.

Further, a loose alliance of big pharma companies including Gilead, Novartis, Schrödinger, Takeda Pharmaceutical, and WuXi AppTec, all have formed to share ideas, resources, and data to develop custom pan-coronavirus antivirals. The overarching goal is for the scientific community to come up with a solution to this—or the next—pandemic.

2. GlaxoSmithKline and Vir’s “Sotrovimab (on the BOP Formulary), “is the first monoclonal antibody to record demonstrated activity against all” (SARS CoV-2 which developed into) COVID-19, then mutating into its “variants of concern and interest to date, including omicron”.

Masks (N95) along with others, recommended by the CDC offer protection against all variants. Yes, while none of us want to wear them, and ‘this COVID thing’ is getting old, any one of us does not want to take the chance of dying.

IV) Definitions:

Pandemic: when diseases spread rapidly, crossing country’s borders, globally

Endemic: when the spreading is more localized, like the flu.

 

I believe that the responsibility for a client’s Mental and Physical Health should be safeguarded to protect them from themselves and others, …while providing a safe environment for the duration of their incarceration. Ultimately this is the responsibility of the Court, Defense Team, and BOP.

If this was helpful, please share it with your colleagues. With more to follow, should you have any questions, are interested in engaging my services, or have any ideas for future topics, I am easy to reach, and thank you for your time.

Wishing you and your families a safe and healthy Holiday Season and New Year

Marc

Dr. Blatstein

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  • email, info@PPRSUS.com,
  • Voice: 240-888-7778.
  • Or through my website: PPRSUS.com

Plus a 50+ minute PowerPoint (which time-wise, can be adjusted to meet your needs), for groups, some of the topics covered:

  • COVID
  • Medical History
  • Medication Availability
  • Dementia Wing- 1 Facility, 35 beds
  • Security Level / Public Safety Factors
  • Medical and Mental Healthcare, CARE LEVEL I-IV
  • Psychology Programs Availability (Security Level Specific)
  • Military Veteran-1 facility with 1 wing, Veterans Train Service Guide Dogs for Other Vets With PTSD  or other disabilities

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