Instead, commissioners in June 2018 handed CorrectHealth a new three-year deal worth $22 million. During the bidding process, Reuters found, CorrectHealth shared inflated budget costs with its competitors, allowing it to make a cheaper offer.

The Chatham County Detention Center’s troubles offer a look into the challenges American communities face in holding accountable the private companies that have been entrusted with managing healthcare services at a growing number of jails and prisons. The failed reform effort in Savannah also speaks to the power of local politics, in a county where two state officials had a piece of the jail medical contract.

After the county terminated Rosenberg’s contract in October 2017, medical and guard staff shortages persisted and medicines continued to go missing. Six inmates have died – five by their own hands – since CorrectHeath took over three years ago.

Wilcher said in a February interview he was “happy” with CorrectHealth. He declined to answer all follow up questions and referred Reuters to the county attorney, who did not reply.

CorrectHealth did not respond to interview requests or questions sent in writing. Quick Rx told Reuters it won the work on merit, not politics.

The United States incarcerates more prisoners than any other wealthy democracy, and an increasing number of local jails, housing over 700,000 inmates, contract with for-profit healthcare companies. The companies offer local governments ways to control jail spending and manage a notoriously unhealthy population.

Yet the for-profit industry operates with little local or national oversight, monitored only if localities volunteer to seek review by non-government accrediting groups. Despite the Georgia jail’s continued problems with suicides, it received coveted accreditations from a national industry body for inmate medical and mental health care.

“Healthcare providers do what they want to do. There's often nobody monitoring the contract,” said U.S. Justice Department consultant Steve Martin, a former Texas Corrections Department general counsel who has inspected some 500 prisons and jails.

Friends in high places

Carlo Musso, an emergency room doctor who founded CorrectHealth in 2000, has built an operation that now holds 41 contracts at jails across Georgia and Louisiana, with 2017 operating revenue of nearly $45 million. He is also a generous donor to politicians and sheriffs and a fundraising stalwart for the Georgia Sheriffs Association. Musso, his wife and companies donated $363,000 over a dozen years to Georgia politicians seeking state office, records show.

In Chatham County, Musso’s chance came in August 2015 when the jail’s healthcare contract opened for bidding. The relationship between the county and the jail's previous medical provider, Corizon Health Inc, had deteriorated after a string of deaths, straining their ability to work together and ultimately leading to its loss of the contract. In a letter to the county, Corizon said it had been made a “scapegoat” for problems.

Musso promised sweeping change at the Chatham County Detention Center.

That November, the county sheriff at the time died of cancer, triggering a special election. Wilcher, a 40-year veteran of local law enforcement, won in March 2016. Pitching himself as a reformer, he vowed to “make the sheriff’s office great again.”

In June 2016, CorrectHealth won the deal, taking over the jail’s healthcare that August. The county viewed the new tender as a way to improve jail medical care. “The old contract really had no teeth in it,” said Roy Harris, the acting sheriff before Wilcher was elected.

The new contract set requirements for medical staffing and fines for failing to meet them. Intake screenings had to be completed within four hours or the company faced a $500 penalty per violation. Inmates had to receive medications within two hours of their prescription schedule; violations brought $100 fines per case.

As CorrectHealth won the job, Musso promised to retain the jail’s pharmacy firm, Quick Rx, owned by Ron Stephens, a titan of the state Republican Party and two-decade veteran of the Georgia House of Representatives.

Quick Rx had held the jail contract since the 1990s, but faced recent criticism. In 2014, jail medical staff said a pharmacy technician, not a licensed pharmacist, was taking prescription orders in violation of Georgia law, leading to medication errors. Quick Rx denied the allegation, saying it adheres to state laws.

Musso initially wanted to hire another drug supplier, not Stephens’ company, said Karen Cotton, a retired major in charge of jail operations in 2016 with first-hand knowledge of the negotiations. “It was a political thing. Musso had to back off,” she said.

Stephens said his company was hired because it provides "exceptional pharmacy services" at good rates. CorrectHealth did not respond to queries about the hiring.

Musso had also forged a partnership with another politician, State Senator Lester Jackson, a Democrat popular with Chatham’s black community, who had served on the Democratic National Committee from 2009 to 2012.

Jackson owned a dentistry practice, Atlantic Dental Associates, that worked with Musso across the state since 2014. Today, Atlantic runs dental services at 18 jails with CorrectHealth.

Atlantic landed the Chatham County jail’s $197,500 annual dental contract from CorrectHealth a few months before Jackson appeared in pamphlets for Sheriff Wilcher during the white Republican’s campaign for a full four-year term that November. The image of a smiling Jackson shaking the sheriff’s hand cut across racial and partisan lines in the largely Democratic county, which is 41% African-American. It was a blow to Wilcher’s rival, McArthur Holmes, a black Democrat.

“See how politics comes into this thing?” Holmes said in an interview.

Jackson said he did not formally endorse Wilcher, but considers him a friend and did not object to the use of his picture. Holmes never sought his endorsement, he added.

Wilcher won by 10 percentage points, emerging as a steadfast CorrectHealth defender.

The monitors

In July 2016, the county hired Rosenberg’s firm, Community Oriented Correctional Health Services. Founded in 2006, the Oakland nonprofit has served as a consultant to local governments in New York, Florida, California, New Jersey and Washington, D.C., at times called to testify before Congress.

In Savannah, it would assess the jail’s medical operations. If CorrectHealth performed poorly, it would suggest fines. Rosenberg’s account is taken from his team’s confidential reports, which Reuters obtained through an open records request.

Almost immediately, he and CorrectHealth began clashing.

At the end of CorrectHealth’s first month at the jail – August 2016 – the monitors urged the company to craft policies for dealing with mentally ill inmates, and told the county the provider was struggling to hire registered nurses for inmate intake screenings.

Long-running challenges over staffing “have not been rectified by CorrectHealth,” the monitors reported.

Soon, CorrectHealth grappled with its first inmate suicide.

At 5:19 a.m. on September 30, Guy Leonard hanged himself with a telephone cord barely three hours after he was booked. On an intake form, the nurse wrote that Leonard said he had no plans to hurt himself and did not appear intoxicated, though he had been arrested on a charge of public drunkenness.

After the suicide, the nurse changed the original intake form to say Leonard looked intoxicated at booking. The sheriff’s department scolded the medical team in a letter, saying altered forms “will give the appearance of impropriety by CorrectHealth.” The sheriff also fired two guards over their failure to check Leonard’s cell in the hour before he died, while a third officer resigned.

The monitors returned in November and reported that “not all inmates” were getting a full physical and mental health assessment in their first 14 days – a standard recommended by the correctional industry’s medical accreditation body. The reason, the monitors reported, was “staffing shortages.”

They also reported a breakdown in the delivery of prescriptions. Medications ordered for inmates were sometimes missing; at times, an inmate would be listed for the same prescription twice. CorrectHealth told the monitor the Quick Rx records system did not synchronize with its own electronic records, leading to prescription mistakes.

Nearly three months later, the monitors reported that a guard told them nursing staff had falsely claimed inmates were refusing medications, “when they actually just did not have the medication to administer to the patient because it had not been received from the pharmacy.”

The questions over Quick Rx were a potential embarrassment for the sheriff. Quick Rx owner Stephens, the ranking Savannah Republican in Georgia’s state house, had supported Wilcher with a $1,000 campaign donation. Stephens said the two have been friends “for many years” and that he contributes to many local officials.

In February 2017, Rosenberg’s firm recommended $3 million in fines for CorrectHealth over its staffing failures and the late delivery of medicines. By June 2017, the monitors had raised their fine recommendation to $5.2 million.

“There’s often nobody monitoring the contract.”

Suicides, questions

On March 11, 2017, Demilo Glover, jailed a week earlier after an arrest on a drunk driving charge, told a nurse his medications had been changed and he hallucinated that a little boy had appeared in his room holding a can of green beans, a department report said. The CorrectHealth team moved him to a rear infirmary cell. Throughout the night, he screamed. Earlier, Glover, who described himself as bipolar, told medical staff he had not taken his antipsychotic and antidepressant prescriptions for one to two days before his arrest and made bad decisions when not medicated.

The next morning, March 12, two guards collected his breakfast tray and asked Glover if he was OK. After they left, Glover knotted his bed sheet around his neck and slung it from a pipe. Minutes later, the guards returned to the cell, finding his corpse.

Twice in the months before the suicide, monitors warned that the infirmary’s cells were dangerous for suicidal inmates. When the monitors told Wilcher the infirmary did not have enough nurses, he bristled. The sheriff, they wrote, “does not want to hear about anything having to do with CorrectHealth.”

On April 3 of that year, Jerome Hill, 36, was arrested for allegedly threatening his girlfriend with a handgun.

Barely 90 minutes after being jailed, Hill said he wanted to kill himself, a department internal affairs report said. At 6:20 p.m. on April 7, guard Sharon Pinckney opened Hill’s cell in the mental health wing to take him for a shower. Hill raced up the stairs to the wing’s second floor and, ignoring her pleas, jumped from the walkway’s railing, landing head first. He died 18 days later, while in a coma at a hospital.

Pinckney told investigators “she did not understand why she was alone dealing with inmates on suicide watch and who had other mental issues.”

The internal affairs report into Hill’s death makes no mention of his meeting CorrectHealth’s psychiatrist in his four days at the jail.

Sheriff pushes back

As the deaths mounted, the sheriff began pushing back against the monitor’s scrutiny. In a June 2017 email, an aide to the sheriff told Rosenberg’s team they didn’t need to visit the jail so often.

On August 24, 2017, Wilcher emailed the county manager he “WOULD LIKE TO GET THE COACH [monitors] GONE THANKS SHERIFF.” He contended they hadn’t offered “one piece of advice” on how to correct problems.

Within two months, Rosenberg’s contract was terminated. At the same time, Wilcher was advocating that CorrectHealth’s contract be extended.

As the sides negotiated new contract terms, CorrectHealth balked at the millions in pending fines. At this impasse, county administrators began negotiating with Virginia healthcare provider MHM Centurion. CorrectHealth quoted a contract price of $8.6 million, saying the county had pressed it to hire more staff. But then Centurion quoted the county budget price of $7.1 million, and won the job.

At a county commission meeting October 20, 2017, Wilcher chastised the county. “I am happy with the provider I got,” he said.

Commissioners rebuffed him, voting 6-3 for Centurion. The company was supposed to take over one week later. But suddenly, the sheriff announced he could not finish the background checks for Centurion’s medical staff in time.

Faced with uncertainty, Centurion walked away. In turn, commissioners approved CorrectHealth staying on through June 2018 – ahead of the awarding of a new three-year contract. Centurion declined to comment.

The county waived CorrectHealth’s fines. Just one county commissioner, Chester Ellis, objected. “I think that was a conflict of interest because of the campaign donation,” he told Reuters, citing Musso’s donations to Wilcher.

Inflated numbers

In April 2018, CorrectHealth bid on a new healthcare tender. Among three bidders, its proposal received the poorest score from a county screening committee, but offered the lowest bid. One reviewer wrote: “1/10 on suicide prevention. Very little detail; Not thorough.”

Wilcher continued to back the company.

Without debate, County Commission Chairman Al Scott called an up or down vote on keeping CorrectHealth in June 2018. The vote was 6-1 in favor, with Ellis dissenting. Scott told Reuters the jail was the sheriff’s jurisdiction, so he followed Wilcher’s suggestion.

During the bidding, Reuters found, the company had inflated the costs of providing medical care when the county requested numbers to provide rival bidders.

Musso told the county he spent just over $1 million on drug costs. However, a Reuters review of CorrectHealth’s invoices from Quick Rx shows the actual spending on drugs in 2017 was $280,000 less. The inflated number allowed Musso to offer a lower bid than competitors. Musso did not answer questions about the conflicting numbers.

As CorrectHealth won the contract renewal, Wilcher hired his own monitor to offer guidance on securing a coveted accreditation from the National Commission on Correctional Health Care, an industry body that provides voluntary health standards for jails and state prisons and offers its seal of approval.

“We are not interested in, nor have or will we engage in, ANY activities or work that can be perceived to discredit you, the County, or its contractors,” monitor Ken Ray wrote the sheriff in his proposal. Ray did not respond to interview requests.

That June, NCCHC accreditation teams toured the jail and, two months later, the group sent notice it was granting a preliminary accreditation for the detention center’s healthcare services. The NCCHC also said it was awarding the jail the group’s first-ever certification for mental health services. At the time of its visit, the group said, the jail had not had a suicide in 12 months.

That was true, but the letter omitted the subsequent death of inmate Mosheh Underwood, 24, who hung himself in his cell August 4, 2018.

Upset after a call with his lawyer, Underwood had asked for paper to cover his cell window so he could have privacy to use the bathroom. A guard provided it – despite previous warnings from Rosenberg’s team about letting inmates cover their windows.

An hour later, Underwood, who hanged himself, was found dead.

Jaime Shikmus, the NCCHC’s vice president, said the sheriff's office was not required to disclose the suicide because it occurred after the surveyors visited.

In the 48 hours before the jail’s certifications were formally unveiled, the sheriff and county worried in internal documents that its standing would be in peril if the organization got a complete picture of its problems.

In one email, jail administrator Todd Freesemann, then the sheriff’s policy and accreditation supervisor, advised Wilcher that the jail “does not have adequate mental health professionals to deal with the volume of mental health requirements.” In another, the county’s attorney warned the sheriff that the lack of registered nurses “jeopardizes your accreditations.”

On February 14, 2019, the news was officially announced. The Chatham County jail had won full accreditation for its mental health and healthcare services, becoming the first local jail to win this honor.

Four months later, a fifth inmate killed himself on CorrectHealth's watch. Guards and medical staff rushed to resuscitate the inmate, but when they tried to revive his heart with a defibrillator, the first device was broken and the second’s battery was uncharged, a jail report said.

Today, CorrectHealth continues to hold its $22 million contract.

Additional reporting by Peter Eisler and Grant Smith

Jail deaths & politics By Ned Parker, Jason Szep and Linda So Photo editing: Steve McKinley Video: Linda So Design: Pete Hausler Edited by Ronnie Greene