OIG Annual Report

Roy W. Wesley, Inspector General Bryan B. Beyer, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight May 2019 2018 Annual Report Summary of Reports and Status of Recommendations Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website at www.oig.ca.gov. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov/pages/mail-list.php. For questions concerning the contents of this report, please contact Shaun R. Spillane, Public Information Officer, at 916-255-1131. STATE of CALIFORNIA OIG OFFICE of the Roy W. Wesley, Inspector General INSPECTOR GENERAL Bryan B. Beyer, Chief Deputy Inspector General Independent Prison Oversight Regional Offices Sacramento Bakersfield Rancho Cucamonga May 14, 2019 Dear Governor and Legislative Leaders: This annual report summarizes the work the Office of the Inspector General completed during 2018, including our complaint intake function. In 2018, we issued 22 public reports that detailed our oversight of the California Department of Corrections and Rehabilitation, which comprised the following: 16 reports on medical inspection results; two reports concerning monitoring the department’s internal investigations and its employee disciplinary process; one report on monitoring the department’s use of force; one report concerning the status of the Blueprint; one report on the California Rehabilitation Oversight Board; and the OIG’s annual report for 2017. This report also enumerates the recommendations we made to the California Department of Corrections and Rehabilitation in 2018, as well as, when required, the department’s responses and its action plans to address our recommendations. Respectfully submitted, Roy W. Wesley Inspector General Gavin Newsom, Governor 10111 Old Placerville Road, Suite 110 Sacramento, California 95827 Telephone: (916) 255-1102 www.oig.ca.gov iv 2018 Annual Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California 2018 Annual Report v Contents Foreword vii Organizational Overview and Functions 1 Reports Published in 2018 5 Internal Investigations and Employee Discipline Monitoring 5 Use-of-Force Monitoring 6 Cycle 5 Medical Inspection Reports 9 Complaint Intake 13 Warden/Superintendent Vetting 21 The Blueprint Report 23 California Rehabilitation Oversight Board 25 Corrective Action Plan Updates for the Department 29 Status of Recommendations Made to the Department in 2018 29 Appendix: Reports Released in 2018 53 Office of the Inspector General, State of California vi 2018 Annual Report Illustrations Figures 1. Office of the Inspector General Organizational Chart, 2019 2 2. Types of Allegations Received in 2018 14 Tables 1. OIG Cycle 5 Medical Inspections: Final Reports Published, 2018 10 2. OIG Cycle 5 Medical Inspections, 2018: Health Care Indicator Results 11 3. OIG Cycle 5 Medical Inspections, 2018: Frequency of Recommendations by Indicator 12 4. Sexual Misconduct Allegations 19 5. Adult Rehabilitative Program Capacity, 2017–2018 26 Photograph Inmate-Manufactured Weapon 16 Exhibits 1. Status of Recommendations on Monitoring Internal Investigations and the Employee Disciplinary Process, 2018 30 2. Status of Recommendations on Monitoring the Use of Force, 2018 34 3. Medical Inspection Recommendations, 2018 44 4. Status of Blueprint Recommendations, 2018 48 5. Status of C-ROB Recommendations, 2018 51 Office of the Inspector General, State of California 2018 Annual Report vii Foreword Vision The California prison system, by its very nature, operates almost entirely behind walls, both literal and figurative. The Office of the Inspector General (the OIG) exists to provide a window through which the citizens of the state can witness that system and be assured of its soundness. By statutory as well as judicial mandate, our agency oversees and reports on several operations of the California Department of Corrections and Rehabilitation (the department). We act as the eyes and ears of the public, measuring the department’s adherence to its own policies and, when appropriate, recommending changes to improve its operations. Our objective is to create an oversight agency that provides outstanding service to our stakeholders, our government, and the people of the State of California. We do this through diligent monitoring, honest assessment, and dedication to improving the correctional system of our state. Our overriding concern is providing transparency to the correctional system so that lessons learned may be adopted as best practices. Mission Although the OIG’s singular vision is to provide transparency, our mission encompasses multiple areas, and our staff serve in numerous roles overseeing distinct aspects of the department’s operations, which include discipline monitoring, complaint intake, warden vetting, medical inspections, the California Rehabilitation Oversight Board (C-ROB), and a variety of special assignments. Therefore, to safeguard the integrity of the state’s correctional system, we work to provide oversight and transparency through monitoring, reporting, and recommending improvements on the policies and practices of the department. — Roy W. Wesley Inspector General Office of the Inspector General, State of California viii 2018 Annual Report T here is hereby created the independent Office of the Inspector General which shall not be a subdivision of any other governmental entity. — State of California Penal Code section 6125 Office of the Inspector General, State of California 2018 Annual Report 1 Organizational Overview and Functions The Office of the Inspector General (OIG) is an independent agency of the State of California. First established by state statute in 1994 to conduct investigations, review policy, and conduct management review audits within California’s correctional system, California Penal Code sections 2641 and 6125–6141 provide our agency’s statutory authority in detail, outlining our establishment and operations. The Governor appoints the Inspector General to a six-year term, subject to California State Senate confirmation. The Governor appointed our current Inspector General, Roy W. Wesley, on September 13, 2017; his term will expire in 2023. The OIG is organized into a headquarters operation, which encompasses executive and administrative functions and is located in Sacramento, and three regional offices: north, central, and south. The northern regional office is located in Sacramento, the central regional office is in Bakersfield, and the southern regional office is in Rancho Cucamonga. Our staff consist of a skilled team of professionals, including attorneys with expertise in internal investigations, criminal law, and employment law, as well as inspectors knowledgeable in correctional policy, operations, and investigations. The OIG also employs a cadre of medical professionals, including doctors and nurses, in the Medical Inspection Unit. These practitioners evaluate policy adherence and quality of care within the prison system. Analysts, editors, and administrative staff within the OIG contribute in various capacities, all of which are integral in achieving our mission. Office of the Inspector General, State of California 2 2018 Annual Report Figure 1. Office of the Inspector General Organizational Chart, 2019 Executive Team Discipline Force Information Medical Oversight, Special Administration Monitoring Unit Accountability Technology Unit Inspection Unit C-ROB,* Assignments Compliance Team and Intake Team Human Discipline Use-of-Force Internal IT Medical Complaint Special Resources Monitoring Monitoring Services Inspections Intake Reports AOD Business (Administrative Critical Incidents Warden Vetting Central Intake Services Officer of the Day) Monitoring Contraband Critical Incidents Background Surveillance C-ROB* Rollout Investigations Watch * C-ROB is the abbreviation for the California Rehabilitation Oversight Board. Office of the Inspector General, State of California 2018 Annual Report 3 The OIG performs a variety of oversight functions relative to the department, including the areas listed below: • Medical inspections • Warden/superintendent vetting • Serving as the ombudsperson for, and monitor of, Sexual Abuse in Detention Elimination Act (SADEA)/Prison Rape Elimination Act (PREA) cases • Reviewing and investigating retaliation complaints • Coordinating and chairing the California Rehabilitation Oversight Board (C-ROB) • Handling complaints filed directly with the OIG by inmates, employees, and other stakeholders regarding the department • Special reviews authorized by the Legislature or the Governor’s Office • Monitoring of: » Internal investigations and litigation of employee disciplinary actions » Critical incidents, including inmate deaths, large-scale riots, hunger strikes, and so forth » Use of force » Contraband surveillance watch » Adherence to the Blueprint plan for the future of the department Office of the Inspector General, State of California 4 2018 Annual Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California 2018 Annual Report 5 Reports Published in 2018 In 2018, we issued 22 public reports detailing our oversight of the California Department of Corrections and Rehabilitation: 16 reports on medical inspection results; two reports on monitoring the department’s internal investigations and employee disciplinary process; one report on monitoring the department’s use of force; one report on the status of the Blueprint; one report on the California Rehabilitation Oversight Board; and our 2017 annual report. Visit our website, www.oig.ca.gov, to view our public reports. Internal Investigations and Employee Discipline Monitoring Attorneys in the OIG’s Discipline Monitoring Unit are responsible for the contemporaneous oversight of the department’s internal investigations and employee discipline processes. Our Discipline Monitoring Unit also oversees the department’s response to critical incidents within institutions. We provide an accounting of our activities in monitoring internal investigations and the litigation of disciplinary actions on a regular basis when we publish our semiannual reports. These reports document the department’s adherence to its operating rules and procedures, as well as provide a record attesting to the quality of the investigation and legal representation regarding employee discipline. Our attorneys monitor and assess the department’s internal investigations that Office of Internal Affairs’ special agents conduct. In addition, we monitor and assess the performance of departmental attorneys throughout the disciplinary process, including any appeals. As part of our monitoring process, we participate weekly in the Office of Internal Affairs central intake panel meetings for cases the department receives from hiring authorities. In 2018, hiring authorities referred 1,917 cases for investigation or approval for authorization to take direct disciplinary action, of which the Office of Internal Affairs (OIA) opened 1,804 cases. Of the cases the OIA opened, the OIG opened 491 for monitoring purposes. We monitor the most sensitive internal investigations against staff members, including those involving allegations of dishonesty, sexual misconduct, unreasonable use of force, deadly force, code of silence, abuse of authority, and criminal conduct. Furthermore, we monitored and closed 496 cases during our reporting period. Of this group, 430 alleged administrative misconduct, and 66 alleged criminal misconduct. In addition to the 496 administrative Office of the Inspector General, State of California 6 2018 Annual Report and criminal cases we reviewed, we also reviewed 22 use-of-deadly- force incidents. We found that, from January through December 2018, the department generally performed well in the investigative and disciplinary phases. However, based on concerns we identified and our assessments, the OIG made recommendations for some changes. For example, in 2018, we recommended the department eliminate the current practice of special agents identifying allegations at the beginning and during investigations, and instead allow the hiring authority to determine the appropriate allegations upon the conclusion of the Office of the Internal Affairs’ investigation and after the hiring authority had reviewed and considered the evidence. We also recommended the department approve and conduct interviews of employees suspected of misconduct in all cases, even in cases in which a full investigation was not warranted, including those the Office of Internal Affairs approved for “direct action” by a hiring authority (see Exhibit 1, pages 30–32). Use-of-Force Monitoring Another means by which we fulfill our oversight mandate is by monitoring the department’s review process for use-of-force incidents at institutional executive review committee meetings, departmental executive review committee meetings, and division force review committee meetings. We utilize a comprehensive database designed to allow our staff to effectively examine the various circumstances surrounding occurrences of the department’s use of force. This tool aggregates information concerning these types of incidents, allowing for an in-depth analysis of each use of force. We share some of the collected data with the department each month and continue to explore how we can improve in sharing data on any trends we observe. The OIG also participates as a nonvoting member of the department’s Deadly Force Review Board. In July 2018, we published Monitoring the Use of Force: The California Department of Corrections and Rehabilitation’s Process for Reviewing Staff Use of Force Is Thorough, but It Must Address Low Compliance Rates With Its Policies and Procedures. This report covered use-of-force incidents we monitored for which the department completed a review between July 1, 2017, and December 31, 2017. Our process included having inspectors visit every adult and juvenile institution, headquarters, and the northern and southern parole regions to attend 778 of the 825 executive review committee meetings (a 94 percent attendance record). During this six-month period, our inspectors reviewed and analyzed 4,001 instances, including Office of the Inspector General, State of California 2018 Annual Report 7 3,709 use-of-force incidents and 292 allegations of excessive or unnecessary uses of force. Statistics Regarding the Use of Force from July 1, 2017, Through December 31, 2017 • Approximately 92 percent of the use-of-force incidents (3,405 of 3,709) occurred at the state prisons and contract facilities housing adult inmates, with the remainder involving the juvenile facilities (269), parole regions (29), and the Office of Correctional Safety (6). • Approximately one-third of the incidents occurred at five state prisons: California State Prison, Corcoran; California State Prison, Sacramento; Kern Valley State Prison; California Correctional Institution; and Salinas Valley State Prison. • Of the 3,709 incidents we monitored, 11,046 involved “applications” of force; for example, two baton strikes count as two applications during a single incident. The use of chemical agents accounted for 5,121 (46 percent) of the total applications, while physical strength and holds accounted for 3,662 (33 percent). The remaining 21 percent of applications comprised force options such as less-lethal projectiles, baton strikes, tasers, and firearms. Highlights of Our Monitoring The department has a sound process in place for evaluating use-of- force incidents, and it works well to identify instances in which its staff members’ actions varied from departmental policy and training. However, the department found that only 52 percent of the incidents during this period fully met policy standards. The OIG concurred with the department’s in-policy decisions in all but 46 incidents. Overwhelmingly, the department remedied the deficiencies it identified by providing training to staff (95 percent of the out-of-policy incidents). The department took other corrective action by counseling staff in 6 percent of the out-of-policy incidents. The department took disciplinary action for staff misconduct in 16 incidents and referred another 18 incidents to the Office of Internal Affairs for consideration of further investigation. Officers did not always articulate their need to use force, and in some instances, their own actions may have contributed to the need to use force. The department’s policy for the use of immediate force requires that its officers’ reports articulate their reasoning for using force. Despite this requirement, officers did not adequately articulate an Office of the Inspector General, State of California 8 2018 Annual Report imminent threat in 68 of the incidents we monitored, leading us to question whether the force was necessary. Moreover, the actions of officers in 47 of the 3,709 incidents unnecessarily contributed to the need to use force, such as opening the incorrect cell door, failing to properly secure an inmate prior to escort, or not using the proper de- escalation techniques to avoid the need to use force. The department continues to have low compliance with its procedures for video-recording interviews with inmates. Departmental policy requires video-recording interviews with inmates who allege unnecessary or excessive force, or who sustain serious or great bodily injury possibly from the use of force. Policy further requires staff to record these interviews within 48 hours of the discovery of the injury or allegation, and that a supervisor who neither used nor observed force conduct the interview. We noted the department’s compliance rate with its standards was only 57 percent during this six-month period. The department experienced a high rate of noncompliance with its policies during controlled use-of-force incidents. The department deployed “controlled force” when an inmate’s presence or conduct posed a threat, and the inmate is located in an area that can be controlled or isolated. Of these 61 controlled use-of-force incidents we monitored during our six-month review period, the department found that staff violated one or more policies in 46 incidents (75 percent) (see Exhibit 2, pages 34–42). Summary of Recommendations In our report, we recommended, among other things, the department consider the following actions: • Reevaluate its training curriculum and provide additional training to staff to address its relatively low compliance rate in conducting video-recorded interviews and utilizing controlled use of force. • Optimize the use of its recently implemented use-of-force tracking system to analyze the following: trends related to policy deviations; staff who frequently violate use-of-force policies; and actions hiring authorities impose to address violations. This would enable the department to focus its training on the most common types of violations. See Exhibit 2, pages 34–42, for the status of all the recommendations we made in our report. Office of the Inspector General, State of California 2018 Annual Report 9 Cycle 5 Medical Inspection Reports One of the critical responsibilities of the OIG is to conduct an objective, clinically appropriate, and metric-oriented medical inspection program. This program is directed toward reviewing the health care provided to patients housed at each of California’s adult prisons. During 2018, our staff continued working on our fifth cycle of correctional institution medical inspections. In 2018, we published 16 public reports for Cycle 5; we rated 2 institutions proficient, 10 institutions adequate, and 4 institutions inadequate. We also issued two additional draft reports to external stakeholders. In 2018, the federal receiver delegated the following prisons back to the department: • California Correctional Center (March) • California Men’s Colony (May) • Valley State Prison (July) • California State Prison, Corcoran (October) The Cycle 5 medical inspection process includes qualitative case review testing as well as quantitative compliance testing. Our inspection teams are staffed with expert physicians and nurses. We use up to 15 health care quality indicators to assess the medical care at each institution. We started our sixth cycle of medical inspections in 2019. The following table lists the month of publication and the overall rating for each institution that we inspected and for which we issued a final report in 2018: Office of the Inspector General, State of California 10 2018 Annual Report Table 1. OIG Cycle 5 Medical Inspections: Final Reports Published in 2018 Publication Overall Institution Inspected Month Rating Kern Valley State Prison January Adequate Folsom State Prison January Adequate Pelican Bay State Prison January Proficient California State Prison, Centinela January Adequate Chuckawalla Valley State Prison March Adequate High Desert State Prison April Adequate Central California Women’s Facility May Inadequate Correctional Training Facility June Inadequate California City Correctional Facility June Proficient Mule Creek State Prison August Inadequate California Men’s Colony August Adequate Avenal State Prison August Adequate California Institution for Women August Adequate Sierra Conservation Center August Adequate Calipatria State Prison October Adequate California State Prison, Sacramento November Inadequate Source: Office of the Inspector General, Medical Inspection Unit. Office of the Inspector General, State of California 2018 Annual Report 11 Table 2 below shows the distribution of the 2018 health care indicator results. Table 2. OIG Cycle 5 Medical Inspections, 2018: Health Care Indicator Results Number of Institutions Health Care Indicator Not Proficient Adequate Inadequate Applicable Access to Care 0 5 7 4 Diagnostic Services 0 2 13 1 Emergency Services 0 1 10 5 Health Information Management 0 9 5 2 Health Care Environment 0 1 3 12 Inter- and Intra-System Transfers 0 1 8 7 Pharmacy and Medication 0 1 4 11 Management Prenatal and Post-Delivery Services 14 1 1 0 Preventative Services 0 9 6 1 Quality of Nursing Performance 0 2 11 3 Quality of Provider Performance 0 2 10 4 Reception Center Arrivals 15 0 0 1 Specialized Medical Housing 3 2 8 3 Specialty Services 0 4 8 4 Administrative Operations (secondary) 0 4 8 4 Source: Office of the Inspector General, Medical Inspection Unit. We found that many institutions performed at an acceptable level in several areas of health care delivery; most institutions passed the indicators Diagnostic Services, Health Information Management, Preventative Services, Quality of Nursing Performance, and Specialized Medical Housing. On the other hand, most institutions did not pass the Health Care Environment and Pharmacy and Medication Management indicators. OIG Cycle 5 Medical Inspections, 2018: Recommendations In 2018, we offered 54 recommendations to improve health care delivery within the institutions (see Exhibit 3, pages 44–46). The reader should not interpret the presence of recommendations as evidence of poor performance. We offer recommendations regardless of an institution’s rating in that area. The following types of recommendations were our most frequent in 2018: Office of the Inspector General, State of California 12 2018 Annual Report Table 3. OIG Cycle 5 Medical Inspections, 2018: Frequency of Recommendations by Indicator Health Care Indicator Recommendations Institutions Emergency Services 9 7 Inter- and Intra-System Transfers 3 3 Pharmacy and Medication Management 8 7 Quality of Nursing Performance 11 7 Quality of Provider Performance 9 6 Specialty Services 6 5 Source: Office of the Inspector General, Medical Inspection Unit. In addition, we highlighted four best practices in three institutions and recommended that California Correctional Health Care Services (CCHCS) explore the feasibility of implementing those practices statewide: • Centinela State Prison (CEN) nurses included important information not usually seen on transfer records, such as phone numbers and addresses for pending specialists’ appointments. The OIG recommends that CCHCS adopt this process statewide. • In the correctional treatment center, CEN nurses developed a useful report sheet that contained information relevant to all team members including nursing assistants. The information on the report sheet included the patient’s name, diagnoses, care plan information, diet, and TABE (Test of Adult Basic Education) score. The OIG recommends that CCHCS adopt this process statewide. • CCHCS should examine California City Correctional Facility’s (CAC) excellent medication processes and consider replicating those processes statewide. • CCHCS should examine Calipatria State Prison’s (CAL) well- run morning huddle process and consider the feasibility of replicating it statewide. Furthermore, we had one recommendation specifically for CCHCS, based on our experience inspecting all medical programs at departmental institutions: • CCHCS should eliminate time frames for both routine and urgent priority requests from its specialty access policies. Instead, CCHCS should monitor specialty access by measuring the ability of each institution to provide specialty Office of the Inspector General, State of California 2018 Annual Report 13 services within the time frames specified in each order in the electronic health records system (EHRS). Cycle 5 Medical Inspection Summary Our OIG medical inspection staff completed a summary report for Cycle 5, with publication anticipated for summer 2019. The summary report will further analyze and compare results from Cycle 5 with those from Cycle 4. Complaint Intake The OIG maintains a statewide complaint intake process that provides anyone a point of contact regarding allegations of improper activity within the department. We receive complaints submitted by inmates, parolees, families, departmental employees, and advocacy groups. People submit complaints by sending us letters, calling our toll-free public phone line, calling our main telephone number, and emailing us through our website. We screen all complaints within 24 hours of receipt to identify potential safety concerns involving departmental employees or inmates. In 2018, the OIG received 3,270 allegations of improper governmental activities, shown as Figure 2 on the next page. Based on these allegations, we opened 2,405 cases. After we reviewed each complaint, we provided a written response to the complainant. Our office does not have the authority to conduct investigations;1 however, our staff conducted an inquiry by reviewing policies and procedures, by requesting relevant documentation from the institution, or by visiting the institution to observe and make recommendations to department administrators. In 167 cases, we determined that we did not have jurisdiction because the allegations involved county jails, federal prisons, or local law enforcement. In these cases, we referred the complainant to the most appropriate entity. Our office conducted either a preliminary or field inquiry into the remaining 2,238 cases to assist the complainant or to look into the alleged improper activity. We performed a preliminary inquiry for 2,209 cases wherein our staff researched the alleged activity, reviewed policies and procedures, 1 In July 2011, the OIG’s mission was restructured and removed our authority to conduct discretionary audits and investigations, and required that special reviews be authorized only by the Governor, the Senate Committee on Rules, or the Speaker of the Assembly. Office of the Inspector General, State of California 14 2018 Annual Report reviewed the inmate’s case file, and requested additional documentation from the department, as needed. In the vast majority of the cases, our inquiry work resulted in our office providing the complainants with advice on how to address their concerns with the department. Common examples of such advice involved how to request services or navigate through the department’s appeal process, sentence calculation process, disciplinary process, and visiting process. On occasion, our advice included instructions for how to contact specific departmental divisions and offices for services or additional help. Figure 2. Types of Allegations Received in 2018 No OIG Jurisdiction Medical, Dental, or 167 Mental Health Care (5%) 270 (8%) 289 Legal Concerns (9%) N = 3,270 1,671 (51%) Allegations Grievances and Staff Misconduct 873 (27%) Prison Conditions and Operations Source: Office of the Inspector General. Below, we discuss a sampling of the preliminary inquiries that we completed in 2018. These inquiry summaries provide examples of our assistance provided to complainants regarding the department’s appeals process and to an inmate who had not received adequate dental treatment. Each of these complainants had been unsuccessful in their initial attempts to remedy these situations with various departmental staff. In one complaint, an inmate’s mother alleged that her son’s sentence calculation following Proposition 57 was incorrect because her son had not received credits from college coursework he completed. She claimed his scheduled release date in July 2018 was in error. During our review, we found the inmate had not utilized his administrative remedies with the department regarding this complaint. Our office found that the inmate’s records were, in fact, in error because they contained an incorrect course code and illegible college transcripts. Office of the Inspector General, State of California 2018 Annual Report 15 We determined that her son, by completing a college course, was eligible for milestone completion credits. We contacted departmental staff regarding these errors, who received clarification from a principal and corrected the errors. Ultimately, the inmate received two weeks of milestone completion credits, which advanced his release date to June 2018. In another complaint, a third party alleged on behalf of an inmate that an appeal was submitted timely to the third level of review, but was incorrectly denied by the Office of Appeals. The inmate included supporting documents that he had attempted to submit his appeal timely. We reviewed the inmate’s legal and confidential mail log and found the primary reason for the delay was mail processing, which took six days to reach the Office of Appeals from the institution. Consequently, the OIG requested the Office of Appeals reconsider the circumstances involving the delay; the Office of Appeals accepted our request and processed the appeal. In another complaint, a third party alleged that an inmate did not receive adequate dental treatment. The third party alleged that he and the inmate had previously attempted to remedy the situation for more than one year by contacting two institutions and the California Correctional Health Care Services. The third party claimed the inmate suffered substantial tooth loss and bone deterioration due to the delay in receiving these services. Our staff reviewed the inmate’s extensive dental history during 2017 through 2018, including dental progress notes and health care requests the inmate had submitted. In June 2018, a partial denture agreement and dental services were requested by the California Correctional Health Care Services, on behalf of the inmate, from the Prison Industries Authority Dental Laboratory. We found the inmate transferred to another prison in October 2018 without having received his needed dental services. Our staff contacted the institution in October 2018 to ensure continuity of dental care and to obtain a status report concerning the inmate’s denture. The institution notified us one week later that the inmate received his denture, just over four months after the inmate completed his agreement for dental services. Some preliminary inquiries involved more serious matters, such as safety and security threats or mental health conditions, and resulted in our referral to the department. Our staff contacted institutions on 25 occasions to recommend department staff conduct checks on an inmate’s safety or mental health condition. Office of the Inspector General, State of California 16 2018 Annual Report In one complaint, an inmate alleged that he was in fear for his life from other inmates and staff, and that he was in possession of an inmate- manufactured weapon to protect himself (photo, left). Our office requested that departmental staff conduct a threat assessment for possible safety and security concerns. When interviewed by a lieutenant, the inmate confirmed that he possessed a weapon. An unclothed body search revealed an Photograph courtesy of the California Department of Corrections and Rehabilitation. inmate-manufactured weapon hidden within the inmate’s boxer shorts. As pictured, the weapon measured 7 inches long by 3/8 of an inch wide, and was made from metal stock sharpened to a point at one end. The inmate received a mental health consultation, and received ongoing treatment and evaluation within the correctional clinical case management system level of care.2 In another complaint, an inmate claimed that departmental staff were ignoring his concerns for a pending transfer. The inmate further stated that he was a gang dropout and had a pending criminal case and would be providing testimony. We located documents of a recent committee meeting that recommended the inmate transfer to a nondesignated programming facility.3 The committee notified the inmate that all enhanced outpatient facilities were nondesignated programming facilities and noted the inmate’s objection to transfer due to enemy concerns. Our office notified departmental staff of the inmate’s alleged safety concerns, and the department conducted a mental health risk assessment and screened the inmate. Due to a change in the inmate’s circumstances (medical risk factors and mental health level of care), the inmate subsequently transferred to a sensitive needs yard instead of a nondesignated programming facility. In another complaint, an inmate housed in a reception center during her first week of incarceration had not yet been assessed for the department’s mental health services delivery system, but she was exhibiting signs of mental health concerns. We expedited our review 2 The department’s program guide for its mental health services delivery system states that inmates who require a correctional clinical case management system (CCCMS) level of care shall be seen by a primary clinician within 30 days of placement in CCCMS and at least every 90 days thereafter while at a reception center, or more often if clinically indicated. Inmates at the CCCMS level of care shall be evaluated by a psychiatrist a minimum of every 90 days regarding psychiatric medication issues. 3 The department developed new criteria in which it combined inmates designated as general population and sensitive needs yard within the same facility, thus creating a nondesignated programming facility. All enhanced outpatient program housing units were converted to nondesignated programming facilities in January 2018. Office of the Inspector General, State of California 2018 Annual Report 17 because her account was supported by her complaint that concerned her husband’s financial struggles and her daughters’ alleged exposures to nerve gas. The inmate requested an investigation and protective custody for her daughters. During our review, we found the inmate had not utilized her administrative remedies with the department regarding these concerns. Our office submitted a mental health referral on behalf of the inmate. The inmate received a mental health consultation and ongoing treatment and evaluation within the correctional clinical case management system level of care. Moreover, some inquiries required site visits to the institution: we call these field inquiries. During 2018, we completed 29 field inquiries. For example, in one of the field inquiries, a third party and an inmate submitted separate complaints alleging the department was not properly applying sex offender registration requirements to the inmate, causing an erroneous release date. The institution’s staff had previously determined the inmate must register as a sex offender under California Penal Code section 290. However, OIG staff reviewed the applicable sex offender registration requirements and found the institution had misapplied a mandatory registration requirement. The department agreed and corrected his release date. In another complaint, an inmate’s grandfather alleged departmental staff falsified the inmate’s commitment offense documents and were going to transfer the inmate to another institution where the inmate feared for his safety. Our staff reviewed the inmate’s past disciplinary reports and notified departmental staff of errors in the inmate’s criminal history. Departmental staff made corrections to the inmate’s criminal history, updated the inmate’s confidential enemy list, and did not transfer the inmate to the institution where he feared for his safety. In another complaint, an inmate alleged that the department had refused to place him in administrative segregation upon arrival to a new institution. The inmate claimed he was instead placed in general population housing and, three days later, was attacked by three other inmates, causing him to lose an eye. We reviewed the department’s appeal response to the inmate, which acknowledged that departmental staff did not follow policy by allowing the maximum-custody inmate to be released to general population housing prior to a committee action. Our office found that the hiring authority issued letters of instruction and provided training to the responsible departmental staff as corrective action. The OIG recommended the hiring authority consider referral for adverse action against departmental staff members. The hiring authority disagreed, stating the inmate did not have a documented enemy at the facility to which he was released and did not express any safety concerns to departmental staff. In addition, the hiring authority cited that departmental staff did not purposely endanger the inmate, but Office of the Inspector General, State of California 18 2018 Annual Report had inaccurately assessed the inmate’s custody designation. The hiring authority affirmed that the instructional letters and training were the appropriate resolution. Our staff concurred with the hiring authority’s decision. In another complaint, an inmate’s attorney alleged that officers were present, but failed to intervene when other officers used unreasonable force on three inmates. According to the attorney, this alleged inaction resulted in injuries to these inmates. Our staff reviewed the use-of-force incident package and noted discrepancies among departmental staff reports. We also found the hiring authority identified inmate injuries not consistent with the use of force reported, and the hiring authority requested an investigation by the Office of Internal Affairs. The Office of Internal Affairs conducted an inquiry, which involved review of incident reports, interviews of inmates, and a review of a mobile phone video. However, the Office of Internal Affairs determined that there was insufficient evidence of staff misconduct to support an investigation and rejected the hiring authority’s request. In addition, the institution’s executive review committee determined that the force used was in compliance with departmental policy. Our staff concurred with the Office of Internal Affairs Central Intake Panel’s rejection of the case and the department’s determination that the force used was within policy. Sexual Abuse in Detention Elimination Act Ombudsperson Claims According to California Penal Code section 2641, the OIG is authorized to serve as the ombudsperson (a designated, impartial advocate) for complaints related to the Sexual Abuse in Detention Elimination Act (SADEA).4 Acting in this capacity, we reviewed allegations of mishandled sexual abuse investigations within correctional institutions, maintained the confidentiality of sexual abuse victims, and ensured an impartial resolution of inmate and ward sexual abuse complaints. Our staff supplied informational posters to all adult institutions, Division of Juvenile Justice facilities, and parole offices that explain how to report these allegations through our toll-free phone line or by mail. By acting as an external reporting mechanism, we increase transparency and provide another option to inmates who are concerned with reporting the alleged abuse or harassment directly to departmental staff. During 2018, the department notified the OIG of sexual harassment or sexual misconduct allegations, commonly referred to as Prison Rape 4 The federal Prison Rape Elimination Act (PREA) of 2003 provided national standards to eliminate sexual abuse in detention facilities. In 2005, California enacted Assembly Bill 550, the Sexual Abuse in Detention Elimination Act (SADEA), which provides the Office of the Inspector General with the authority to investigate reports of the mishandling of sexual abuse incidents. Office of the Inspector General, State of California 2018 Annual Report 19 Elimination Act or “PREA” allegations, from sexual incident reports or critical incident notifications. As seen in Table 4 below, we received 943 sexual incident reports. The department also notified us regarding 658 critical incidents relating to sexual misconduct or sexual harassment allegations made against a departmental staff member. According to departmental policy, an inmate may report an allegation of sexual violence, staff sexual misconduct, or sexual harassment to any staff member verbally or in writing, through the inmate appeals process, through the sexual assault hotline, or through a third party. In addition, an inmate may report these allegations directly to the OIG’s ombudsman for sexual abuse in detention elimination. Any departmental employee who observes the incident or is provided a report by the victim must complete the required reports, including a sexual incident report.5 These allegations must be investigated by a trained departmental investigator and reviewed by the institution’s hiring authority. Table 4. Sexual Misconduct Allegations Sexual Incident Critical Incident Report Notification Non-Consensual Sexual Acts 230 127 Abusive Sexual Acts 146 93 Inmate-on- Inmate Sexual Harassment 101 27 Subtotal 477 247 Sexual Misconduct 298 287 Staff-on- Sexual Harassment 168 124 Inmate Subtotal 466 411 Total Sexual Misconduct Allegations 943 658 Source: Office of the Inspector General Tracking and Reporting System. One allegation we received from the department through a critical incident notification alleged that an officer engaged in sexual misconduct with two inmates and provided one with a mobile phone, methamphetamine, and food in exchange for sexual favors. The Office of Internal Affairs conducted an investigation, and our office monitored the case. The Office of Internal Affairs determined there was insufficient evidence for a probable cause referral to the district attorney. The OIG 5 The Survey of Sexual Violence (SSV) form is part of the U.S. Department of Justice, Bureau of Justice Statistics National Prison Rape Statistics Program, which gathers mandated data of sexual assault in correctional facilities, under the Prison Rape Elimination Act (PREA) of 2003. Office of the Inspector General, State of California 20 2018 Annual Report concurred with the probable cause determination. The Office of Internal Affairs did not open an administrative investigation due to lack of evidence. In addition, during 2018, our staff reviewed 153 complaints directly from inmates, family members, and third parties alleging sexual misconduct or sexual harassment policy violations. In 31 instances, our office referred these allegations as notifications to the department for its staff to conduct an initial investigation or inquiry. One allegation involved an inmate who reported being a victim of an inmate-on-inmate nonconsensual sexual act, stating, “I am being forced to perform oral [sex] on another man…. He will not stop this rape.” Our review of institutional records showed the alleged victim and aggressor were housed in the same facility, but in different buildings. We reported the allegation to the institution’s PREA Compliance Manager, who confirmed this allegation had not been reported to departmental staff. Our staff reviewed the inquiry conducted by a locally designated investigator and found that the alleged victim was interviewed on the same day our office made the report. During the interview, the inmate denied making any PREA allegation and denied being the victim of any physical or sexual assault. The inmate stated he did not know who would have filed a false report that he was sexually assaulted. As a result, departmental staff concluded the allegation was unfounded. Another allegation involved an inmate’s mother, who contacted our toll-free public line in Spanish alleging her son was a victim of an inmate-on-inmate nonconsensual sexual act, stating that her son was being raped. OIG staff were not able to get additional details, such as the date of the act or the name of the alleged aggressor. Our review of institutional records found that her son had reported to institutional staff he had been the victim of unwanted sexual contact by his cellmate. Departmental staff initiated a PREA inquiry for this allegation. Each inmate received sexual assault examinations. Departmental staff performed a cell search to collect possible evidence and conducted interviews of possible witnesses. The inmates were no longer being housed together as of the reported incident date, since the alleged victim considered the alleged aggressor his enemy. Ultimately, departmental staff concluded this allegation was unsubstantiated. Retaliation Claims In addition to receiving complaints as described in the preceding paragraphs, our statutory authority directs us to receive and review complaints of retaliation that departmental employees levy against members of their management. Our Legal Services Unit analyzes each complainant’s allegations to determine whether the complaint Office of the Inspector General, State of California 2018 Annual Report 21 presents the legally required elements of a claim of retaliation. If the complaint meets this initial legal threshold, our staff investigate the allegations to determine whether retaliation did occur. If we determine the department’s management subjected a departmental employee to unlawful retaliation, our office reports its findings to the department along with a recommendation for appropriate corrective action. Due to public misperception regarding what constitutes whistleblower retaliation, few complaints present the legally required elements to state an actionable claim of retaliation. To counteract this misunderstanding, we engage with complainants to educate them regarding the elements of a retaliation claim, invite complainants to supplement their complaints with the necessary information, and correspond with complainants to clarify any questions we have regarding the information they submitted. In 2018, we received nine retaliation complaints. The Legal Services Unit completed analysis of five complaints received in 2018 and the only two complaints that remained pending from 2017, determining that none of them met the legal threshold for retaliation. Four of the nine complaints received in 2018 remain pending. Warden/Superintendent Vetting We are also responsible for evaluating the qualifications of each candidate whom the Governor nominates for appointment as a warden at an adult institution or a superintendent at a juvenile facility, reporting the recommendation in confidence to the Governor within 90 days of the request. Typically, candidates have been serving as acting wardens or superintendents for at least three months before our evaluation begins. In 2018, we completed seven warden vettings, as depicted in the following list: Warden • Central California Women’s Facility • Sierra Conservation Center • California State Prison, Solano • Pelican Bay State Prison • Folsom State Prison/ Folsom Women’s Facility • California City Correctional Facility • California State Prison, Corcoran Office of the Inspector General, State of California 22 2018 Annual Report In addition to conducting a background investigation of the candidate and surveying designated stakeholders, our staff use a three-phase vetting model. In the first phase, an OIG team of inspectors visit the institutional site and provide the Inspector General with an overview of the institution’s operations. During the second phase, the Inspector General interviews members from the institution’s management team and tours the institution with the candidate. In the final phase, the Inspector General conducts a one-on-one interview with the candidate. The Inspector General next reviews all the information gathered during the vetting process and evaluates the candidate’s suitability for the position of warden or superintendent. The Inspector General then submits a confidential recommendation to the Governor. Demand has continued for warden and superintendent vetting in 2019 due to departmental management retirements resulting in a high turnover rate. On many occasions, experienced wardens and superintendents serve as mentors to newer, less experienced administrators. As of December 31, 2018, the following seven adult institutions and one juvenile facility did not have permanent wardens or superintendents assigned to them: • California Correctional Institution • California Medical Facility • California State Prison, Los Angeles County • Correctional Training Facility • Deuel Vocational Institution • Richard J. Donovan Correctional Facility • Salinas Valley State Prison • Ventura Youth Correctional Facility Office of the Inspector General, State of California 2018 Annual Report 23 The Blueprint Report As part of our legislative mandate, we periodically review the reforms identified in The Future of California Corrections: A Blueprint to Save Billions of Dollars, End Federal Court Oversight, and Improve the Prison System (the Blueprint), published by the department in April 2012. The OIG monitors the department’s progress in implementing five of its key goals: • Establish and adhere to the standardized staffing model at each institution; • Establish and adhere to the new inmate classification scoring system; • Implement and adhere to the comprehensive housing plan; • Establish and adhere to the new prison gang management system; and • Increase the percentage of inmates served in rehabilitative programs to 70 percent of the target population prior to the inmate’s release. In January 2016, the department issued An Update to the Future of California Corrections, which provided a summary of the goals identified and progress achieved since the initial Blueprint was published four years earlier. It also laid out the department’s future vision for rehabilitative programming, along with safety and security concerns. In July 2018, we issued our Blueprint Monitoring: Ninth Report on the California Department of Corrections and Rehabilitation’s Progress Implementing Its Future of California Corrections Blueprint and Update to the Blueprint. Our report covered data we collected at all 35 adult institutions from December 2017 through February 2018, and was organized into two sections, representing key areas OIG staff monitored: rehabilitative programs, and population and housing. Our staff analyzed data and performed fieldwork to determine the operational status of various programs at each institution during the 2017–18 fiscal year. Rehabilitative Program Review Although the department implemented rehabilitation programs at all institutions, it has been unsuccessful in providing rehabilitative programs to 70 percent of its target population. To address counting methodology concerns we raised in our previous Blueprint reports, on Office of the Inspector General, State of California 24 2018 Annual Report July 1, 2017, the department developed a new method for counting that it believed will better track program information for all offenders. The department is now focused on “minimal participation,” which it defines as enrollment in a program for a minimum of 30 calendar days. This change may make it more difficult for the department to achieve its past target rate of 70 percent; however, the department expects that this change will allow its staff to more accurately evaluate its ability to address offenders’ needs. The department anticipates analyzing and redefining any prior goals related to offender participation or target populations. We also determined that 90 percent of academic programs and 82 percent of career technical education programs were operational. In addition, 91 percent of the substance use disorder treatment slots were filled, 95 percent of the cognitive behavioral therapy slots were filled, and 91 percent of the preemployment transitions’ classes were operational. Although the overall compliance rate increased, our review identified ongoing recruitment concerns for career technical education positions at Salinas Valley State Prison and Richard J. Donovan Correctional Facility. These two prisons were operating only 20 and 45 percent of their available career technical education courses, respectively.6 Housing and Population Review During the reporting period, the department continued its efforts to address housing and population challenges, including making changes to the sensitive needs yard population by creating two separate housing options: programming and nonprogramming. The department has also continued expanding its nondesignated programming facilities at seven institutions, which are designated to provide rehabilitative environments for offenders who have demonstrated positive programming efforts and a desire to refrain from violent behaviors. Additionally, all enhanced outpatient program and inpatient mental health beds were converted to nondesignated housing in January 2018. The department continued to slowly transition lower-level and other traditional programming institutions to nondesignated programming facilities during 2018. In the Blueprint report, we included two new recommendations to the department for 2018 (see Exhibit 4, pages 48–49): 6 According to the department, in 2019, Richard J. Donovan Correctional Facility had filled seven of its nine (78 percent) career technical education positions, while Salinas Valley State Prison had filled five of its six (83 percent) career technical education positions. Office of the Inspector General, State of California 2018 Annual Report 25 • The Office of the Inspector General recommends that the department clarify how it is meeting an inmate’s rehabilitative needs and improve upon its existing performance measures. The department should utilize existing Strategic Offender Management System data, if deemed reliable, to identify individual offender progress in rehabilitation programming. • The Office of the Inspector General recommends that the department increase the percentage of operational courses by requiring each supervisor of Correctional Education Programs to provide regular updates to the director of the Division of Rehabilitation Programs regarding recruiting and retaining sufficient teachers. California Rehabilitation Oversight Board In 2007, the California Legislature established the 11-member California Rehabilitation Oversight Board (C-ROB) chaired by the Inspector General. Our agency convenes C-ROB meetings up to three times per year to examine the department’s various mental health, substance abuse, educational, and employment programs for inmates and parolees. The C-ROB report is published annually, on September 15. In 2018, OIG staff visited all 35 adult institutions from January through February and again from June through August. During these visits, we met with both departmental staff (including academic and vocational instructors, community resource managers, and correctional counselors) and inmates to identify successes and challenges in rehabilitative programming. OIG staff also obtained data from the department concerning its rehabilitative programs, including academic education, career technical education, and substance use disorder treatment. Rehabilitative programs continue to expand as a result of both Proposition 57 and innovative programming grants. Hundreds of inmate activity groups are now eligible for rehabilitative achievement credits, a process that has incentivized programming statewide. Reentry programming at each institution combined with the rehabilitative case plan provided to both parole or postrelease community supervision furthers transition efforts and is a noted progress point for successful reentry. The following table offers additional details on rehabilitative program capacity from 2016 to 2018: Office of the Inspector General, State of California 26 2018 Annual Report Table 5. Adult Rehabilitative Program Capacity, 2017–2018 Location of Seats available in June Program Delivery Rehabilitative Program 2017 2018 Academic Education* 44,365 45,030 Career Technical Education 9,045 9,052 Transitions Program 21,405 20,734 Cognitive Behavioral Treatment: In-Prison Substance Use Disorder Treatment 11,645 13,603 Anger Management 8,208 9,840 Criminal Thinking 8,160 9,840 Family Relationships 4,072 4,936 Victim Impact 696 1,488 Education Programs 6,999 7,841 Post-Release Substance Use Disorder Treatment 8,926 9,975 Employment Programs 5,940 6,162 Total Capacity for All Programs 129,465 138,501 * Academic and career technical education report as a daily budgeted capacity. All other programs report the average number of times a program can be completed in one fiscal year (annualized). Source: California Department of Corrections and Rehabilitation, Division of Rehabilitative Programs, as of June 2017 through June 2018; data are not validated by the OIG. The board commends the department for increasing its rehabilitative program capacity, as noted in Table 5 above. We found institutional site visit successes during this reporting period, including increases in volunteer programs, credit-earning opportunities, and the expansion of face-to-face college programs in all 35 institutions. The board recognizes the department’s efforts at collaborating with community colleges to expand access to both correspondence courses and face-to-face instruction at all institutions. Innovative grant funding for three-year support has expanded volunteer-led rehabilitative programming, and the department has provided additional support staff to assist with programming coordination. The department extended its datasharing agreement with the California Department of Health Care Services through June 20, 2019, allowing both departments to continue exchanging Medi-Cal applications to improve benefit outcomes for the inmates served through the transitional case management program. In 2018, the department successfully screened nearly 100 percent of inmates for health benefit eligibility and also improved the health benefit approval process for prerelease benefits, resulting in a higher rate of authorization. Office of the Inspector General, State of California 2018 Annual Report 27 Program expansion has also posed some challenges, including a less-than-50-percent completion rate for in-prison substance use disorder treatment programs, and the aftercare completion rate was also extremely low, averaging 29 percent for the fiscal year. The board underscored the importance of an effective substance use disorder treatment program, in both prison and community aftercare, and is hopeful the department will take measures to increase the completion rate in both areas. The department continues to ensure offenders and parolees receive risk and needs assessments, with 98 percent of the offender population and 98 percent of the parole population receiving a California Static Risk Assessment. Currently, 95 percent of the total parole population received a reentry Correctional Offender Management Profiling for Alternative Sanctions (COMPAS) assessment, which is an increase of 25 percent over the previous fiscal year. There were three categories of reentry COMPAS assessments still reporting a moderate-to-high need for just over 50 percent of the parole population. The board recommends that the department address this high percentage of parolees who were released having a moderate-to-high need in three key areas: substance use disorder treatment, reentry financial, and reentry employment expectations. As a result of site visits and the work of the board, the C-ROB report included two new recommendations offered to the department for 2018 (see Exhibit 5, page 51): • The board recommends the department’s Division of Rehabilitative Programs continue to work with the Division of Adult Institutions to strengthen and maximize inmate rehabilitative programming and credit earning potential. The department should determine if its Strategic Offender Management System requires process improvements to improve tracking in key areas, such as assigning inmates to available milestone and rehabilitative achievement credit programs and tracking of inmate program waitlists that are currently prepared at the local institutional level. • The board recommends the department, with the assistance of C-ROB members, determine ways to allow for an exchange of information among federal, state, and county programs to ensure released offenders have access to (and may be approved for) available benefits. The goal is to identify strategies to better link those formerly incarcerated to the various services available to help them become stable and self-sufficient as they reintegrate into the community. Office of the Inspector General, State of California 28 2018 Annual Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California 2018 Annual Report 29 Corrective Action Plan Updates for the Department The OIG published 22 formal reports containing recommendations in 2018. The recommendations in these reports promote greater transparency, process improvements, increased accountability, and higher adherence to policies and constitutional standards. Status of Recommendations Made to the Department in 2018 The following exhibit outlines the 11 recommendations we made in March and November 2018 as published in our two monitoring reports relating to investigation and disciplinary processes. The department has fully implemented two recommendations, has not implemented eight recommendations, and one recommendation remains pending. Office of the Inspector General, State of California 30 2018 Annual Report Office of the Inspector General, State of California 8102 ,snoitadnemmoceR tropeR ssecorP yranilpicsiD eeyolpmE dna snoitagitsevnI lanretnI fo sutatS .1 tibihxE GIO noitatnemelpmI noitagitsevnI sa sutatS dna nalP noitcA desoporP s’tnemtrapeD ehT noitadnemmoceR fo noitpircseD eht yb denimreteD yranilpicsiD GIO ssecorP stropeR detnemelpmi toN ot trepxe tnednepedni na gniyfitnedi fo ssecorp eht ni si tnemtraped ehT sriaffA lanretnI fo ecfifO eht taht dednemmocer GIO ehT eht gnidrager noitadnemmocer a ekam dna smrofer dirdaM eht weiver gniyfitnedi stnega laiceps fo ecitcarp tnerruc eht etanimile .sessecorp dna selor ’sredlohekats dna snoitagitsevni gnirud dna fo gninnigeb eht ta snoitagella etairporppa eht enimreted ot ytirohtua gnirih eht wolla daetsni lanretnI eht fo ecfifO eht fo noisulcnoc eht nopu snoitagella deweiver sah ytirohtua gnirih eht retfa dna noitagitsevni ’sriaffA .ecnedive eht deredisnoc dna detnemelpmi toN .emit siht ta detnemelpmi eb ton lliw noitadnemmocer sihT evorppa sriaffA lanretnI fo ecfifO eht dednemmocer GIO ehT tcudnocsim fo detcepsus seeyolpme fo sweivretni tcudnoc dna si noitagitsevni lluf a hcihw ni sesac ni neve ,sesac lla ni enuJ–.naJ sriaffA lanretnI fo ecfifO eht esoht gnidulcni ,detnarraw ton 8102 .ytirohtua gnirih a yb ”noitca tcerid“ rof sevorppa deussI( )8102 .voN detnemelpmI esaC tnerruc eht ni ”reggirt“ a detaroprocni tnemtraped ehT edivorp sriaffA lanretnI fo ecfifO eht dednemmocer GIO ehT sriaffA lanretnI fo ecfifO eht nehw GIO eht yfiton ot metsyS tnemeganaM ot stcejbus ro snoitagella sdda ti revenehw eciton GIO eht .snoitagitsevni ot stcejbus sdda eht gnirud ro ssecorp ekatni lartnec eht retfa snoitagitsevni .snoitagitsevni fo esruoc detnemelpmI yranilpicsid ni egaugnal eht dneme ot deerga dna GIO eht htiw tem TPAE lanretni dnema tnemtraped eht dednemmocer GIO ehT etatS ot tnausrup dnopser ot thgir rieht fo seeyolpme esivda ot snoitca edulcni syenrotta tnemtraped taht eriuqer ot serudecorp derrucnoc GIO ehT .)elur yllekS( 6.25 noitalugeR )BPS( draoB lennosreP rieht fo seeyolpme gnisivda snoitca yranilpicsid lla ni egaugnal .egaugnal dednema eht htiw eht ni devlovni ton saw ohw reganam a ot dnopser ot thgir .noitagitsevni .egap txen no deunitnoC 2018 Annual Report 31 Office of the Inspector General, State of California )deunitnoc( .1 tibihxE GIO noitatnemelpmI noitagitsevnI sa sutatS dna nalP noitcA desoporP s’tnemtrapeD ehT noitadnemmoceR fo noitpircseD eht yb denimreteD yranilpicsiD GIO ssecorP stropeR gnidneP .tnempoleved rednu yltnerruc si metsys SMC detadpu nA gnipoleved etidepxe tnemtraped eht dednemmocer GIO ehT rof gniniart edivorp dna metsys tnemeganam esac wen sti no metsys wen eht ni noitamrofni retne ohw seeyolpme retne yltnetsisnoc yeht erusne ot metsys wen eht esu ot woh .ytlanep cfiiceps lanfi eht gnidrager noitamrofni detnemelpmi toN eht weiver ot TPAE dna GIO eht htiw noitatlusnoc desoporp AIO etaruccani tcerroc tnemtraped eht dednemmocer GIO ehT .noitadnemmocer ,metsys tnemeganam esac eht ni noitamrofni etelpmocni dna esoht rof neve ,esac hcae ni ytlanep cfiiceps lanfi eht gnidulcni .desolc neeb evah taht sesac enuJ–.naJ 8102 detnemelpmi toN .emit siht ta detnemelpmi eb ton lliw noitadnemmocer sihT a poleved tnemtraped eht taht dednemmocer GIO ehT deussI( lanretni etelpmoc dluohs ti hcihw yb enildaed a rof ycilop )8102 .voN ot ecnerefed ni—dednemmocer osla eW .snoitagitsevni ni sesac emos eb lliw ereht taht nrecnoc s’tnemtraped eht ni ylralucitrap ,tem eb tonnac enildaed denimreted a hcihw poleved tnemtraped eht taht—snoitagitsevni xelpmoc erom GIO eht ,eroferehT .enildaed eht ot snoitpecxe rof airetirc a rof ycilop a poleved tnemtraped eht taht dednemmocer a htiw snoitagitsevni lanretni fo noitelpmoc eht rof enildaed eht ot noitpecxe na eriuqer hcihw sesac esoht rof noisivorp .enildaed .egap txen no deunitnoC 32 2018 Annual Report Office of the Inspector General, State of California )deunitnoc( .1 tibihxE GIO noitatnemelpmI noitagitsevnI sa sutatS dna nalP noitcA desoporP s’tnemtrapeD ehT noitadnemmoceR fo noitpircseD eht yb denimreteD yranilpicsiD GIO ssecorP stropeR detnemelpmi toN ,41 elcitrA ni debircsed ssecorp deredro-truoc dirdaM eht fo trap sA ngissa sriaffA lanretnI fo ecfifO eht dednemmocer GIO ehT eht sa evres stnegA )UIC( tinU ekatnI lartneC eht ,.qes te 04113 MOD stnega laiceps tinU ekatnI lartneC sriaffA lanretnI fo ecfifO dna riaf a ni dessessa era stseuqer evitagitsevni lla erusne ot tiudnoc na ylno hcihw ni sesac ni sweivretni eeyolpme tcudnoc ot ylno-tcejbus eht tcudnoc stnegA lanoigeR s’AIO .rennam tnetsisnoc .devorppa si weivretni eeyolpme seriuqer 41 elcitrA .noiger evitcepser rieht ot niatrep taht sweivretni a nI .tpiecer fo syad 03 nihtiw detelpmoc eb sweiver esac UIC lla taht sti devorpmi UIC detacidni GIO eht ,)RAS( tropeR launnA-imeS tnecer .tnecrep 89 ot 28 morf tnemeriuqer yad-03 siht htiw ecnailpmoc detnemelpmi toN eht gnirud snoitagella fo gnipocs dna gnidda rof ssecorp tnerruc ehT eht yb detfard eb snoitagella esac dednemmocer GIO ehT dna ,deweiver ,mrofer dirdaM lanigiro na saw ssecorp ekatnI lartneC eht tcudnoc ot dengissa tnega laiceps sriaffA lanretnI fo ecfifO tnetsisnoc serusne tinu ekatni lartnec ehT .truoc dirdaM eht yb devorppa dluohs snoitagella ehT .weivretni eeyolpme ro noitagitsevni ehT .etats eht tuohguorht noitagitsevni rof stseuqer fo noitaulave ni yenrotta tnemtraped eht htiw noitatlusnoc ni detfard eb depocs dna detaulave era snoitagella serusne ssecorp noitaulave mrofinu .sesac derotinom ni yenrotta GIO eht htiw dna sesac detangised ssecorp laitrapmi dna riaf a serusne dna ,etats eht tuohguorht yltnetsisnoc ,GIO eht htiw noitatlusnoc sedulcni ssecorp ehT .seeyolpme lla rof gniriH eht dna ,)TPAE( maeT noitucesorP dna ycacovdA eeyolpmE eht osla ecitcarp tnerruC .ssecorp ekatni lartnec eht gnirud )AH( ytirohtuA ot gniteem ekatni lartnec eht gnirud stnemeergasid tnacfiingis rof swolla sretrauqdaeH feihC eht ot dnammoc fo niahc AIO eht nihtiw detaulave eb .ceD–yluJ .rotceriD ytupeD eht yrassecen fi dna snoitarepO 7102 deussI( detnemelpmi toN ro snrecnoc redlohekats redisnoc dna ,etaulave ,weiver ot laog s’AIO si tI na nepo sriaffA lanretnI fo ecfifO eht dednemmocer GIO ehT )8102 .raM revenehw stnemeergasid yna evloser ot tpmetta dna snoitadnemmocer eht si taht nehw weivretni eeyolpme na tcudnoc ro noitagitsevni largetni dna tnatropmi na era syenrotta TPAE dna GIO ehT .elbissop noitucesorP dna ycacovdA tnemyolpmE eht fo noitadnemmocer dna etabed segaruocne AIO dna ,ssecorP ekatnI lartneC eht fo trap ecfifO eht ta yenrotta GIO eht fo ro yenrotta tnemtraped maeT ot srovaedne dna sredlohekats lla fo snoitisop eht seulav AIO .noissucsid .gniteem lenaP ekatnI lartneC sriaffA lanretnI fo .dradnats feileb elbanosaer a no desab noisiced tsuj dna riaf a hcaer nac rebmem lenap TPAE ro GIO eht ,rucco stnemeergasid suoires nehW noisiced ekatnI lartneC eht etavele dna tnemeergasid rieht tnemucod s’feihC eht ,yrassecen fI .noitarepO sretrauqdaeH AIO fo feihC eht ot .rotceriD ytupeD AIO eht ot detavele eb nac noisiced eht weiver ot stnatlusnoc gnirih ni degagne yltnerruc si tnemtraped ehT ,ssecorp yranilpicsid ,ssecorp ekatni lartnec eht gnidulcni smrofer dirdaM .elor thgisrevo s’GIO eht dna detnemelpmi toN sreffid 7.234 noitces )CL( edoC robaL fo noitaterpretni s’tnemtrapeD ehT ycilop a tnemelpmi tnemtraped eht dednemmocer GIO ehT .noitaterpretni s’GIO eht morf a ta edulcni ot ,noitagitsevni tnednepedni na gnitcudnoc fo desab sesac ni ,eeyolpme detceffa eht fo weivretni na muminim siht si noinipo GIO ehT .tnemecrofne wal edistuo yb stroper no .7.234 noitceS edoC robaL eht htiw ylpmoc ot deriuqer si ycilop 2018 Annual Report 33 The following exhibit outlines the nine recommendations we made in July 2018 as published in the report on monitoring the use of force. The department has fully implemented two recommendations, and the status of the remaining seven reflects various stages of implementation. Office of the Inspector General, State of California 34 2018 Annual Report Office of the Inspector General, State of California 8102 ,ecroF fo esU eht gnirotinoM no snoitadnemmoceR fo sutatS .2 tibihxE sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb denimreteD ecitcarP fo foorP dna tinU noitadnemmoceR :dluohs tnemtraped eht ,metsys gnikcart ecrof-fo-esu detnemelpmi yltnecer s’tnemtraped eht fo esu eht ezimitpo oT.1 detnemelpmI dna CRFI ylhtnom ytilicaf eht fo seipoC eettimmoC weiveR ecroF noitutitsnI ylhtnoM fo noisiviD enimreteD 1.1 .stroper ylretrauq ytilicaf .tropeR CRFI ylretrauQ .tropeR )CRFI( elinevuJ fo sepyt hcihw )JJD( ecitsuJ ecrof-fo-esu ylhtnom sretrauqdaeh eht fo seipoC .troper ezylanA .atad TATSPMOC dna seitilicaF tnemeganam .troper atad TATSPMOC lecxE gnikcart )FOU( ecrof-fo-esu sretrauqdaeH sretrauqdaeH tius tseb stroper .teehsdaerps ffats evitucexe sti gnirih lacol dna .sdeen ’seitirohtua detnemelpmI stroper tsrfi dna ,etarotcerid yb devorppA htiw gnola detareneg eb lliw stroper atad suoiraV noisiviD txen eht ta snedraw ot detneserp eb lliw lliw noitadnemmocer a dna dlefi eht morf tupni tludA fo ,13–92 yraunaJ ,gniteem ylretrauq ’snedraw lliw stroper hcihw no rotcerid eht ot detneserp eb snoitutitsnI .9102 .ffats evitucexe eht ot detubirtsid dna deriuqer eb )IAD( detnemelpmI rieht rof stroper etareneg srotanidrooc FOU snoitutitsnI .nedraw evitcepser detnemelpmI evitceriD OPAD fo stnemeriuqer eht ecrofnieR fo noisiviD weiveR evitucexE dleiF ecroF-fo-esU ,20-21 .oN eloraP tludA setaretier hcihw ,gniteeM )CREF( eettimmoC snoitarepO ,.qes te ,8623 noitceS ,3 noisiviD ,51 eltiT RCC )OPAD( CREF ehT .stnemeriuqeR weiveR dna gnitropeR yreve gnidulcni FOU lla gniweiver htiw deksat si ecrof yrassecennu ro evissecxe fo noitagella .gnikcart dna aera ro noiger evitcepser rieht nihtiw ,margorP lortnoC ytilauQ sretrauqdaeH OPAD semoctuO dna ecnarussA ytilediF sa nwonk won lanfi rof stnedicni FOU lla seviecer )UOAF( tinU .eengised ro rotcerid eht yb weiver ehT – detnemelpmi yllaitraP rof sisylana TATSPMOC gnizilitu yltnerruC sisylana dna daolpu ataD .teehsdaerps lecxE FOU JJD ylenituoR 2.1 yltnerruc si ti taht detats tnemtraped dna gnipoleved yltnerruC .sdnert FOU lliw ypoc A .sisab ylhtnom a no detcudnoc eb lliw sretrauqdaeH -esu eht ezylana FOU fo sisylana rof TATSPMOC gnisu dna atad ezylana ot loot lanoitidda gninfier etaicossa ,rotcerid ytuped ,rotcerid eht ot tnes eb ta atad ecrof-fo osla tI .level sretrauqdaeh eht ta sdnert .sdnert ,stnednetnirepus .tssa ,stnednetnirepus ,srotcerid ’sretrauqdaeh eht poleved ot seunitnoc ti taht detats .niatpac sretrauqdaeh .sdnert rof level ezylana ot sloot lanoitidda enfier dna .sdnert .egap txen no deunitnoC 2018 Annual Report 35 Office of the Inspector General, State of California )deunitnoc( .2 tibihxE denimreteD sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb ecitcarP fo foorP dna tinU noitadnemmoceR ehT – noitatnemelpmi gnidneP weiver ’sredlohekats rof BMPR htiw yltnerruC .oN evitceriD OPAD fo stnemeriuqer eht ecrofnieR OPAD ylenituoR 2.1 -esu niatniam ot nalp s’tnemtraped noitatnemelpmi rof kcart nO .lavorppa dna lanoigeR seriuqer taht gniteeM CREF FOU ,20-21 -esu eht ezylana dna noitaulave rof atad ecrof-fo .lavorppa BMPR retfa tcudnoc ot )CFOUR( eettimmoC ecroF-fo-esU ta atad ecrof-fo si stnedicni ecrof-fo-esu fo sisylana edulcni ot segakcap tnedicni fo weiver htped-ni ’sretrauqdaeh eht s’tnemtraped eht yb lavorppa gnidnep dna euqitirC eettimmoC weiveR evitucexE eht .sdnert rof level tnemeganaM yciloP dna noitalugeR CREF hcae rof ,sisylanA/noitaulavE .evitatilauQ ).tnoc( eht rotinom ot eunitnoc lliw eW .hcnarB .rebmem ssergorp noitatnemelpmi s’tnemtraped yciloP dna snoitalugeR eht morf lavorppa nopU .noitadnemmocer siht rof desiver eht fo )BMPR( hcnarB tnemeganaM rof elbisnopser eb ot UOAF ,snoitaluger FOU lacitsitats dna atad FOU OPAD lla gniniatniam sesoprup eht rof stnedicni FOU ot detaler stroper ,ecrof fo snrettap gnitceted ,sdnert gnirotinom fo .ffats evitucexe OPAD eht ot atad gnitroper dna ehT – noitatnemelpmi gnidneP etaicossa hcae tneserp lliw noissiM CR ehT atad eht weiver lliw )DA( rotcerid etaicossa hcaE IAD tnerruc sti taht detats tnemtraped ,sredneffo elamef ,ytiruces hgih[ rotcerid rieht htiw krow dna noissim evitcepser rieht rof .elbailer ton si metsys noitcelloc atad htiw ]noissim CR dna ,noitalupop lareneg yeht seussi yna no ytirohtua gnirih evitcepser gnikrow yltnerruc si tnemtraped ehT )STRI( metsyS gnikcarT gnitropeR tnedicnI .ees thgim .egap txen n.eog. edagepau ptnx iettxnneo nnCo n od eduenuitnnitonCoC ,metsys gnikcart tnemecalper a no eht yb devorppa erew taht stroper atad ni detnemelpmi eb ot deludehcs .weiver rof sisab ylretrauq a no ,rotcerid stcepxe tnemtraped eht ;9102 tsuguA tnenopmoc a yb decalper eb lliw STRI :etoN eht evorpmi ot metsys gnikcart wen eht tnemeganaM redneffO cigetartS eht fo FOU ezylana ot ytiliba s’tnemtraped tropeR tnedicnI dellac )SMOS( metsyS .sdnert detcepxe si noitatnemelpmI .)TRI( gnikcarT seod STRI tnerruc ehT .9102 tsuguA dnuora lliw TRI taht atad rof ytilibailer eht teem ton .SMOS ni ssessop .egap txen no deunitnoC 36 2018 Annual Report Office of the Inspector General, State of California )deunitnoc( .2 tibihxE yb denimreteD sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht ecitcarP fo foorP dna tinU noitadnemmoceR noitatnemelpmi gnidneP eht htiw gnikrow yltnerruc si JJD taht ffats eht tnemucod lliw rotanidrooc FOU JJD ffats rotinoM 3.1 ;snoitaleR robaL fo ecfifO s’tnemtraped no seicilop FOU etaloiv ot dnuof era yltneuqerf yltneuqerf ohw ,dettimbus saw loot noitaitogen robal eht edivorp dna teehsdaerps gnikcart lecxE FOU eht erew ro ecrof esu .snoitaitogen elbat gnidnep tnatsissa ,tnednetnirepus eht ot etadpu ylkeew a evah ot dnuof .niatpac/tnednetnirepus detaloiv yltneuqerf ecrof-fo-esu /tnednetnirepus tnatsissa ,tnednetnirepus ehT .seicilop gnikcart lecxE FOU eht weiver lliw niatpac taht ffats esoht fo sisab ylkeew a no teehsdaerps .defiitnedi erew gnikcart lecxE FOU eht gniweiver retfA tnatsissa eht ,ti gnivorppa dna teehsdaerps ot ypoc a edivorp lliw niatpac/tnednetnirepus .)s(reganam/)s(rosivrepus rieht eht fo ypoc a edivorp lliw reganam/rosivrepus ehT defiitnedi si taht ffats eht ot erudecorp dna ycilop /)s(rosivrepus eht ,dengis ecnO .ngis dna daer ot nekat saw taht noitca eht edivorp lliw )s(reganam no tnemucod ot rotanidrooc FOU eht ot etad dna .teehsdaerps lecxE gnikcart FOU eht noitatnemelpmi gnidneP weiver ’sredlohekats rof BMPR htiw yltnerruC eht senimreted )AH( ytirohtua gnirih ehT OPAD noitatnemelpmi rof kcart nO .lavorppa dna dna gnitagitim no desab level ytlanep yranilpicsid .lavorppa BMPR retfa tcejbus dna ,esneffo eht fo srotcaf gnitavargga yranilpicsiD eeyolpmE ,)J( 91.03033§ MOD ot .ecroF fo esU ,xirtaM noitaluger FOU desiver eht ,lavorppa BMPR nopU dna atad drawrof ot UOAF eht eriuqer lliw ot stnedicni FOU ot detaler stroper lacitsitats gnirotinom fo sesoprup eht rof AH lanoiger eht llahs AH ehT .ecrof fo snrettap gnitceted ,sdnert si noitca yranilpicsid ro gnirotinom fi enimreted etaloiv ro esu yltneuqerf ohw ffats rof etairporppa .seicilop FOU eht noitatnemelpmi gnidneP sdohtem tnerruc ezilitu nac seitirohtua gniriH esu ohw ffats kcart ot ytilibapac eht sah STRI IAD ro evitcerroc dna ,gniniart gnikcart rof ot ytiliba eht evah seitirohtua gniriH .ecrof sdrocer gniniart gnikcehc yb noitca esrevda ta ecrof esu taht ffats fo steehsdaerps etareneg dna ,tnemtraped gniniart ecivres-ni eht aiv .level rieht ot selfi yrosivrepus ro lennosrep laicfifo snedraw ot detareneg eb lliw mudnaromem A suoiverp yna neeb evah ereht fi niatrecsa gnirotinom fo sdohtem dehsilbatse gnitaretier .snoitcarfni ralimis rof seussi yranilpicsid .ycilop FOU eht detaloiv evah taht ffats gnirih ot dedivorp eb lliw mudnaromem A tnerruc fo esu eht gnitaretier seitirohtua esahp laitini dna latnempoleved eht gniruD eeyolpme gnikcart fo sdohtem dehsilbatse noitcelloc eht taht denimreted saw ti ,STRI fo .snoitca esrevda dna evitcerroc dna ,gniniart yranilpicsid ro gniniart ’sffats fo egarots dna rof ytilibailer eht teem ton seod STRI :etoN .STRI eht ni deniatniam eb ton lliw noitamrofni .SMOS ni ssessop lliw TRI taht atad .egap txen no deunitnoC 2018 Annual Report 37 Office of the Inspector General, State of California )deunitnoc( .2 tibihxE denimreteD sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb ecitcarP fo foorP dna tinU noitadnemmoceR detnemelpmI ylhtnom eht ,ytilaitnedfinoc ot euD dna tnemucod lliw tsylana noitca esrevda ehT JJD eht kcarT 4.1 ytuped eht ot detubirtsid ylno si troper a no snoitca esrevda ro evitcerroc eht kcart dna seitilicaF ro evitcerroc .tssa eht dna ,tnednetnirepus ,rotcerid .teehsdaerps gnikcart sretrauqdaeH snoitca esrevda eb tonnac seipoc ,erofereht ;tnednetnirepus seitirohtua gnirih tnatsissa dna stnednetnirepus ehT .ecitcarp fo foorp sa decudorp rieht no esopmi troper ylhtnom a eviecer lliw stnednetnirepus .ffats noitca esrevda ro evitcerroc eht fo seipoC gniyfitnedi rotanidrooc noitca esrevda eht morf .teehsdaerps gnikcart ffatS .snoitca esrevda ro evitcerroc evah taht ffats .snoitca esrevda ro evitcerroc evah taht tnednetnirepus tnatsissa dna tnednetnirepus ehT ytuped eht ot sgnidnfi rieht fo ypoc a drawrof lliw .troper ylhtnom s’tnednetnirepus eht ni rotcerid noisivid ehT – detnemelpmi yllaitraP yciloP dna ,20-21 .oN evitceriD OPAD ecrofnieR OPAD gnikcart sti fo seipoc htiw su dedivorp tnemucod ot ,ssecorP gnitropeR tnedicnI ,60-90 teehsdaerps eht hguohtlA .teehsdaerps eeyolpme lanoiger ehT .FOU ot gnitaler stnedicni eht ,snoitagitsevni fo tsil a dedulcni ,esabatad a otni sgol dna skcart recfifo snoitaler ffats yna edulcni ton did teehsdaerps no desopmi snoitca esrevda ro evitcerroc eht rof ssenlufesu sti stimil hcihw ,seman .ffats .noitadnemmocer ruo fo esoprup eht ehT – detnemelpmi yllaitraP esahp laitini dna latnempoleved eht gniruD IAD mudnaromem a deussi tnemtraped noitcelloc eht taht denimreted saw ti ,STRI fo gnitcurtsni ,9102 ,11 yraunaJ no ro evitcerroc dna ,gniniart ’sffats fo egarots dna weiver ot sreganam dna srosivrepus ni deniatniam eb ton lliw noitamrofni yranilpicsid selfi yrosivrepus dna sdrocer gniniart .STRI eht noitca evitcerroc eeyolpme gnidrager ni msinahcem a evah yltnerruc seitirohtua gniriH .enilpicsid dna ,MOD – noitca esrevda ro evitcerroc kcart ot ecalp deltitne ,03033 noitceS ,22 elcitrA ,3 retpahC .enilpicsiD eeyolpmE tnerruc ezilitu ot detcepxe era seitirohtua gniriH ro evitcerroc dna ,gniniart gnikcart rof sdohtem aiv sdrocer gniniart gnikcehc yb noitca esrevda ro lennosrep laicfifo dna ,tnemtraped TSI eht neeb evah ereht fi niatrecsa ot selfi yrosivrepus ralimis ro emas rof seussi yranilpicsid suoiverp yna .snoitcarfni .egap txen no deunitnoC 38 2018 Annual Report Office of the Inspector General, State of California )deunitnoc( .2 tibihxE denimreteD sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb ecitcarP fo foorP dna tinU noitadnemmoceR :dluohs tnemtraped eht ,serudecorp dna seicilop ecrof fo-esu eht htiw ecnailpmoc fo etar llarevo eht esaercni oT .2 ehT – noitatnemelpmi gnidneP rof sisylana TATSPMOC gnizilitu yltnerruC .elbacilppa fi esiver dna mulucirruc tnerruc weiveR notkcotS JJD sti sucoF 1.2 gniniart detnemelpmi sah tnemtraped na gninfier dna gnipoleveD .sdnert FOU retneC gniniarT mulucirruc gniniart .eludehcs gniniart a poleveD metsys gnikcart tnerruc eht no .sdnert dna atad ezylana ot loot lanoitidda tsom eht no ni si gniniart kcolb dna ,)TATSPMOC( eht ,denfier si )metsys gnikcart( loot eht ecnO .gniniart ediwnoisivid tnemelpmI dna nommoc dedivorp tnemtraped ehT .ssergorp noitaloiv fo sepyt suoires dna nommoc tsom sepyt suoires tsom eht yfitnedi hcihw stuodnah poleveD gnimocpu rof sadnega gniniart dna ffats niart lliw JJD dna ,defiitnedi eb lliw snoitaloiv fo eht morf snoitaloiv fo sepyt suoires dna nommoc rof metsys gnikcart wen A .gniniart .eussi eht sserdda ot stuodnah etaerc morf defiitnedi sucof rotcurtsni eht evah dna metsys gnikcart wen lliw ew dna ,ssergorp ni llits si JJD gnikcart wen eht .tuodnah eht no s’tnemtraped eht rotinom ot eunitnoc .metsys .ssergorp noitatnemelpmi detnemelpmi toN eht fo snoitaloiv ”suoires“ kcart ton seod STRI IAD tnedicni na rehtehw skcart STRI .ycilop FOU ro ,gnirud ,ot roirp FOU htiw ecnailpmoc ni si ton seod STRI ,noitidda nI .FOU eht gniwollof .yrujni ylidob suoires kcart detnemelpmI ylhtnom eht ,ytilaitnedfinoc ot euD tnemucod lliw tsylana noitca esrevda ehT JJD redisnoC 2.2 .eg.eagpa ptx etxne nno n. eodg edaupenu ittnxneitonnC onCo deunitnoC ytuped eht ot detubirtsid ylno si troper dna derrucco evah snoitaloiv taeper nehw dna seitilicaF regnorts .tssa eht dna ,tnednetnirepus ,rotcerid tnatsissa ,tnednetnirepus eht ot ypoc a edivorp sretrauqdaeH evissergorp eb tonnac seipoc ,erofereht ;tnednetnirepus .niatpac/)s(tnednetnirepus ffats rof enilpicsid .ecitcarp fo foorp sa decudorp yldetaeper ohw )s(tnednetnirepus tnatsissa ,tnednetnirepus ehT -fo-esu etaloiv noitca esrevda ro evitcerroc eht fo seipoC a dna ,teehsdaerps eht weiver lliw niatpac dna .seicilop ecrof .teehsdaerps gnikcart /dna enilpicsid evissergorp tnemelpmi ot noisiced esoht rof elbacilppa nehw snoitca esrevda ro eb lliw seicilop ecrof-fo-esu etaloiv taht ffats .denimreted ylhtnom a eviecer lliw rotcerid ytuped ehT .etadpu .egap txen no deunitnoC 2018 Annual Report 39 Office of the Inspector General, State of California )deunitnoc( .2 tibihxE denimreteD sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb ecitcarP fo foorP dna tinU noitadnemmoceR noisivid ehT – detnemelpmi toN level ytlanep yranilpicsid eht senimreted AH ehT OPAD redisnoC 2.2 gnikcart sti fo seipoc htiw su dedivorp fo srotcaf gnitavargga dna gnitagitim no desab regnorts teehsdaerps eht hguohtlA .teehsdaerps ,)J( 91.03033§ MOD ot tcejbus dna ,esneffo eht evissergorp eht ,snoitagitsevni fo tsil a dedulcni .ecroF fo esU ,xirtaM yranilpicsiD eeyolpmE ffats rof enilpicsid ffats yna edulcni ton did teehsdaerps yldetaeper ohw si noisivid eht ,eroferehT .seman -fo-esu etaloiv snoitaloiv taeper yfitnedi ot elbanu .seicilop ecrof ffats eht fo yfitnedi eht gniwonk tuohtiw ).tnoc( .steehsdaerps eht no dedulcni ehT – detnemelpmi yllaitraP ,eettimmoC weiveR evitucexE noitutitsnI gniruD IAD eunitnoc lliw ti taht detats tnemtraped ffats rotinom dna yfitnedi ot eunitnoc snedraw gnidrager ycilop tnerruc wollof ot ralimis ro emas rof ycilop FOU eht etaloiv ohw eht ,noitidda nI .enilpicsid eeyolpme wollof ot detcepxe era snedraW .snoitcarfni no mudnaromem a deussi tnemtraped ,3 retpahC ,MOD ni deniltuo sa ycilop gnitsixe tnerruc ecrofnier ot ,9102 ,11 yraunaJ eeyolpmE deltitne ,03033 noitceS ,22 elcitrA srosivrepus stcurtsni hcihw ,ycilop .enilpicsiD gniniart weiver ot sreganam dna gnirih ot dedivorp eb lliw mudnaromem A gnidrager selfi yrosivrepus dna sdrocer tnerruc fo esu eht gnitaretier seitirohtua dna noitca evitcerroc eeyolpme eeyolpme gnikcart fo sdohtem dehsilbatse .enilpicsid .snoitca esrevda dna evitcerroc dna ,gniniart detnemelpmI ylhtnom eht ,ytilaitnedfinoc ot euD erusne ot )s(reganam/)s(rosivrepus htiw pu-wolloF JJD dloH 3.2 ytuped eht ot detubirtsid ylno si troper era ffats esoht tsniaga nekat snoitca evitcerroc sretrauqdaeH srosivrepus .tssa eht dna ,tnednetnirepus ,rotcerid ’seeyolpme ni detnemucod dna tuo deirrac gnieb sreganam dna eb tonnac seipoc ,erofereht ;tnednetnirepus .selfi elbatnuocca .ecitcarp fo foorp sa decudorp ffats rieht nehw eht gniod ton era )s(reganam/)s(rosivrepus eht fI etaloiv yldetaeper A :ecalp ekat lliw snoitca gniwollof eht ,evoba noitca esrevda ro evitcerroc eht fo seipoC ecrof-fo-esu ;weiver rof dedivorp eb lliw ycilop eht fo ypoc .teehsdaerps gnikcart .seicilop esrevda ;noissucsid tnemevorpmi krow ;gniniart .noitca tnednetnirepus tnatsissa dna tnednetnirepus ehT ytuped eht ot sgnidnfi rieht fo ypoc a drawrof lliw .troper ylhtnom s’tnednetnirepus eht ni rotcerid .egap txen no deunitnoC 40 2018 Annual Report Office of the Inspector General, State of California )deunitnoc( .2 tibihxE denimreteD sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb ecitcarP fo foorP dna tinU noitadnemmoceR did noisivid ehT – detnemelpmi toN level ytlanep yranilpicsid eht senimreted AH ehT OPAD dloH 3.2 ni noitadnemmocer ruo sserdda ton srotcaf gnitavargga dna gnitagitim no desab srosivrepus noitadnemmocer ruO .esnopser sti tnemtrapeD ot tcejbus dna ,esneffo eht fo sreganam dna tnemtraped eht taht detalpmetnoc ,)J( 91.03033§ )MOD( launaM snoitarepO elbatnuocca sreganam dna srosivrepus dloh .ecroF fo esU ,xirtaM yranilpicsiD eeyolpmE ffats rieht nehw yldetaeper ffats rieht nehw elbatnuocca etaloiv yldetaeper .seicilop ecrof-fo-esu etaloiv ecrof-fo-esu ).tnoc( .seicilop did noisivid ehT – detnemelpmi toN rof elbatnuocca dleh eb ot eunitnoc lliw ffatS IAD ni noitadnemmocer ruo sserdda ton enil ni gnipeek ,snoitcarfni emas/ralimis detaeper noitadnemmocer ruO .esnopser sti ,03033 noitceS ,22 elcitrA ,3 retpahC ,MOD htiw tnemtraped eht taht detalpmetnoc .enilpicsiD eeyolpmE deltitne sreganam dna srosivrepus dloh yldetaeper ffats rieht nehw elbatnuocca .seicilop ecrof-fo-esu etaloiv .egap txen no deunitnoC .eg.eagpa ptx etxne nno n. eodg edaupenu ittnxneitonnC onCo deunitnoC 2018 Annual Report 41 Office of the Inspector General, State of California )deunitnoc( .2 tibihxE denimreteD sa sutatS noitatnemelpmI stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb ecitcarP fo foorP dna tinU noitadnemmoceR detnemelpmI dna ycilop tnerruc desiver eht fo seipoC erudecorp dna ycilop tnerruc esiver dna weiveR notkcotS JJD ffats erusne oT .3 .)elbacilppa fi( mulucirruc dna erudecorp .)elbacilppa fi( mulucirruc dna retneC gniniarT ot woh dnatsrednu JJD dna tuo yrrac ylreporp .eludehcs gniniart eht fo ypoC ni etapicitrap dna tcudnoc nac ohw hsilbatsE seitilicaF dedrocer-oediv tcerroc no sucof dna sweivretni dedrocer-oediv .sdrocer gniniart ffats ydotsuc fo seipoC gnirud sweivretni htuoy rof ecnailpmoc/serudecorp dna ssecorp fo esruoc eht .sweivretni dedrocer-oediv ,seitud boj rieht .eludehcs gniniart a poleveD tnemtraped eht etaulaveer dluohs ycilop yb ro gniniart ediwtnemtraped tnemelpmI ti gniniart eht .somem meht ot sreffo detnemelpmI gnitaretier 91/11/1 no deussi saw omem A esiver dna nalp nossel eht fo tnetnoc eht etaulavE IAD tcerroc eht no gnidrager sreganam fo seitilibisnopser eht gniniart eht etaulavE .etauqeda demeed ton fi ot erudecorp ot setaler ti sa sweivretni dedrocer-oediv yreviled fo edom esiver dna dohtem yreviled nehw wollof esu yrassecennu ro evissecxe fo snoitagella .etauqeda demeed ton fi )dohtem gniniart( eseht gnitcudnoc .ecrof fo .sweivretni .egap txen no deunitnoC 42 2018 Annual Report Office of the Inspector General, State of California )deunitnoc( .2 tibihxE denimreteD sa sutatS noitatnemelpmI fo foorP dna stnemmoC s'tnemtrapeD ehT latnemtrapeD fo noitpircseD nalP noitcA desoporP s’tnemtrapeD ehT GIO eht yb ecitcarP tinU noitadnemmoceR detnemelpmI eht ta deweiver erew serudecorp dna yciloP erudecorp dna ycilop tnerruc esiver dna weiveR notkcotS JJD erusne oT .4 JJD ,esira seussi wen sA .level sretrauqdaeh tcerroc no sucoF .)elbacilppa fi( mulucirruc dna retneC gniniarT erehda ffats taht srecfifo ecaep llA .mulucirruc eht esiver lliw FOU dellortnoc rof ecnailpmoc/serudecorp taht seicilop ot dellortnoc launna eviecer ot eunitnoc lliw tnemelpmI .eludehcs gniniart poleveD .stnedicni eht ot niatrep edulcni lliw hcihw ,gniniart ecrof-fo-esu dna somem ycilop eussi ro gniniart ediwnoisivid esu dellortnoc .serudecorp dna ycilop no setadpu rof yllaunna detcudnoc si gniniart rehserfer erusne eht ,ecrof fo .ffats ydotsuc lla tnemtraped etaulaveer dluohs detnemelpmi toN dna deweiver saw nalp nossel tnerruc ehT etaulaveeR .mulucirruc gniniart eht etaulaveeR IAD gniniart sti .etauqeda demeed etaulavE .ffats ot gniniart lanoitidda rof deen eht ,mulucirruc etapicitrap ot ffats fo puorg tceles a rof deen eht dellortnoc fo tnuoma tneuqerfni ehT lanoitidda edivorp neeb evah yeht retfa secrof fo sesu dellortnoc ni eht ot detubirtta eb nac stnedicni FOU ,ffats ot gniniart .gniniart lanoitidda eviecer dna detceles gnisu gniod era ffats boj gnidnatstuo rof tceles dna noitalacse-ed dna noitacinummoc ni noitapicitrap eb ton lliw gniniart puorg tceleS .seuqinhcet -esu dellortnoc eunitnoc lliw srecfifo ecaep llA .detnemelpmi stnedicni ecrof-fo ecrof-fo-esu dellortnoc launna eviecer ot ohw esoht ylno .gniniart detelpmoc evah .gniniart lanoitidda gnidnatsrednu ffats htiw segnellahc sA :etoN .eg.eagpa ptx etxne nno n. eodg edaupenu ittnxneitonnC onCo deunitnoC CR eht ,defiitnedi era ycilop FOU eht fo s’tnemtraped eht htiw krow lliw ffats noissiM eht etadpu ot ,)UDC( tinU ngiseD mulucirruC dna tnerruc era yeht erusne ot snalp nossel .sloot gniniart evitceffe 2018 Annual Report 43 We offered 54 recommendations in our medical inspection reports to both California Correctional Health Care Services and the department. Currently, while we do not formally follow up on responses or actions to these recommendations from either California Correctional Health Care Services or the department, we continue to observe and address the concerns expressed in prior recommendations from previous cycles. Office of the Inspector General, State of California 44 2018 Annual Report Exhibit 3. Medical Inspection Recommendations, 2018 Institution Description of Recommendations Provide cross-training to staff members across several responsibility areas and have periodic cross-training updates. Access Kern Valley to specialty services was problematic when the regular nurse was on medical leave. Periodic cross-training may have helped State Prison the covering staff to perform the work properly. Folsom State FSP should develop monitoring strategies to ensure first medical responders check and document patients’ vital signs when Prison responding to medical emergencies. CEN nurses included important information not usually seen on transfer records, such as phone numbers and addresses for California pending specialists’ appointments. The OIG recommends that CCHCS adopt this process statewide. State Prison, In the CTC, CEN nurses developed a useful report sheet that contained information relevant to all team members including Centinela nursing assistants. The information on the report sheet included the patient’s name, diagnoses, care plan information, diet, and TABE (Test of Adult Basic Education) score. The OIG recommends that CCHCS adopt this process statewide. Chuckawalla CVSP nursing managers should develop guidelines, implement training, and establish job performance monitoring strategies Valley State for licensed vocational nurse (LVN) care coordinators. Prison The HDSP chief physician and surgeon (CP&S) or chief medical executive (CME) should periodically check the electronic health record system (EHRS) message center to ensure providers promptly review all pertinent results and reports. HDSP should designate an on-site physician supervisor who can support mid-level providers, review their work, and provide High Desert appropriate supervision. State Prison At the time of the OIG’s on-site inspection, HDSP unnecessarily delayed transmitting telemedicine specialty recommendations. The institution should send telemedicine specialty recommendations to the provider immediately, as it already does for off-site specialty recommendations. By using similar rapid processes for transmitting both types of specialty recommendations, HDSP can reduce the risk of lapses in care. CCWF should implement strategies to evaluate, improve, and monitor the TTA nurses’ clinical performance during urgent/ emergent encounters to ensure that they make appropriate and timely nursing assessments and interventions. CCWF medical leadership, including the pharmacist in charge and staff, should implement a quality improvement process to ensure that staff properly closes encounters within the EHRS when patients transfer between CCWF units, and that staff administers medications ordered in the skilled nursing facility (SNF) timely. Central CCWF medical leadership should arrange additional EHRS training for providers and nurses. The training should explain California barriers and challenges to the medication management process and should demonstrate the correct procedures to Women’s overcome those barriers with the EHRS. Facility Nursing and physician managers need to improve the consultation process between clinic nurses and providers; CCWF managers must ensure timely notification and communication processes are in place to handle patient situations requiring urgent medical consultation. CCWF should provide certain specialty services, such as physical therapy. California regulations require skilled nursing facilities, including CCWF, to provide these services; if the service cannot be provided at the facility, then CCWF should arrange for transportation to and from the physical therapy service location. Based on the results of the Cycle 5 medical inspection at CTF, the OIG recommends CTF provide additional EHRS training Correctional so that staff gain proficiency in using the built-in EHRS functions and can easily identify all orders that were active before a Training Facility patient’s hospitalization. Additional training should help with some of the hospital return medication errors that CTF staff explained were due to their inability to identify previously active medication orders before a patient’s hospitalization. California City CCHCS should examine CAC’s excellent medication processes and consider replicating those processes statewide. Correctional Facility The CEO should rectify the emergency medical response review committee (EMRRC) review process because the committee failed to identify problems with MCSP’s emergency response as well as with the care provided by the TTA providers and nurses. The institution needs a properly functioning EMRRC to identify and correct its various lapses in emergency care. The CEO should develop effective methods for evaluating the quality of its providers and nurses because of the poor performance of the medical staff in our review. MCSP’s development of reliable and accurate methods to assess provider and nurse performance should form the basis for subsequent quality improvement in these areas. The CEO should identify and correct several of its specialty services processes because of the institution’s problems with Mule Creek providing specialty appointments for patients with urgent referrals, for newly arrived patients with pending referrals, or for State Prison patients who need specialty follow-up appointments. The CEO should isolate and fix those laboratory processes that resulted in the high, recurring rate of noncompletion of laboratory tests we identified in this cycle. The CEO should analyze and adjust many of its pharmacy and nursing processes to correct the problems we found with medication administration and medication continuity. The CEO should create an institution-wide anticoagulation management system to help track, monitor, and intervene for patients taking anticoagulation medication because the individual providers were unable to do so independently. Continued on next page. Office of the Inspector General, State of California 2018 Annual Report 45 Exhibit 3. (continued) Institution Description of Recommendations The CEO should rectify the EMRRC review process because the committee failed to identify problems with the care provided by the TTA providers and nurses. The institution needs a properly functioning EMRRC to identify and correct its various lapses in emergency care. The CEO should analyze and adjust many of the pharmacy and nursing processes because the institution demonstrated poor California compliance with most measures of medication administration, observed medication practices, and storage controls. Men’s Colony The CEO should identify and correct several specialty services processes because of the institution’s problems with scheduling urgent specialty referrals and providing follow-up specialty appointments. The CNE should analyze and correct the sick call processes because the CMC nurses did not see patients promptly as medically necessary. Furthermore, when the nurses referred patients with sick calls to providers, the provider appointments sometimes occurred late or not at all. ASP’s pharmacist in charge (PIC) and chief nurse executive (CNE) should implement quality improvement measures to adjust Avenal State their pharmacy and nursing administration processes and ensure medications are available when patients need them. In Prison this inspection, the institution did not reliably give needed medications to patients who transferred from other institutions, returned from the hospital, or needed intravenous antibiotics. The pharmacist in charge (PIC) and the chief nurse executive (CNE) should implement quality improvement processes to improve the medication administration of newly prescribed medications and to improve the medication continuity for chronic care patients and patients returning from an outside hospital or emergency department. We found significant problems in these medication delivery areas during this inspection. The CEO should expand the institution’s quality improvement efforts to include both nursing and medical provider care in the psychiatric inpatient program (PIP) and the outpatient housing unit (OHU). Because of the problems we found in these areas, CIW should target clinical care assessments, transitions of care during patient hand-offs among staff, and communication between providers and nurses as areas for improvement in these locations. The CEO should have the EMRRC conduct clinical reviews of all nonscheduled emergency transports, including those that California involved a patient’s departure from mental health areas, including the PIP and the mental health CTC. We found substandard Institution for medical care in those areas, resulting in patients needing emergency transfers to higher levels of care. Women The CNE should reevaluate and improve the institution’s current process of evaluating nurses’ knowledge and skills competency because we found problems with nursing assessment and intervention, and the lack of provider notification in the inpatient (CTC) and outpatient sick-call areas. The CNE should monitor and train the providers to be more thorough when making assessments and reviewing patient records, particularly in the specialized medical housing units. Furthermore, the CME should also arrange diabetes and opioid management training due to these problems we found. The CEO should install bedside or mobile computers in the TTA to enable CIW staff to record their care documentation into the electronic health record system (EHRS) because we found that the TTA staff did not have sufficient computer access during our clinician on-site inspection. The CEO and chief medical executive (CME) should improve provider staffing and decrease the institution’s reliance on a “rover” provider because the use of the rover provider resulted in poor provider continuity in all areas of the institution. The CEO should apply quality improvement methods to develop the institution’s ability to properly care for patients transferring into SCC. In this inspection, we found numerous problems with the transfer-in process, including nurses failing to ensure that their transfer patients received provider and nurse follow-ups, the inability to maintain medication continuity, and Sierra the inability to provide specialty appointments for those patients who had pending specialty referrals. Conservation The chief nurse executive and the pharmacist in charge should improve the institution’s ability to administer medications Center promptly for patients returning from an outside hospital and for those patients with prescriptions for new medications. The CEO should expand the institution’s diagnostic report tracking system to improve its ability to retrieve, review, and communicate pathology reports because we found the institution had difficulty properly processing these important reports. The CEO should ensure that the institution’s information technology department installs and verifies that all providers in all areas, including Yard C, are able to view images in the radiology system. Continued on next page. Office of the Inspector General, State of California 46 2018 Annual Report Exhibit 3. (continued) Institution Description of Recommendations The chief nurse executive (CNE) should implement training for the triage and treatment area (TTA) and first medical responder nurses regarding documentation, time line accuracy, and proper nursing assessment due to problems the institution’s nurses demonstrated in the emergency services case reviews. Specifically, the CNE should choose the nursing assessments of patients’ gastrointestinal conditions as a target for improved care. The CNE should implement a quality improvement program to evaluate and monitor the various transfer-in processes due to errors identified during our case reviews. The CNE should focus on improving the receiving nurses’ performance and ensuring prompt provider appointments. The CNE should audit and track newly arrived patients’ pending diagnostic tests Calipatria State and specialty referrals to ensure that CAL provides those needed services without incurring lapses in care. Prison The CNE should improve its methods for evaluating the quality of care provided by nurses who assess sick call patients and those who assess new patients transferring in from other facilities due to the various concerns we identified in these areas during our inspection. The CNE should revamp the way the institution appraises the performance of the OHU nurses. Nursing care was substandard in the majority of OHU cases we reviewed. CCHCS should examine CAL’s well-run morning huddle process and consider the feasibility of replicating it statewide. The institution’s chief executive officer (CEO) and CNE should coordinate with both custody staff and emergency response medical staff to provide education and training to ensure that first medical responders respond to patients with emergent symptoms, assess them, and transport them appropriately to receive medical care. We found multiple cases in which first medical responders failed to respond to emergencies and did not assess patients with life-threatening symptoms. In these cases, custody staff required patients to walk, unaccompanied and unmonitored by medical staff, to the clinic or TTA for further care. The CEO should rectify the review process of the Emergency Medical Response Review Committee (EMRRC) because the committee failed to identify problems with SAC’s emergency response as well as with the care provided by the TTA providers and nurses. The institution needs a properly functioning EMRRC to identify and correct its various lapses in emergency care. The CEO, CNE, and pharmacist in charge (PIC) should remedy the problems we identified with medication continuity, inconsistent medication administration, delays with dispensing medications, and failures to properly identify duplicate orders across most of the institution’s health care areas. These poorly functioning processes were especially worrisome for patients returning from a community hospital and for patients transferring to other departmental institutions. The CNE should audit the hospital return process because of the nurses’ inability to properly review hospital discharge instructions and ensure medication continuity for these patients. The chief medical executive (CME) should assign a provider to the TTA to handle emergent and urgent situations. With a dedicated TTA provider, clinic providers would have fewer conflicting responsibilities. Clinic providers could focus on their regularly scheduled clinic patients and would not have to reschedule appointments whenever there was a medical emergency. California State Prison, The CEO should improve the scheduling process for newly arrived patients and monitor these appointments to ensure Sacramento patients receive their required appointments timely. The CME should instruct the providers to specify the appropriate clinical time frame for the ordered specialty service within the electronic health record system (EHRS) and eliminate their use of handwritten requests to expedite specialty services. The CNE should also direct the specialty department for follow the time frame specified in the EHRS order when scheduling services. CCHCS should eliminate time frames for both routine and urgent priority requests from its specialty access policies. Instead, CCHCS should monitor specialty access by measuring the ability of each institution to provide specialty services within the time frames specified in each order in the EHRS. The CME should identify providers who are not carefully reviewing their patients’ specialty consultations, progress notes, medications, and appointments. The CME should provide additional EHRS training for those providers who claimed their errors were because of their inability to locate this information in the EHRS. The CME should ensure providers in the correctional treatment center (CTC) and outpatient housing unit (OHU) perform a thorough chart review before each patient encounter. Providers should also discuss the status of each of the patient’s current conditions in their progress notes whenever they pass the care of the patient to another provider. The CME should monitor provider performance in the CTC and OHU regularly by reviewing the care of these patients. The CNE should develop and implement new strategies to appraise and improve nursing competency and quality across all areas of nursing care because of the poor overall nursing performance we identified during this inspection. The CNE should clarify and communicate specific duties and expectations to the nurse care managers. The CNE should then provide training and monitor the care managers to ensure they perform appropriate chronic care management for their patients. Office of the Inspector General, State of California 2018 Annual Report 47 The following exhibit outlines the two recommendations we made in July 2018 as published in our ninth report on The California Department of Corrections and Rehabilitation’s Progress Implementing Its Future of California Corrections Blueprint. The department has fully implemented one recommendation and is in the process of implementing the other. Office of the Inspector General, State of California 48 2018 Annual Report Exhibit 4. Status of Blueprint Recommendations, 2018 Implementation Status as Description of Recommendation The Department’s Proposed Action Plan Determined by the OIG The Office of the Inspector General The Division of Rehabilitative Programs (DRP), in collaboration with the Implemented recommended that the department clarify Division of Adult Institutions (DAI) and Enterprise Information Systems how it is meeting an inmate’s rehabilitative (EIS) utilizing the Strategic Offender Management System (SOMS) has needs and improve upon its existing finalized counting rules and reporting for all rehabilitative SOMS items, performance measures. not limited to, but including the items listed below, which are tied to offender level detail: The department should take steps to implement a data collection plan that • CSRA scores, documents current and future in-prison • COMPAS scores, programming. The department should • Scheduling for assignments, utilize existing Strategic Offender • Attendance (x-time) hours in assignments, Management System (SOMS) data, if deemed reliable, to identify individual • Program start and end dates, and offender progress in rehabilitation • Assignment status to include completions and unassignment programming. Existing SOMS data includes, reasons. in part: a California Static Risk Assessment (CSRA) score; a Core Correctional Offender * Completion status and attendance for programs is limited to calendar Management Profiling for Alternative year 2015–forward with SOMS implementation. Sanctions (COMPAS) score; times and hours an inmate attended programming; program The DRP currently utilizes minimal participation as an operational start and graduation dates; and program measure to indicate whether there is significant turnover in the completion or reason for dropout. programs that may need further review. Similar to the latter portion of the recommendation, the DRP assesses completion as the measure The department’s new metric for assessing of appropriate success. Similarly, during year-end cohort reviews for program participation defines “minimal participants, three measures are proposed to indicate the full scope of participation” as the number of offenders programming: who have been enrolled in a program for a minimum of 30 calendar days. However, • Those unique offenders assigned at any point to a particular this metric does not identify if an inmate program, attended and participated during this • Of those unique offenders, those who were enrolled for a 30-day period nor does it measure if the 30-day period (minimal participation), and inmate actually completed the program or if it met the inmate’s needs. Thus, • Of those unique offenders, those who completed the identified an attendance participation rate should program (those who have been unassigned with a status of be added as a metric to account for a completed). minimum attendance benchmark during this period, such as 70 percent. Alternatively, In all, these measures provide a multilevel review of those inmates the department can identify the number participating in academic and treatment programming. Any percentage and percentage of inmates who actually measure assigned to programming (e.g., 50 percent – 70 percent) complete a program after they have met completed may give the impression that 50 percent of a targeted the 30-day enrollment benchmark. benchmark will show appropriate outcomes, which DRP believes should not be recognized without definitive outcome-based research on partial programming impacts. Continued on next page. Office of the Inspector General, State of California 2018 Annual Report 49 Exhibit 4. (continued) Implementation Status as Description of Recommendation The Department’s Proposed Action Plan Determined by the OIG The Office of the Inspector General The DRP’s Office of Correctional Education submits monthly reports Implemented / recommended that the department take from submissions within the field that identify those positions which ongoing the following actions to increase the have been vacant for a number of months noting the following percentage of operational courses: categories, by specific position: vacant for less than 30 days; vacant one to six months; and vacant six months or longer. Require each supervisor of Correctional Education Programs to provide regular Beginning in January 2019, DRP has taken a multifaceted approach to updates to the director of the Division identifying and planning/prioritizing filling of those identified vacancies: of Rehabilitation Programs regarding the • Monthly vacancy information is being collected and analyzed. difficulties programs face in recruiting and retaining sufficient teachers, especially for • Bimonthly, the DRP headquarters personnel staff are included positions remaining vacant for more than on a statewide principal call to discuss difficulties in hiring and 90 days. notate those hires that appear to be stagnating or where they could have the largest impact in targeted assistance (i.e., those For teacher positions considered “hard to institutions with the highest number of and/or longest-running fill” or those the department has actively vacancies). “attempted to fill,” develop a plan to assess and prioritize the impact a teacher • Coordinating with the local institutions and human resource could make for the inmates in providing recruitment to assist the local institution if necessary, including rehabilitative services to them. assisting with job advertisements, local interviewing/scheduling, or potentially participating in local employment forums. Office of the Inspector General, State of California 50 2018 Annual Report We made two additional recommendations in the September 2018 C-ROB report, as seen in the following exhibit. C-ROB is an independent board and, unlike the OIG, does not have the authority to request specific responses to recommendations; nonetheless, the department is reviewing both recommendations. Office of the Inspector General, State of California 2018 Annual Report 51 Exhibit 5. Status of C-ROB Recommendations, 2018 Implementation Status as Description of Recommendation The Department’s Proposed Action Plan Determined by the OIG The Board recommends the department’s The department has completed a number of initiatives aimed at: Not implemented Division of Rehabilitative Programs • Ensuring the highest-risk and highest-need offenders are continue to work with the Division of Adult appropriately placed into programs (prioritizing placement), Institutions to strengthen and maximize inmate rehabilitative programming and • Offenders are assigned to one or more waitlists tracked through credit-earning potential. This would involve SOMS, and prioritizing enrollment of its highest-risk and highest-need inmates in evidence- • That offenders, once assigned, are monitored to ensure based rehabilitation programs. Secondarily, attendance issues are being mitigated, and offenders are given it would ensure that an inmate is able to the highest likelihood of completing assigned programming. take full advantage of available credits for rehabilitative and educational achievements Prioritizing Highest Risk/Need: The department is accomplishing to advance his or her release date or initial prioritization and placement through a change request that has been parole hearing date. The department developed over the prior 12+ months in SOMS that will automatically should determine if its Strategic Offender sort waitlist in SOMS, based upon policy prioritization (e.g., risk, need, Management System (SOMS) needs and time left to serve), and has created two web-based data analytics process improvements to improve tracking tools to assist both treatment and education in identifying eligible in key areas, such as assigning inmates offenders at the local details that should be placed onto waitlists and to available milestone and rehabilitative that should be prioritized for programming immediately. achievement credit programs (check for Offender Waitlists: Although waitlists have existed for treatment and inmate scheduling conflicts) and tracking of education, there are also waitlists now included and built into SOMS for inmate program waitlists that are currently inmate activity groups. These lists display category, by institution and prepared at the local institutional level. facility, group name, and available filled/available capacity. Ongoing Monitoring: The Department of Rehabilitative Programs has created detailed monthly operational dashboards that now extract and display attendance breakdowns in both hours and overall percentages of time in class and has created detailed monthly dashboards related to completions and unassignment reasons to assist local institutions in reviewing monthly information and creating solutions to mitigate issues that are impacting both participation or completion rates. The Board recommends the department, Although there has not been involvement from C-ROB members to Not implemented with the assistance of C-ROB members, date, the department has committed to the U.S. Department of Labor determine ways to allow for an exchange and California Workforce Investment Board to a data sharing and of information between federal, state, research opportunity (CAAL-Skills), pending a statutory change to the and county programs to ensure released sharing of social security numbers provided by U.S. Department of offenders have access to (and may Justice data. be approved for) available benefits. This exchange may include data-sharing opportunities from the This exchange may include a pilot or following agencies and associations: memorandum of understanding involving partnerships between the Social Security • California Workforce Investment Board Administration (SSA)/Supplemental Security Income (SSI), the U.S. Department of • California State Board of Education Veterans Affairs (VA), county social services offices, county probation departments, and • California Community College Chancellor’s Office the Division of Adult Parole Operations. The • California State Department of Education goal is to identify strategies to better link those formerly incarcerated to the various • California Department of Industrial Relations services available to help them become stable and self-sufficient as they reintegrate • California Department of Rehabilitation into the community. • California Department of Social Services • California Employment Development Department • California Employment Training Panel • California Welfare Directors Association Office of the Inspector General, State of California 52 2018 Annual Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California 2018 Annual Report 53 Appendix: Reports Released in 2018 Annual and Semiannual Reports • Monitoring Internal Investigations and the Employee Disciplinary Process of the California Department of Corrections and Rehabilitation, July–December 2017 (March 29, 2018) • 2017 Annual Report (May 8, 2018) • Monitoring the Use of Force: The California Department of Corrections and Rehabilitation’s Process for Reviewing Staff Use of Force Is Thorough, but It Must Address Low Compliance Rates With Its Policies and Procedures, July–December 2017 (July 16, 2018) • Monitoring Internal Investigations and the Employee Disciplinary Process of the California Department of Corrections and Rehabilitation, January–June 2018 (November 8, 2018) Medical Inspection Reports: Cycle 5 Results • Kern Valley State Prison (January 3, 2018) • Folsom State Prison (January 11, 2018) • Pelican Bay State Prison (January 16, 2018) • California State Prison, Centinela (January 31, 2018) • Chuckawalla Valley State Prison (March 1, 2018) • High Desert State Prison (April 25, 2018) • Central California Women’s Facility (May 2, 2018) • Correctional Training Facility (June 13, 2018) • California City Correctional Facility (June 18, 2018) • Mule Creek State Prison (August 2, 2018) • California Men’s Colony (August 8, 2018) • Avenal State Prison (August 8, 2018) Office of the Inspector General, State of California 54 2018 Annual Report • California Institution for Women (August 28, 2018) • Sierra Conservation Center (August 31, 2018) • Calipatria State Prison (October 12, 2018) • California State Prison, Sacramento (November 14, 2018) Blueprint Monitoring Report • Ninth Report on The California Department of Corrections and Rehabilitation’s Progress Implementing Its Future of California Corrections Blueprint and Update to the Blueprint (July 23, 2018) California Rehabilitation Oversight Board (C-ROB) Report • C-ROB September 15, 2018, Annual Report (September 14, 2018) All reports are available on our website: www.oig.ca.gov/pages/reports.php. Office of the Inspector General, State of California 2018 Annual Report Summary of Reports and Status of Recommendations OFFICE of the INSPECTOR GENERAL Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General STATE of CALIFORNIA May 2019 OIG