OIG
Avenal State Prison Medical Inspection Results Cycle 2
AVENAL STATE PRISON
MEDICAL INSPECTION RESULTS
OFFICE OF THE
INSPECTOR GENERAL
STATE OF CALIFORNIA
February 2012
Contents
Executive Summary ......................................................................................… 1
Introduction …................................................................................................… 3
Background …....................................................................................… 3
About the Institution …......................................................................… 4
Objectives, Scope, and Methodology ….............................................. 4
Medical Inspection Results ….......................................................................… 7
Appendix – Comparative Medical Inspection Scores …...............................28
California Correctional Health Care Services' Response ........................... 29
Executive Summary
An April 2001 class action lawsuit filed by inmates represented by the Prison Law Office alleged that
the state provided constitutionally inadequate medical care at California state prisons in violation of
inmates’ constitutional rights. In October 2005, the U.S. Court for the Northern District of California
declared that California’s delivery system for prison medical care was “broken beyond repair” and still
not meeting constitutional standards. As a result, the federal court imposed a receivership to raise the
delivery of medical care to constitutional standards. To evaluate and monitor the progress of medical
care delivery to inmates, the receiver requested, and the Office of the Inspector General agreed, to
establish an objective, clinically appropriate, and metric-oriented medical inspection program to review
the delivery of medical care at each state prison.
In November 2011, we inspected Avenal State Prison (ASP) for the second time.
Overall Our medical inspection encompassed 19 components of medical delivery and
Score comprised 129 questions. The questions are weighted based on their importance
86.9% to the delivery of medical care to inmates. ASP received 86.9 percent of the total
weighted points possible. This is a 16.5 percentage point improvement over the
score of 70.4 percent from our first inspection report of this prison issued in
November 2009.
The following summary table lists the components we inspected in order of importance (highest to
lowest), with the institution’s score and the definitions of each inspection component. The detailed
medical inspection results, with the questions for each component, begin on page 7 of this report.
While we are committed to helping each institution achieve a higher level of medical care, it is not our
intent to determine the percentage score needed by an institution to meet constitutional standards—that
is a legal matter for the federal court to determine.
Executive Summary Table
Component Weighted Score Definition
Chronic Care 73.2% Examines how well the prison provided care and medication to inmates with specific
chronic care conditions, which are those that affect (or have the potential to affect) an
inmate's functioning and long-term prognosis for more than six months. Our inspection tests
anti-coagulation therapy and the following chronic care conditions: asthma, diabetes, HIV
(Human Immunodeficiency Virus), and hypertension.
Clinical Services 86.4% Evaluates the inmate's access to primary health care services and focuses on inmates who
recently received services from any of the prison's facility or administrative segregation unit
clinics. This component evaluates sick call processes (doctor or nurse line), medication
management, and nursing.
Health Screening 84.0% Focuses on the prison's process for screening new inmates upon arrival to the institution for
health care conditions that require treatment and monitoring, as well as ensuring inmates'
continuity of care.
Specialty Services 89.6% Focuses on the prison's process for approving, denying, and scheduling services that are
outside the specialties of the prison's medical staff. Common examples of these services
include physical therapy, oncology services, podiatry consultations, and neurology services.
Urgent Services 82.9% Addresses the care provided by the institution to inmates before and after they were sent to a
community hospital.
Emergency Services 79.8% Examines how well the prison responded to inmate medical emergencies.
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Office of the Inspector General State of California
Component Weighted Score Definition
Prenatal N/A Focuses on the prenatal and post-delivery medical care provided to pregnant inmates. This
Care/Childbirth/Post- component is not applicable at men's institutions.
delivery
Diagnostic Services 95.2% Addresses the timeliness of radiology (x-ray) and laboratory services and whether the prison
followed up on clinically significant results.
Access to Health Care 90.2% Addresses the prison's effectiveness in filing, storing, and retrieving medical records and
Information medical-related information.
Outpatient Housing Unit 95.6% Determines whether the prison followed department policies and procedures when placing
inmates in the outpatient housing unit. This component also evaluates whether the
placement provided the inmate with adequate care and whether the physician's plan
addressed the placement diagnosis.
Internal Reviews 73.0% Focuses on the activities of the prison's Quality Management Committee and Emergency
Medical Response Review Committee. This component also evaluates the timeliness of the
inmates' medical appeals and the prison's use of inmate death reviews.
Inmate Transfers 100.0% Focuses on inmates pending transfer to determine whether the sending institution
documented medication and medical conditions to assist the receiving institution in
providing continuity of care.
Clinic Operations 100.0% Addresses the general operational aspects of the prison's facility clinics. Generally, the
questions in this component relate to the overall cleanliness of the clinics, privacy afforded
to inmates during non-emergency visits, use of priority ducats (slip of paper the inmate
carries for scheduled medical appointments), and availability of health care request forms.
Preventive Services 94.3% Focuses on inmate cancer screening, tuberculosis evaluation, and influenza immunizations.
Pharmacy Services 93.1% Addresses whether the prison's pharmacy complies with various operational policies, such
as conducting periodic inventory counts, maintaining the currency of medications in its
crash carts and after-hours medication supplies, and having valid permits. In addition, this
component also addresses whether the pharmacy has an effective process for screening
medication orders for potential adverse reactions/interactions.
Other Services 100.0% Examines additional areas that are not captured in the other components. The areas
evaluated in this component include the prison's provision of therapeutic diets, its handling
of inmates who display poor hygiene, and the availability of the current version of the
department's Inmate Medical Services Policies and Procedures.
Inmate Hunger Strikes 100.0% Examines medical staff's monitoring of inmates participating in hunger strikes lasting longer
than three days.
Chemical Agent 100.0% Addresses the prison's process of handling inmates who may be predisposed to an adverse
Contraindications outcome during cell extractions involving Oleoresin Capsicum, which is commonly referred
to as "pepper spray." For example, this might occur if the inmate has asthma.
Staffing Levels and 100.0% Examines the prison's medical staffing levels and training provided.
Training
Nursing Policy 100.0% Determines whether the prison maintains written policies and procedures for the safe and
effective provision of quality nursing care. The questions in this component also determine
whether nursing staff review their duty statements and whether supervisors periodically
review the work of nurses to ensure they properly follow established nursing protocols.
Overall Score 86.9%
Medical Inspection Unit Page 2
Office of the Inspector General State of California
Introduction
Under the authority of California Penal Code section 6126, which assigns the Office of the Inspector
General (OIG) responsibility for oversight of the California Department of Corrections and
Rehabilitation (CDCR), and at the request of the federal receiver, the OIG developed a comprehensive
inspection program to evaluate the delivery of medical care at each of CDCR’s 33 adult prisons.
In November 2011, we inspected Avenal State Prison (ASP). Our medical inspection encompassed 19
components of medical delivery and comprised 129 questions. To help readers understand the medical
risk associated with certain components of medical delivery—which pose a greater risk to an inmate-
patient—we developed a weighting system and assigned points to each question. Consequently, we
assigned more total points to more critical components, such as chronic care, clinical services, and
health screening. We assigned fewer total points to less critical components, such as inmate hunger
strikes, staffing levels and training, and chemical agent contraindications. (For a detailed description of
the weighting system, see Objectives, Scope, and Methodology on the next page.)
Background
In April 2001, inmates represented by the Prison Law Office filed a class action lawsuit, known as
Plata v. Brown. The lawsuit alleged that the state provided constitutionally inadequate medical care at
California state prisons in violation of inmates’ constitutional rights. In June 2002, the parties entered
into a Stipulation for Injunctive Relief, and the state agreed to implement over several years
comprehensive new medical care policies and procedures at all institutions.
Nevertheless, the U.S. Court for the Northern District of California declared in October 2005 that
California’s delivery system for prison medical care was “broken beyond repair” and still not meeting
constitutional standards. Thus, the federal court imposed a receivership to raise the delivery of medical
care to constitutional standards. In essence, the court ordered the receiver to manage the state’s delivery
of medical care and restructure day-to-day operations to develop and sustain a system that provides
constitutionally adequate medical care to inmates. The court stated that it would remove the receiver
and return control to the state once the system is stable and provides for constitutionally adequate
medical care.
To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested that
the OIG establish an objective, clinically appropriate, and metric-oriented medical inspection program.
To that end, the Inspector General agreed to inspect each state prison on a cycle basis. In June 2010, we
completed the fieldwork for our first cycle of medical inspections of the state’s 33 prisons. This report
presents the results of the second medical inspection conducted at this institution. The appendix to this
report provides summary comparative data for the first and second cycle inspections conducted at this
institution. We are committed to helping each institution achieve a higher level of medical care, but it is
up to the federal court to determine the percentage score necessary for an institution to meet
constitutional standards.
Medical Inspection Unit Page 3
Office of the Inspector General State of California
About the Institution
The primary mission of ASP is to provide for the control, care and treatment of the inmates under its
custody. ASP is designated as a low-medium security institution to provide housing for general
population inmates. As of February 1, 2012, CDCR reported that ASP had custody over 5,486 male
inmates. ASP operates six medical clinics where staff handle non-urgent requests for medical services.
ASP also treats inmates needing urgent or emergency care in its triage and treatment area. According to
information provided by the institution, ASP's vacancy rate among medical managers, primary care
providers, nursing supervisors, and nursing staff is 3.15 percent.
Donald B. McElroy currently serves as the prison's chief executive officer of health care services, while
Robert Chapnick, M.D., serves as the prison's chief medical executive.
Objectives, Scope, and Methodology
In designing the medical inspection program, we reviewed CDCR’s policies and procedures, relevant
court orders, guidelines developed by the department’s Quality Medical Assurance Team, and guidance
developed by the American Correctional Association. We also reviewed professional literature on
correctional medical care, consulted with clinical experts, and met with stakeholders from the court, the
receiver’s office, the department, and the Prison Law Office to discuss the nature and scope of the
inspection program. Based on input from these stakeholders, we developed a medical inspection
program that evaluates medical care delivery. Within each of 20 components, we created “yes” or “no”
questions designed to gauge performance.
To make the inspection results meaningful to both a medical expert and a lay reader, we worked with
clinical experts to create a weighting system that factors the relative importance of each component
compared to other components. Further, the program considers the relative importance of each question
within a component to the other questions in that component. This weighting ensures that more critical
components—such as those that pose the greatest medical risk to the inmate-patient—are given more
weight compared to those considered less serious. For example, we assign a high number of possible
points to the chronic care component because we consider this the most serious of all the components.
We assign proportionately fewer points to all other components.
Each inspection question is weighted and scored. The score is derived from the percentage of “yes”
answers for each question from all items sampled. We then multiply the percentage of “yes” answers
within a given question by the question’s weight to arrive at a score. The following example shows how
this scoring system works.
Example Question: Institution X
Answers Weighting Points
Yes No Yes + No Yes % Possible Received Score % N/A Unk
Is the clinical history adequate? 40 10 50 80% 20 16 80.0% 0 0
Medical Inspection Unit Page 4
Office of the Inspector General State of California
If the institution receives 40 “yes” answers and 10 “no” answers, the percentage of “yes” answers to
this question equals 80 percent. We calculate the number of points the institution would receive by
multiplying the “yes” percent of 80 by the number of possible points for this question, which is 20, to
arrive at 16 points.
To arrive at the total score, we add the points received for each question and then for each program
component. Finally, we calculate the institution’s overall score by dividing the sum of the points
received by the sum of the points possible. We do not include in the institution’s overall score the
weight for questions that are not applicable or, in some cases, where a lack of documentation would
result in numerous “no” answers for one deviation from policy (unknown). For instance, an institution
may not be able to provide documentation that its Emergency Medical Response Review Committee
met for a particular month. Therefore, when we evaluate whether meeting minutes document monthly
meetings for a particular month, the institution would receive a “no” answer for that question.
However, when we evaluate whether the meeting minutes document the warden’s attendance at the
meeting, the answer would be “unknown” so that the institution’s score is not penalized twice for the
same reason, not documenting the meeting. Further, we do not include a score for any question for
which only one sample item is found to apply unless we know that the sample item represents the
entire population related to the question in the time period under review. In these cases, the one sample
item is identified as not applicable in our report and thereby not included in the inspection scores.
To evaluate the institution’s delivery of medical care, we obtained various electronic data files
maintained by the institution for inmate medical scheduling and tracking, pharmacy, and census data.
We used these electronic data files only to identify random samples of inmates receiving or requiring
specific medical services. We then reviewed the medical file for each inmate in our sample. We did not
rely on the medical care information contained in these electronic data files.
Our inspection program assumes that if a prison's medical staff does not document an event in an
inmate's unit health record, the event in question did not happen. If an inmate's record does not show
that the inmate received his medications on a specified date, for example, we assume that the inmate
did not receive the medications. While it is possible that the inmate received his medications and the
staff neglected to document the event, our program cannot assume that appropriate care was provided.
Our medical inspection at ASP encompassed 19 of the 20 components of medical delivery. One of the
components was not applicable during the period inspected. In total, we reviewed 198 inmate medical
files, which are referred to as unit health records. In addition, we reviewed staffing level reports,
medical appeals summaries, nursing policies and procedures, summaries of medical drills and
emergencies, minutes from Quality Management Committee and Emergency Medical Response
Review Committee hearings, contents of inmate transfer envelopes, and assorted manual logs or
tracking worksheets related to medical care delivery. Finally, we interviewed medical and custody staff
members about the delivery of medical care to inmates, and we observed day-to-day medical delivery
at the institution.
We do not test the care provided in the licensed hospitals or correctional treatment centers because they
are subject to inspections and oversight by other regulatory agencies.
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Office of the Inspector General State of California
Consistent with our agreement with the receiver, our report only addresses the conditions found related
to the medical care criteria. We do not discuss the causes of noncompliance, nor do we make specific
recommendations in this report. Further, we do not review for efficiency and economy of operations.
However, if we learn of an inmate-patient who needs immediate care, we notify the chief executive
officer of health care services and request a status report. Moreover, if we learn of significant
departures from community standards, we may report such departures to the institution’s chief
executive officer or the receiver’s office. Because these matters involve confidential medical
information protected by state and federal privacy laws, specific details related to these cases are not
included in our report.
Following completion of the first cycle of 33 prison medical inspections in June 2010, we evaluated the
medical inspection program for improvement opportunities with input from the stakeholders involved
with the Plata v. Brown litigation. As a result, we made a limited number of revisions. These revisions
include eliminating a medical emergency drill, adding five questions and eliminating seven others, and
adjusting the weighting of certain questions. To assist the reader in comparing the results of the two
inspections at this institution, taking into account the program revisions, this report includes an
appendix.
For ease of reference, following is a table of abbreviations used in the remainder of this report.
Abbreviations used in this report
CEO Chief Executive Officer
CME Chief Medical Executive
FTF Face-to-Face
INH Isoniazid (antituberculous medication)
LVN Licensed Vocational Nurse
MD Medical Doctor
OB Obstetrician
OHU Outpatient Housing Unit
OIG Office of the Inspector General
PCP Primary Care Provider
RN Registered Nurse
TB Tuberculosis
TTA Triage and Treatment Area
UHR Unit Health Record
Medical Inspection Unit Page 6
Office of the Inspector General State of California
OFFICE OF THE INSPECTOR GENERAL AVENAL STATE PRISON
Overall Score:
MEDICAL INSPECTION RESULTS
86.9%
11/07/2011 – 11/10/2011
Answers Weighting Points Questions Not Answered
Component Page Yes No Yes + No Yes % Points Possible Points Received Score % Not Applicable Unknown
Chronic Care 8 151 50 201 75.1% 133 97.3 73.2% 11 1
Clinical Services 9 308 37 345 89.3% 100 86.4 86.4% 42 0
Health Screening 11 83 12 95 87.4% 53 44.5 84.0% 85 0
Specialty Services 12 103 11 114 90.4% 71 63.6 89.6% 58 0
Urgent Services 13 112 11 123 91.1% 59 48.9 82.9% 26 1
Emergency Services 14 31 7 38 81.6% 58 46.3 79.8% 0 2
Diagnostic Services 15 49 4 53 92.5% 52 49.5 95.2% 11 1
Access to Health Care Information 16 7 1 8 87.5% 51 46.0 90.2% 0 0
Outpatient Housing Unit 17 65 3 68 95.6% 48 45.9 95.6% 4 0
Internal Reviews 18 31 3 34 91.2% 40 29.2 73.0% 0 0
Inmate Transfers 19 15 0 15 100.0% 22 22.0 100.0% 10 0
Clinic Operations 20 25 0 25 100.0% 33 33.0 100.0% 0 0
Preventive Services 21 38 2 40 95.0% 30 28.3 94.3% 0 0
Pharmacy Services 22 8 1 9 88.9% 29 27.0 93.1% 0 0
Other Services 23 6 0 6 100.0% 9 9.0 100.0% 1 0
Inmate Hunger Strikes 24 6 0 6 100.0% 19 19.0 100.0% 0 0
Chemical Agent Contraindications 25 2 0 2 100.0% 8 8.0 100.0% 2 0
Staffing Levels and Training 26 8 0 8 100.0% 16 16.0 100.0% 1 0
Nursing Policy 27 15 0 15 100.0% 14 14.0 100.0% 0 0
Totals 1063 142 1205 88.2% 845 733.9 86.9% 251 5
Medical Inspection Unit Page 7
Office of the Inspector General State of California
Answers Weighting Points
Reference
Chronic Care
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
03.076 Was the inmate's most recent chronic care visit within the time frame 14 10 24 58.3% 20 11.7 58.3% 0 1
required by policy?
03.082 Did the institution document that it provided the inmate with health care 20 5 25 80.0% 6 4.8 80.0% 0 0
education?
03.175 Did the inmate receive his or her prescribed chronic care medications during 15 10 25 60.0% 16 9.6 60.0% 0 0
the most recent three-month period or did the institution follow
departmental policy if the inmate refused to pick up or show up for his or
her medications?
03.235 Is the clinical history adequate? 15 10 25 60.0% 18 10.8 60.0% 0 0
03.236 Is the focused clinical examination adequate? 16 6 22 72.7% 16 11.6 72.7% 3 0
03.237 Is the assessment adequate? 15 5 20 75.0% 18 13.5 75.0% 5 0
03.238 Is the plan adequate? 19 3 22 86.4% 21 18.1 86.4% 3 0
03.262 Is the inmate's Problem List complete and filed accurately in the inmate's 25 0 25 100.0% 8 8.0 100.0% 0 0
UHR?
03.293 Are immunizations current for the chronic care condition? 12 1 13 92.3% 10 9.2 92.3% 0 0
Component Subtotals: 151 50 201 75.1% 133 97.3 73.2% 11 1
Medical Inspection Unit Page 8
Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinical Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.024 RN FTF Documentation: Did the inmate's request for health care get 29 1 30 96.7% 6 5.8 96.7% 0 0
reviewed the same day it was received?
01.025 Did the RN complete an FTF visit within one business day after Form 7362 28 2 30 93.3% 10 9.3 93.3% 0 0
(Health Care Services Request) was reviewed?
01.027 If the RN determined a referral to a PCP was necessary, was the inmate seen 11 6 17 64.7% 10 6.5 64.7% 13 0
within the time lines specified by the RN during the FTF triage?
01.246 Did documentation indicate that the RN reviewed all of the inmate's 28 2 30 93.3% 4 3.7 93.3% 0 0
clinically significant complaints listed on Form 7362?
01.157 RN FTF Documentation: Did the RN's subjective note address the nature 29 1 30 96.7% 6 5.8 96.7% 0 0
and history of the inmate's clinically significant complaint(s)?
01.159 RN FTF Documentation: Did the RN's objective note include vital signs and 25 5 30 83.3% 5 4.2 83.3% 0 0
a focused physical examination, and did it adequately address the clinically
significant problems noted in the subjective note?
01.244 RN FTF Documentation: Did the RN's objective note include allergies, 29 1 30 96.7% 3 2.9 96.7% 0 0
weight, current medication, and where appropriate, medication compliance?
01.158 RN FTF Documentation: For the clinically significant complaints, did the 30 0 30 100.0% 5 5.0 100.0% 0 0
RN's assessment provide appropriate conclusions based on subjective and
objective data?
01.162 RN FTF Documentation: Did the RN's plan include an adequate strategy to 29 1 30 96.7% 6 5.8 96.7% 0 0
address the clinically significant problems identified during the FTF triage?
01.163 RN FTF Documentation: Did the RN's education/instruction adequately 30 0 30 100.0% 4 4.0 100.0% 0 0
address the clinically significant problems identified during the FTF triage?
01.247 Sick Call Follow-up: If the provider ordered a follow-up sick call 7 6 13 53.8% 5 2.7 53.8% 17 0
appointment, did it take place within the time frame specified?
Medical Inspection Unit Page 9
Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinical Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.124 Sick Call Medication: Did the institution administer or deliver prescription 17 10 27 63.0% 6 3.8 63.0% 3 0
medications (new orders) to the inmate within specified time frames?
15.234 Are clinic response bags audited daily and do they contain essential items? 2 0 2 100.0% 5 5.0 100.0% 0 0
21.278 If pre-existing medical conditions contributed to the need for the TTA visit, 14 2 16 87.5% 25 21.9 87.5% 9 0
was there adequate prior management of those conditions?
Component Subtotals: 308 37 345 89.3% 100 86.4 86.4% 42 0
Medical Inspection Unit Page 10
Office of the Inspector General State of California
Answers Weighting Points
Reference
Health Screening
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
02.016 Did the institution complete the initial health screening on the same day the 20 0 20 100.0% 9 9.0 100.0% 0 0
inmate arrived at the institution?
02.017 If "Yes" was answered to any of the questions on the initial health screening 14 0 14 100.0% 8 8.0 100.0% 6 0
form(s), did the RN provide an assessment and disposition on the date of
arrival?
02.018 If, during the assessment, the RN referred the inmate to a clinician, was the 5 7 12 41.7% 9 3.8 41.7% 8 0
inmate seen within the time frame?
02.020 Did the LVN/RN adequately document the tuberculin test and timely 17 1 18 94.4% 6 5.7 94.4% 2 0
reading of the test results; or, if the inmate did not have a TB test because of
a previous positive TB test, was a review of signs and symptoms
completed?
02.015 Was a review of symptoms completed if the inmate's tuberculin test was 0 0 0 0.0% 0 0.0 0.0% 20 0
positive, and were the results reviewed by the infection control nurse or the
public health nurse?
02.128 If the inmate had an existing medication order upon arrival at the institution, 5 2 7 71.4% 8 5.7 71.4% 13 0
did the inmate receive the medications by the next calendar day, or did a
physician document why the medications were not to be continued?
02.007 Non-reception center: Does the health care transfer information form 18 2 20 90.0% 7 6.3 90.0% 0 0
indicate that it was reviewed and signed by licensed health care staff within
one calendar day of the inmate's arrival at the institution?
02.014 Non-reception center: If the inmate was scheduled for a specialty 0 0 0 0.0% 0 0.0 0.0% 20 0
appointment at the sending institution, did the receiving institution schedule
the appointment within 30 days of the original appointment date?
02.111 Non-reception center: Did the inmate receive medical accommodations 4 0 4 100.0% 6 6.0 100.0% 16 0
upon arrival, if applicable?
Component Subtotals: 83 12 95 87.4% 53 44.5 84.0% 85 0
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Specialty Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
07.037 Did the institution approve or deny the PCP's request for specialty services 26 0 26 100.0% 8 8.0 100.0% 0 0
within the specified time frames?
07.035 Did the inmate receive the specialty service within specified time frames? 15 1 16 93.8% 9 8.4 93.8% 10 0
07.090 Physical therapy services: Did the physical therapist assess the inmate and 2 0 2 100.0% 2 2.0 100.0% 24 0
document the treatment plan and treatment provided to the inmate?
07.043 Did the PCP review the specialist's report and see the inmate for a follow-up 9 4 13 69.2% 10 6.9 69.2% 13 0
appointment within specified time lines following completion of the
specialty service?
07.260 Was the institution's denial of the PCP's request for specialty services 8 1 9 88.9% 15 13.3 88.9% 1 0
consistent with the "medical necessity" requirement?
07.273 Was information provided on the request for services sufficient for the 8 2 10 80.0% 4 3.2 80.0% 0 0
Medical Authorization Review Committee to make a medical necessity
determination?
07.259 Was there adequate documentation of the reason for the denial of specialty 10 0 10 100.0% 4 4.0 100.0% 0 0
services?
07.270 Did the specialty provider provide timely findings and recommendations or 16 0 16 100.0% 6 6.0 100.0% 10 0
did an RN document that he or she called the specialty provider to ascertain
the findings and recommendations?
07.261 Is the institution scheduling high-priority (urgent) specialty services within 2 0 2 100.0% 9 9.0 100.0% 0 0
14 days?
07.288 At the first PCP visit following the denial, did the PCP inform the patient of 7 3 10 70.0% 4 2.8 70.0% 0 0
the denial and appropriately manage the condition that gave rise to the
specialty service request?
Component Subtotals: 103 11 114 90.4% 71 63.6 89.6% 58 0
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Urgent Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
21.248 Upon the inmate's discharge from the community hospital, did the TTA RN 25 0 25 100.0% 6 6.0 100.0% 0 0
document that he or she reviewed the inmate's discharge plan and completed
an FTF assessment of the inmate?
21.249 Upon the inmate's discharge from the community hospital, did the inmate 24 1 25 96.0% 8 7.7 96.0% 0 0
receive a follow-up appointment with his or her PCP within five calendar
days of discharge?
21.281 Upon the inmate's discharge from a community hospital, did the institution 14 0 14 100.0% 7 7.0 100.0% 11 0
administer or deliver all prescribed medications to the inmate within
specified time frames?
21.275 Was the TTA nursing clinical care and documentation adequate? 16 7 23 69.6% 15 10.4 69.6% 1 1
21.276 While the patient was in the TTA, did the provider render adequate and 8 3 11 72.7% 19 13.8 72.7% 14 0
timely clinical care, and adequately document that care?
21.250 Upon the inmate's return from the community hospital, was the inmate 25 0 25 100.0% 4 4.0 100.0% 0 0
placed in housing appropriate for his or her clinical status?
Component Subtotals: 112 11 123 91.1% 59 48.9 82.9% 26 1
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Emergency Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
08.183 Was the medical emergency responder notified of the medical emergency 5 0 5 100.0% 7 7.0 100.0% 0 0
without delay?
08.241 Did the first responder provide adequate basic life support prior to medical 4 1 5 80.0% 8 6.4 80.0% 0 0
staff arriving?
08.184 Did the medical emergency responder arrive at the location of the medical 3 1 4 75.0% 6 4.5 75.0% 0 1
emergency within eight minutes of initial notification?
08.185 Did the medical emergency responder use proper equipment to address the 4 1 5 80.0% 9 7.2 80.0% 0 0
emergency and was adequate medical care provided within the scope of his
or her license?
08.242 Did staff call 911 without unnecessary delay after a life-threatening 3 2 5 60.0% 8 4.8 60.0% 0 0
condition was identified by a licensed health care provider or peace officer?
08.187 Did the institution provide adequate preparation for the ambulance's arrival, 5 0 5 100.0% 6 6.0 100.0% 0 0
access to the inmate, and departure?
08.186 Were both the first responder (if peace officer or licensed health care staff) 4 0 4 100.0% 5 5.0 100.0% 0 1
and the medical emergency responder basic life support certified at the time
of the incident?
08.222 Were the findings of the institution's Emergency Medical Response Review 3 2 5 60.0% 9 5.4 60.0% 0 0
Committee supported by the documentation and completed within 30 days?
Component Subtotals: 31 7 38 81.6% 58 46.3 79.8% 0 2
Medical Inspection Unit Page 14
Office of the Inspector General State of California
Answers Weighting Points
Reference
Diagnostic Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
06.049 Radiology order: Was the radiology service provided within the time frame 5 0 5 100.0% 7 7.0 100.0% 0 0
specified in the physician's order?
06.245 Radiology order: Was the diagnostic report received by the institution 5 0 5 100.0% 6 6.0 100.0% 0 0
within 14 days?
06.200 Radiology order: Did the PCP review the diagnostic report and initiate 5 0 5 100.0% 7 7.0 100.0% 0 0
written notice to the inmate within two business days of the date the
institution received the diagnostic reports?
06.188 All laboratory orders: Was the specimen collected within the applicable time 10 0 10 100.0% 6 6.0 100.0% 0 0
frames of the physician's order?
06.191 All diagnostic services: At the next clinic visit following report of a 7 4 11 63.6% 7 4.5 63.6% 3 1
clinically significant abnormal diagnostic test result, did the PCP document
the abnormal test result in the progress note?
06.263 All diagnostic services: At the next clinic visit following the report of a 7 0 7 100.0% 12 12.0 100.0% 8 0
clinically significant abnormal diagnostic test, did the PCP adequately
manage the result?
06.202 All laboratory orders: Did the PCP review the diagnostic reports and initiate 10 0 10 100.0% 7 7.0 100.0% 0 0
written notice to the inmate within two business days of the date the
institution received the diagnostic reports?
Component Subtotals: 49 4 53 92.5% 52 49.5 95.2% 11 1
Medical Inspection Unit Page 15
Office of the Inspector General State of California
Answers Weighting Points
Reference
Access to Health Care Information
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
19.150 Is the medical records office current with its loose filing? 1 0 1 100.0% 9 9.0 100.0% 0 0
19.169 Did medical records staff make UHRs available to clinic staff for the 2 0 2 100.0% 15 15.0 100.0% 0 0
inmates ducated for medical appointments the next day?
19.243 Was the institution able to account for the OIG's requested UHR files? 1 0 1 100.0% 12 12.0 100.0% 0 0
19.266 Does the institution properly file inmates' medical information? 0 1 1 0.0% 5 0.0 0.0% 0 0
19.271 While reviewing UHRs as part of the OIG's inspection, were the OIG's RN 1 0 1 100.0% 5 5.0 100.0% 0 0
and MD inspectors able to locate all relevant documentation of health care
provided to inmates?
19.272 Does the institution promptly file blood pressure logs in UHRs? 2 0 2 100.0% 5 5.0 100.0% 0 0
Component Subtotals: 7 1 8 87.5% 51 46.0 90.2% 0 0
Medical Inspection Unit Page 16
Office of the Inspector General State of California
Answers Weighting Points
Reference
Outpatient Housing Unit
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
04.052 Did the RN complete an initial assessment of the inmate on the day of 10 0 10 100.0% 5 5.0 100.0% 0 0
placement?
04.051 Did the PCP evaluate the inmate within one calendar day after placement? 10 0 10 100.0% 5 5.0 100.0% 0 0
04.053 While the inmate was placed in the OHU, did the PCP complete the 6 0 6 100.0% 4 4.0 100.0% 4 0
Subjective, Objective, Assessment, Plan and Education note at a minimum
of every 14 days?
04.112 Was the PCP's initial evaluation adequate for the problem(s) requiring OHU 7 3 10 70.0% 7 4.9 70.0% 0 0
placement?
04.230 Was the PCP's initial assessment (or diagnoses) appropriate for the findings 10 0 10 100.0% 7 7.0 100.0% 0 0
in the initial evaluation?
04.056 Did the PCP's plan adequately address the patient's medical needs? 10 0 10 100.0% 7 7.0 100.0% 0 0
04.208 Was the level of care available in the OHU adequate for the patient's clinical 10 0 10 100.0% 7 7.0 100.0% 0 0
needs?
15.103 In the OHU, are patient call buttons operational or does medical staff make 1 0 1 100.0% 3 3.0 100.0% 0 0
rounds every 30 minutes?
15.225 Does the OHU use disinfectant daily in common patient areas? 1 0 1 100.0% 3 3.0 100.0% 0 0
Component Subtotals: 65 3 68 95.6% 48 45.9 95.6% 4 0
Medical Inspection Unit Page 17
Office of the Inspector General State of California
Answers Weighting Points
Reference
Internal Reviews
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
17.221 Did the institution complete a medical emergency response drill for each 0 1 1 0.0% 5 0.0 0.0% 0 0
watch and include participation of health care and custody staff during the
most recent full quarter?
17.174 Did the institution promptly process inmate medical appeals during the most 0 1 1 0.0% 5 0.0 0.0% 0 0
recent 12 months?
17.136 For each death sampled, did the institution complete the death review 5 0 5 100.0% 5 5.0 100.0% 0 0
process?
17.132 Do the Emergency Medical Response Review Committee meeting minutes 6 0 6 100.0% 5 5.0 100.0% 0 0
document monthly meetings for the last six months?
17.138 Do the Emergency Medical Response Review Committee meeting minutes 5 1 6 83.3% 5 4.2 83.3% 0 0
document the warden's (or his or her designee's) attendance?
17.118 Do the Quality Management Committee meeting minutes document 6 0 6 100.0% 5 5.0 100.0% 0 0
monthly meetings for the last six months?
17.119 Did the Quality Management Committee report its findings to the 6 0 6 100.0% 5 5.0 100.0% 0 0
CEO/CME each of the last six meetings?
17.135 Did the last three Quality Management Committee meeting minutes reflect 3 0 3 100.0% 5 5.0 100.0% 0 0
findings and strategies for improvement?
Component Subtotals: 31 3 34 91.2% 40 29.2 73.0% 0 0
Medical Inspection Unit Page 18
Office of the Inspector General State of California
Answers Weighting Points
Reference
Inmate Transfers
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
05.108 Did Receiving and Release have the inmate's UHR and transfer envelope? 5 0 5 100.0% 7 7.0 100.0% 0 0
05.109 If the inmate was scheduled for any upcoming specialty services, were the 0 0 0 0.0% 0 0.0 0.0% 5 0
services noted on Form 7371 (Health Care Transfer Information)?
05.110 Do all appropriate forms in the transfer envelope identify all medications 0 0 0 0.0% 0 0.0 0.0% 5 0
ordered by the physician, and are the medications in the transfer envelope?
05.171 Did an RN accurately complete all applicable sections of Form 7371 based 5 0 5 100.0% 7 7.0 100.0% 0 0
on the inmate's UHR?
05.172 Did the medical records office maintain a copy of the inmate's Form 7371 5 0 5 100.0% 8 8.0 100.0% 0 0
and Form 7231A (Outpatient Medication Administration Record) when the
inmate transferred?
Component Subtotals: 15 0 15 100.0% 22 22.0 100.0% 10 0
Medical Inspection Unit Page 19
Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinic Operations
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
14.023 Does the institution make the Form 7362 (Health Care Services Request) 5 0 5 100.0% 4 4.0 100.0% 0 0
available to inmates?
14.164 Are areas available to ensure audio and visual privacy during RN FTF 3 0 3 100.0% 3 3.0 100.0% 0 0
assessments and doctors' examinations for non-emergencies?
14.166 Were refrigerated drugs stored without food in the refrigerator, or were the 2 0 2 100.0% 2 2.0 100.0% 0 0
drugs stored in a sealed container if food was present?
14.131 Do medication nurses understand that the licensed staff member who 2 0 2 100.0% 4 4.0 100.0% 0 0
prepares the medication must also administer it on the same day it is
prepared?
14.106 Does clinical staff wash their hands (either with soap or hand sanitizer) or 4 0 4 100.0% 6 6.0 100.0% 0 0
change gloves between patients?
14.033 Does the institution have an adequate process to ensure inmates who are 2 0 2 100.0% 4 4.0 100.0% 0 0
moved to a new cell still receive their medical ducats?
14.160 Does the institution have a process to identify, review, and address urgent 2 0 2 100.0% 4 4.0 100.0% 0 0
appointments if a doctor's line is canceled?
14.029 Does medical staff in the facility clinic know which inmates are on modified 2 0 2 100.0% 4 4.0 100.0% 0 0
program or confined to quarters and does staff have an adequate process to
ensure those inmates receive their medication?
14.165 Are the clinic floors, waiting room chairs, and equipment cleaned with a 3 0 3 100.0% 2 2.0 100.0% 0 0
disinfectant daily?
Component Subtotals: 25 0 25 100.0% 33 33.0 100.0% 0 0
Medical Inspection Unit Page 20
Office of the Inspector General State of California
Answers Weighting Points
Reference
Preventive Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
10.228 Inmates prescribed INH: Did the institution properly administer the 4 1 5 80.0% 6 4.8 80.0% 0 0
medication to the inmate?
10.232 Inmates prescribed INH: Did the institution monitor the inmate monthly for 5 0 5 100.0% 6 6.0 100.0% 0 0
the most recent three months he or she was on the medication?
10.229 Annual TB Screening: Was the inmate appropriately screened for TB within 10 0 10 100.0% 7 7.0 100.0% 0 0
the last year?
10.086 All inmates age 65 and older: Did the inmate receive an influenza 10 0 10 100.0% 6 6.0 100.0% 0 0
vaccination for the most recent influenza season?
10.085 All inmates from the age of 51 through the age of 75: Did the inmate 9 1 10 90.0% 5 4.5 90.0% 0 0
appropriately receive colorectal cancer screening?
Component Subtotals: 38 2 40 95.0% 30 28.3 94.3% 0 0
Medical Inspection Unit Page 21
Office of the Inspector General State of California
Answers Weighting Points
Reference
Pharmacy Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
13.139 Does the institution conspicuously post a valid permit in its pharmacy(ies)? 1 0 1 100.0% 2 2.0 100.0% 0 0
13.141 Does the institution properly maintain its emergency crash cart 0 1 1 0.0% 2 0.0 0.0% 0 0
medications?
13.252 Does the institution properly maintain medications in its after-hours 1 0 1 100.0% 2 2.0 100.0% 0 0
medication supply(ies)?
13.253 Does the institution conduct monthly inspections of its emergency crash cart 2 0 2 100.0% 1 1.0 100.0% 0 0
and after-hours medication supply(ies)?
13.142 Is the pharmacist-in-charge's license current? 1 0 1 100.0% 5 5.0 100.0% 0 0
13.144 Does the institution have information to ensure that medications are 1 0 1 100.0% 6 6.0 100.0% 0 0
prescribed by licensed health-care providers lawfully authorized to do so?
13.145 Does the pharmacist-in-charge have an effective process for screening new 1 0 1 100.0% 7 7.0 100.0% 0 0
medication orders for potential adverse reactions?
13.148 Does the pharmacist-in-charge monitor the quantity of medications on 1 0 1 100.0% 4 4.0 100.0% 0 0
hand?
Component Subtotals: 8 1 9 88.9% 29 27.0 93.1% 0 0
Medical Inspection Unit Page 22
Office of the Inspector General State of California
Answers Weighting Points
Reference
Other Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
15.058 If the institution does not offer therapeutic diets, does staff know the 1 0 1 100.0% 2 2.0 100.0% 0 0
department's procedures for transferring inmates who are determined to
require a therapeutic diet?
15.134 Did the institution properly respond to all active cases of TB discovered in 0 0 0 0.0% 0 0.0 0.0% 1 0
the last six months?
15.265 Is the most current version of the Inmate Medical Services Policies and 1 0 1 100.0% 3 3.0 100.0% 0 0
Procedures available in the institution's law library?
20.092 Hygiene Intervention: Did custody staff understand the department's 4 0 4 100.0% 4 4.0 100.0% 0 0
policies and procedures for identifying and evaluating inmates displaying
inappropriate hygiene management?
Component Subtotals: 6 0 6 100.0% 9 9.0 100.0% 1 0
Medical Inspection Unit Page 23
Office of the Inspector General State of California
Answers Weighting Points
Reference
Inmate Hunger Strikes
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
11.097 Did the RN conduct an FTF triage of the inmate within two business days of 2 0 2 100.0% 6 6.0 100.0% 0 0
receipt of the Form 128-B and document the inmate's reasons for the hunger
strike, most recent recorded weight, current weight, vital signs, and physical
condition?
11.099 After the first 48 hours, did an RN or PCP complete daily assessments 2 0 2 100.0% 6 6.0 100.0% 0 0
documenting the inmate's weight, physical condition, emotional condition,
vital signs, and hydration status?
11.100 After the first 72 hours, did a physician perform a physical examination and 2 0 2 100.0% 7 7.0 100.0% 0 0
order a metabolic panel and a urinalysis of the inmate?
Component Subtotals: 6 0 6 100.0% 19 19.0 100.0% 0 0
Medical Inspection Unit Page 24
Office of the Inspector General State of California
Answers Weighting Points
Reference
Chemical Agent Contraindications
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
12.062 Did the institution document that it consulted with an RN or PCP before a 0 0 0 0.0% 0 0.0 0.0% 2 0
calculated use of Oleoresin Capsicum (pepper spray)?
12.064 Did the institution record how it decontaminated the inmate and did it 2 0 2 100.0% 8 8.0 100.0% 0 0
follow the decontamination policy?
Component Subtotals: 2 0 2 100.0% 8 8.0 100.0% 2 0
Medical Inspection Unit Page 25
Office of the Inspector General State of California
Answers Weighting Points
Reference
Staffing Levels and Training
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
18.002 Information purposes only: Calculate the institution's average vacancy 0 0 0 0.0% 0 0.0 0.0% 1 0
percentages, the number of health care staff starting within six months of
the OIG visit, and the number of health care staff hired from the registry.
The institution provided vacancy statistics within four medical
classifications: (1) management; (2) primary care providers; (3) nursing
supervisors; and (4) nursing staff.
Total number of filled positions: 138.57
Total number of vacancies: 4.5
Total number of positions: 143.07
Vacancy percentage: 3.15%
Number of staff hired within last six months: 13
Total number of registry staff: 13
18.004 Did the institution have an RN available on-site 24 hours a day, seven days 1 0 1 100.0% 4 4.0 100.0% 0 0
a week, for emergency care?
18.005 Did the institution have a physician on-site, a physician on-call, or a 1 0 1 100.0% 4 4.0 100.0% 0 0
medical officer of the day available 24 hours a day, seven days a week, for
the last 30 days?
18.006 Does the institution's orientation program for all newly hired nursing staff 1 0 1 100.0% 4 4.0 100.0% 0 0
include a module for sick call protocols that require an FTF triage?
18.001 Are licensed health care staff current with their certifications and did they 5 0 5 100.0% 4 4.0 100.0% 0 0
attend required training?
Component Subtotals: 8 0 8 100.0% 16 16.0 100.0% 1 0
Medical Inspection Unit Page 26
Office of the Inspector General State of California
Answers Weighting Points
Reference
Nursing Policy
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
16.231 Does the institution ensure that nursing staff review their duty statements? 5 0 5 100.0% 2 2.0 100.0% 0 0
16.154 Does the institution have written nursing local operating procedures that 5 0 5 100.0% 5 5.0 100.0% 0 0
adhere to the department's policies and procedures?
16.254 Does the institution's supervising registered nurse conduct periodic reviews 5 0 5 100.0% 7 7.0 100.0% 0 0
of nursing staff?
Component Subtotals: 15 0 15 100.0% 14 14.0 100.0% 0 0
Medical Inspection Unit Page 27
Office of the Inspector General State of California
APPENDIX
COMPARATIVE MEDICAL INSPECTION SCORES
AVENAL STATE PRISON
Following the completion of the first cycle of 33 prison medical inspections in June 2010, we evaluated
the medical inspection program for improvement opportunities with input from the stakeholders involved
with the Plata v. Brown litigation. As a result, we made a limited number of revisions including adding,
deleting, and adjusting the weights of certain questions. The following table shows the medical
inspection scores (rounded) earned by Avenal State Prison during the course of the Office of the
Inspector General’s medical inspection program. To assist the reader in comparing the results of the two
inspections at this institution, we recalculated the scores for each cycle to eliminate the questions that
were not applicable in both inspections for this institution. The recalculated scores give the best
information for evaluating performance by the institution regarding those questions that are applicable in
both inspection cycles. However, the final cycle scores provide the most complete indication of the
measure of health care provided at the institution.
Cycle One Cycle Two
Recalculated Recalculated
Cycle for for
One Cycle Two Comparison Comparison
Final1 Final2 Only3 Only4
Component (rounded) (rounded) (rounded) (rounded)
Chronic Care 59% 73% 62% 72%
Clinical Services 64% 86% 62% 86%
Health Screening 81% 84% 78% 84%
Specialty Services 74% 90% 77% 91%
Urgent Services 70% 83% 61% 83%
Emergency Services 78% 80% 75% 80%
Diagnostic Services 87% 95% 87% 95%
Access to Health Care Information 20% 90% 20% 90%
Outpatient Housing Unit 71% 96% 74% 96%
Internal Reviews 66% 73% 66% 73%
Inmate Transfers 100% 100% 100% 100%
Clinic Operations 94% 100% 94% 100%
Preventive Services 60% 94% 60% 94%
Pharmacy Services 92% 93% 92% 93%
Other Services 70% 100% 67% 100%
Inmate Hunger Strikes N/A 100% N/A N/A
Chemical Agent Contraindications 100% 100% 100% 100%
Staffing Levels and Training 100% 100% 100% 100%
Nursing Policy 67% 100% 71% 100%
Overall Score 70% 87% 70% 87%
1 Cycle One Final: These are the prison’s scores from our November 2009 medical inspection report. This report is part of our first cycle of
medical inspections we conducted at the state’s 33 adult prisons.
2 Cycle Two Final: These are the prison’s scores reported in the body of this report and include results from all questions applicable in cycle
two.
3 Cycle One Recalculated for Comparison Only: These are the cycle one scores recalculated to exclude questions that were not applicable
in both cycles. Also, in making this calculation, for each question we applied cycle two weights to cycle one results for more accurate
comparability.
4 Cycle Two Recalculated for Comparison Only: These are cycle two scores recalculated to exclude questions that were not applicable in
both cycles.
Medical Inspection Unit Page 28
Office of the Inspector General State of California
California Correctional
Health Care Services'
Response
Medical Inspection Unit Page 29
Office of the Inspector General State of California