California Institution for Men Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, California Institution for Men | iii Contents Illustrations iv Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 6 Institution-Specific Metrics 7 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 19 Emergency Services 23 Health Information Management 30 Health Care Environment 36 Transfers 42 Medication Management 49 Preventive Services 58 Nursing Performance 61 Provider Performance 67 Specialized Medical Housing 72 Specialty Services 78 Administrative Operations 84 Appendix A: Methodology 88 Case Reviews 89 Compliance Testing 92 Indicator Ratings and the Overall Medical Quality Rating 93 Appendix B: Case Review Data 94 Appendix C: Compliance Sampling Methodology 98 California Correctional Health Care Services’ Response 106 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | iv Illustrations Tables 1. CIM Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. CIM Master Registry Data as of October 2024 7 3. CIM Health Care Staffing Resources as of October 2024 8 4. CIM Results Compared With State HEDIS Scores 10 5. Access to Care 16 6. Other Tests Related to Access to Care 17 7. Diagnostic Services 21 8. Health Information Management 33 9. Other Tests Related to Health Information Management 34 10. Health Care Environment 40 11. Transfers 46 12. Other Tests Related to Transfers 47 13. Medication Management 55 14. Other Tests Related to Medication Management 56 15. Preventive Services 59 16. Specialized Medical Housing 76 17. Specialty Services 81 18. Other Tests Related to Specialty Services 82 19. Administrative Operations 85 A–1. Case Review Definitions 89 B–1. CIM Case Review Sample Sets 94 B–2. CIM Case Review Chronic Care Diagnoses 95 B–3. CIM Case Review Events by Program 96 B–4. CIM Case Review Sample Summary 96 Figures A–1. Inspection Indicator Review Distribution for CIM 88 A–2. Case Review Testing 91 A–3. Compliance Sampling Methodology 92 Photographs 1. Indoor Waiting Area 36 2. Individual Waiting Modules 37 3. Expired Medical supplies Found Stored Beyond Manufacturers’ Guidelines 38 4. Staff’s Personal Food Stored With Medical Supplies 38 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers the MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7, rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 2 As we did during Cycle 6, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 7 inspection of California Institution for Men, the institution had been delegated back to the department by the receiver. We completed our seventh inspection of the institution, and this report presents our assessment of the health care provided at this institution during the inspection period from March 2024 to August 2024.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between December 2023 and August 2024, anticoagulation reviews between March 2024 and August 2024, and transfer reviews between April 2024 and August 2024. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of CIM in March 2025. OIG inspectors monitored the institution’s delivery of medical care that occurred between March 2024 and August 2024. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at CIM adequate. quality at CIM adequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 50 cases, which contained 1,104 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes, which may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in March 2025 to verify their initial findings. OIG physicians rated the quality of care for 25 comprehensive case reviews. Of these 25 cases, our physicians rated 23 adequate and two inadequate. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 387 patient records and 1,132 data points, and they used the data to answer 92 policy questions. In addition, we observed CIM’s processes during an on-site inspection in November 2024. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 13 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to CIM. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CIM Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG found no adverse events at CIM during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to CIM. Of these 10 indicators, OIG clinicians rated one proficient, eight adequate, and one inadequate. The OIG physicians also rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, 23 were adequate and two were inadequate. In the 1,104 events reviewed, we identified 262 deficiencies, 43 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CIM: • Staff performed very well in providing patient access to providers and clinic nurses. • Staff always completed laboratory and radiology testing within required time frames. • Providers managed patients’ chronic health conditions well. • Staff performed well in ensuring medication continuity for new medications, chronic care medications, transfer-in medications, transfer-out medications, and for patients returning from the hospital and undergoing treatment in the specialized medical housing unit. • Nurses performed well in documenting timelines of emergency events. Our clinicians found the following weaknesses at CIM: • Nurses often did not perform thorough assessments or provide appropriate interventions during emergency events. Furthermore, nursing and medical leadership did not frequently complete thorough clinical reviews of the urgent or emergent events to identify opportunities for improvement. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 6 • Nursing staff needed improvement in initiating care plans at the time of the patient’s admission to the OHU or during the OHU review period. • Providers did not regularly send patient test results notification letters and, when they sent the letters, they did not consistently include all required elements in the test results notification letters. Compliance Testing Results Our compliance inspectors assessed 10 of the 12 indicators applicable to CIM. Of these 10 indicators, our compliance inspectors rated three proficient, four adequate, and three inadequate. We solely tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. CIM showed a high rate of policy compliance in the following areas: • Staff scheduled timely provider follow-up appointments for chronic care patients, newly arrived patients, and patients who returned from a community hospitalization. • Nursing staff processed sick call request forms, performed face-to-face encounters, and completed nurse-to-provider referrals within required time frames. • Staff timely scanned nondictated progress notes, initial health care screening forms, community hospital discharge reports, and requests for health care services into patients’ electronic medical records. • Staff performed well in offering immunizations and providing preventive services for their patients, such as influenza vaccination, annual testing for tuberculosis (TB), and colorectal cancer screenings. CIM revealed a low rate of policy compliance in the following areas: • Staff did not consistently complete STAT laboratory services and intermittently retrieved pathology results within the specified time frames. • Health care staff did not consistently follow hand hygiene precautions before or after patient encounters. • Patients did not consistently receive their ordered chronic care medications, hospital discharge medications, or newly ordered medications within specified time frames. • Nursing staff needed improvement in regularly inspecting emergency medical response bags (EMRBs). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 7 Institution-Specific Metrics Opened in 1941, California Institution for Men (CIM) is located in San Bernardino County. The institution’s primary mission is to provide housing and programming for the general population and sensitive needs (Level II) patients. CIM is a large complex consisting of four separate facilities: Facilities A and C primarily house Level II sensitive-needs-yard (SNY) custody patients; Facility D houses general population patients and is designated as a Secure Level I; Facility B houses medium-and maximum-custody-level patients and also serves as a reception center, where it receives and processes patients who have been newly incarcerated, primarily from Riverside and San Diego Counties. The institution operates 10 medical clinics in which health care staff handle routine requests for medical services. CIM operates a triage and treatment area (TTA) for urgent and emergent patient care, a receiving and release (R&R) clinic for the assessment of arriving and departing patients, and an outpatient housing unit (OHU). In its OHU, staff treat patients who require assistance with activities of daily living but do not require a higher level of inpatient care. CCHCS has designated CIM as an intermediate care institution. These institutions are predominantly located in or near urban areas and are close to tertiary care centers and specialty care providers to enable the provision of the most cost-effective care. As of September 5, 2025, the department reported on its public tracker 80 percent of CIM’s incarcerated population was fully vaccinated for COVID-19 while 68 percent of CIM’s staff was fully vaccinated for COVID-19.7 On October 25, 2024, the Health Care Services Master Registry showed CIM had a total population of 2,284. A breakdown of the medical risk level of the CIM population as determined by the department is set forth in Table 2 below.8 Table 2. CIM Master Registry Data as of October 2024 Medical Risk Level Number of Patients Percentage* High 1 510 22.3% High 2 627 27.5% Medium 682 29.9% Low 465 20.4% Total 2,284 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 10-25-24. 7 For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, CIM had no vacant executive leadership positions, no primary care provider vacancies, 0.2 nursing supervisor vacancies, and 1.9 nursing staff vacancies. Table 3. CIM Health Care Staffing Resources as of October 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 12.5 15.2 177.7 210.4 Filled by Civil Service 7.0 14.0 15.0 175.8 211.8 Vacant 0 0 0.2 1.9 2.1 Percentage Filled by Civil Service 140% 112% 98.7% 98.9% 100.7% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0% 0% 0% 0% 0% Filled by Registry 0 0 0 0 0 Percentage Filled by Registry 0% 0% 0% 0% 0% Total Filled Positions 7.0 14.0 15.0 175.8 211.8 Total Percentage Filled 140% 112% 98.7% 98.9% 100.7% Appointments in Last 12 Months 0 0 3.0 32.0 35.0 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 1.0 0 0 0 1.0 Adjusted Total: Filled Positions 6.0 14.0 15.0 175.8 210.8 Adjusted Total: Percentage Filled 120% 112% 98.7% 98.9% 100.2% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes the classifications of Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 7 medical inspection preinspection questionnaire received on 10-25-24, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered CIM’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. Currently, only two HEDIS measures are available for review: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control, and colorectal cancer screening rates for patients ages 45 to 75. We list the applicable HEDIS measures in Table 4. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CIM’s percentage of patients with poor HbA1c control was significantly lower, indicating very good performance on this measure. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. CIM had a 60 percent influenza immunization rate for adults 18 to 64 years old and an 88 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 93 percent.10 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CIM’s colorectal cancer screening rate of 91 percent was significantly higher, indicating very good performance on this measure. 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 10 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV15, and PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than where the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 10 Table 4. CIM Results Compared With State HEDIS Scores CIM California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 100% – – – Poor HbA1c Control (> 9.0%) ‡,§ 3% 33% 26% 19% HbA1c Control (< 8.0%) ‡ 91% – – – Blood Pressure Control (< 140/90) ‡ 99% – – – Eye Examinations 74% – – – Influenza – Adults (18 – 64) 60% – – – Influenza – Adults (65 +) 88% – – – Pneumococcal – Adults (65 +) 93% – – – Colorectal Cancer Screening 91% 40% 71% 71% Notes and Sources * Unless otherwise stated, data were collected in November 2024 by reviewing medical records from a sample of CIM’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2023 – June 30, 2024 (published April 2025); https://www.dhcs.ca.gov/dataandstats/reports/Documents/CA2023-24-Medi-Cal-Managed-Care- Physical-Health-External-Quality-Review-Technical-Report-Vol1-F1.pdf. ‡ For this indicator, the entire applicable CIM population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 11 Recommendations As a result of our assessment of CIM’s performance, we offer the following recommendations to the department: Diagnostic Services • The department should develop strategies, such as an electronic solution, to ensure providers create patient notification letters when they endorse test results and ensure patient notification letters contain all elements required by CCHCS policy. The department should implement remedial measures as appropriate • Health care leadership should determine the root cause(s) of challenges to the completion and notification of STAT laboratory results and should implement remedial measures as appropriate. Emergency Services • Medical and nursing leadership should determine the root cause(s) of challenges in completing thorough clinical reviews of urgent and emergent events in which patients transfer to the community hospital as well as in identifying opportunities for improvement. Leadership should implement remedial measures as appropriate. • CCHCS should reevaluate the necessity of equipment (cardiac monitor, crash cart, Omnicell, IVs, and IV fluids) required in the clinic satellite TTA areas as well as any licensing steps necessary to provide such equipment, as the institution utilizes these areas to provide urgent and emergent care to the patients. Having the necessary equipment allows for nursing and medical staff to provide the standard of care for urgent and emergent events and may potentially prevent negative outcomes for the patients. • CIM nursing leadership should determine any additional root cause(s) of challenges that prevent nurses from performing thorough assessments and reassessments and providing appropriate interventions for patients with urgent and emergent conditions. Leadership should implement remedial measures as appropriate. Health Care Environment • Health care leadership should determine the root cause(s) for staff not ensuring clinical areas are appropriately disinfected, cleaned, and sanitized and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 12 • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried, stocked, or sealed and should implement remedial measures as appropriate. Medication Management • Health care leadership should determine the challenges related to medication continuity for chronic care medications, new medications, hospital discharge medications, medications for patients in specialized medical housing unit, and medications for patients temporarily housed at CIM. Leadership should implement remedial measures as appropriate. Nursing Performance • Nursing leadership should determine the challenges to nurses performing thorough face-to-face assessments and should implement remedial measures as appropriate. Provider Performance • Medical leadership should determine the root cause(s) of providers not thoroughly reviewing specialty service reports and should implement remedial measures as appropriate. Specialized Medical Housing • Nursing leadership should determine the challenges to nurses performing thorough assessments and initiating individualized care plans. Leadership should implement remedial measures as appropriate. Specialty Services • Health care leadership should determine the root cause(s) of challenges to staff timely providing specialty appointments, including preapproved specialty appointments for transfer-in patients, and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 13 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Proficient Proficient (93.0%) In this cycle, case review found CIM provided excellent access to care, improving compared with Cycle 6. Clinic providers and nursing staff timely evaluated patients who submitted sick call requests, required follow-up after specialty services and hospitalizations, and transferred into the institution. Specialty service appointments also occurred within ordered time frames. Providers and nurses also timely assessed patients in the outpatient housing unit (OHU). As a result, the OIG rated the case review component of this indicator proficient. Compliance testing showed CIM performed excellently in this indicator. Providers always evaluated patients returning from hospitalizations and almost always evaluated newly transferred patients and patients with chronic care conditions timely. Nurses nearly always reviewed patient sick call requests and always completed face-to-face triages timely. Conversely, staff needed improvement in delivering prompt provider follow-ups for patients returning from specialist appointments. Based on the overall Access to Care compliance score result, the OIG rated the compliance testing component of this indicator proficient. Case Review and Compliance Testing Results OIG clinicians reviewed 276 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events, and transfer-in encounters requiring the institution to generate appointments. We identified seven deficiencies related to Access to Care, none of which were significant.11 Access to Care Providers Access to clinic providers is an integral part of patient care in health care delivery. Compliance testing showed CIM performed very well in timely completing chronic care face- to-face follow-up appointments (MIT 1.001, 92.0%) and performed excellently with nurse- to-provider follow-up appointments (MIT 1.005, 100%) and sick call follow-up appointments (MIT 1.006, 100%). OIG clinicians reviewed 53 clinic encounters and did not find deficiencies related to the access provided. However, we identified a pattern of four minor deficiencies in which providers reviewed patient charts instead of scheduling face-to- 11 Deficiencies occurred in cases 20, 22, and 26. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 14 face appointments and labeled the appointments as “completed” instead of voiding or cancelling them.12 The following is an example: • In case 26, the provider was scheduled to see the patient for follow-up after the orthopedic specialty appointment. The provider did not see the patient but performed a chart review and documented the orthopedic surgeon’s recommendations. The provider documented the appointment as completed even though the provider did not see the patient. Access to Specialized Medical Housing Providers CIM provided satisfactory access to providers in the OHU. Compliance testing showed providers generally completed the required history and physical examinations timely (MIT 13.002, 80.0%). OIG clinicians reviewed 47 provider encounters and did not identify any access deficiencies related to specialized medical housing providers. Access to Clinic Nurses CIM provided excellent access to clinic nurses. Compliance testing showed registered nurses almost always reviewed the patients’ requests for service within required time frames (MIT 1.003, 96.9%) and always assessed the patients within one business day after nurses triaged the sick call slips (MIT 1.004, 100%). OIG clinicians reviewed 46 nursing sick call requests and identified only one deficiency related to clinic nurse access in the case below: • In case 22, the RN triaged a health care request as symptomatic for a patient who complained of painful sores on the bottom of the feet causing difficulty walking and standing. However, the sick call RN assessed the patient one day late. Access to Specialty Services CIM performed generally well in referrals to specialty services. Compliance testing showed staff generally completed initial specialty services appointments within required time frames for high-priority referrals (MIT 14.001, 80.0%) and routine-priority referrals (MIT 14.007, 86.7%) but needed improvement for medium-priority referrals (MIT 14.004, 60.0%). Specialty follow-up appointments for high-priority referrals (MIT 14.003, 100%) always occurred timely while specialty follow-up appointments for medium-priority referrals (MIT 14.006, 88.9%) and routine-priority referrals (MIT 14.009, 88.9%) frequently occurred timely. OIG clinicians reviewed 141 specialty encounters and identified two deficiencies.13 The following is an example: • In case 22, the provider evaluated the patient returning from hospitalization for an outpatient housing unit (OHU) admission. The provider documented in the chart the patient “needs F/U with Urology in one week.” However, the urologist did not evaluate the patient until over one month later. Follow-Up After Specialty Services 12 Deficiencies occurred in cases 20 and 26. 13 Deficiencies occurred in case 22. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 15 CIM generally provided timely provider appointments after specialty services. Compliance testing revealed provider appointments after specialty encounters intermittently occurred within the required time frame (MIT 1.008, 73.1%). In contrast, OIG clinicians identified no deficiencies related to provider appointments after specialty services. Follow-Up After Hospitalization Compliance and case review both found CIM always ensured providers evaluated patients after hospitalizations. Compliance testing showed providers always timely completed follow- up appointments with patients after hospitalizations (MIT 1.007, 100%). Similarly, OIG clinicians reviewed 30 events and identified no deficiencies in this category. Follow-Up After Urgent or Emergent Care (TTA) CIM provided excellent access to care for patients following triage and treatment area (TTA) events. OIG clinicians reviewed 18 TTA events and identified no delays in provider follow-up. Follow-Up After Transferring Into CIM Newly arrived patients to CIM received good access to care. Compliance testing showed clinicians frequently evaluated patients who transferred into the institution (MIT 1.002, 92.0%) within the required time frame. OIG clinicians reviewed three transfer-in cases and identified no deficiencies. Clinician On-Site Inspection CIM has three main clinics: facilities A, B, and C. D Yard contains the main health care central services and has TTA, OHU, and specialty services clinics. Facilities A, B, and C each operate a satellite TTA with a medical provider on duty (MOD) on weekdays from 3:00 p.m. to 11:00 p.m. A provider is on call daily for the main TTA after 11:00 p.m. and all day on weekends. Medical leadership reported the response times for emergency ambulance services to arrive at the Facilities A, B, and C are usually more expedient than the times CIM staff transported patients from Facilities A, B, and C to the main TTA in D facility. Staff reported scheduling six to eight patients per day for each clinic provider and adding two to three walk-in patients for the same day. In addition, providers also evaluated patients who were new arrivals for layover, including patients from the Male Community Reentry Program, patients returning from gender affirming procedures, and patients after transplant surgeries. OIG clinicians observed the morning huddles and population management meeting, which were well attended by the patient care team and ancillary staff. Compliance Testing Results Five of the six housing units randomly tested at the time of inspection had access to health care services request forms (CDCR Form 7362) (MIT 1.101, 83.3%). In one housing unit, no forms were available at the time of our inspection. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 16 Compliance Score Results Table 5. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or 23 2 0 92.0% within the ordered time frame, whichever is shorter? (1.001) For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 23 2 0 92.0% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 31 1 0 96.9% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 32 0 0 100% within one business day after the CDCR Form 7362 was reviewed? (1.004) Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the 4 0 28 100% maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time frame 2 0 30 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 25 0 0 100% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 19 7 9 73.1% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 5 1 0 83.3% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 93.0% * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 17 Table 6. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the required N/A N/A N/A N/A time frame? (12.003) For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days (prior to N/A N/A N/A N/A 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the 8 2 0 80.0% required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 4 1 0 80.0% Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 5 0 0 100% provider? (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician Request 9 6 0 60.0% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 8 1 6 88.9% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 13 2 0 86.7% for Service? (14.007) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care 8 1 6 88.9% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 18 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 19 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (66.6%) As in Cycle 6, case review found CIM delivered good performance in this indicator. Staff always completed laboratory and radiology testing within required time frames. Staff also retrieved and providers endorsed these results timely. However, providers often either did not send or sent incomplete test results notification letters to patients. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. CIM compliance testing scored low overall for this indicator. Staff performed excellently in timely completing radiology services, reviewing laboratory results, and endorsing STAT laboratory results. CIM almost always completed laboratory services and often endorsed radiology and pathology results within required time frames. However, staff needed improvement in the notifying and acknowledging STAT laboratory results and performed poorly in generating complete patient test results notification letters with all required elements. Based on the overall Diagnostic Services compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 239 diagnostic events and identified 74 deficiencies, none of which were significant.14 All 74 deficiencies related to health information management. No deficiencies related to delayed or noncompleted ordered tests. Test Completion Compliance testing indicated CIM performed excellently in completing radiology services (MIT 2.001, 100%) and very well in completing laboratory tests within required time frames (MIT 2.004, 90.0%). However, staff needed improvement in timely completing STAT laboratory tests (MIT 2.007, 66.7%). In contrast, OIG clinicians did not find any deficiencies with test completion, even in the one STAT laboratory test we reviewed.15 14 Deficiencies occurred in cases 1-3, 6, 7, 9–18, 20–22, 25, 26, 47, and 49. 15 A STAT diagnostic test occurred in case 8. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 20 Health Information Management CIM staff retrieved laboratory and diagnostic results promptly and sent the results to providers for review. Compliance testing showed providers performed well in endorsing radiology reports within specified time frames (MIT 2.002, 80.0%) and always timely endorsed routine and STAT laboratory results (MIT 2.005, 100% and MIT 2.009, 100%). However, staff needed improvement in timely acknowledging and notifying patients of STAT test results (MIT 2.008, 55.6%). Compliance testing revealed staff performed poorly in communicating radiology, laboratory, and pathology results with complete notification letters to patients (MIT 2.003, 10.0%, MIT 2.006, 40.0%, and MIT 2.012, zero). Similarly, OIG clinicians identified 71 deficiencies related to patient test results notification letters, three of which related to endorsing results late and one of which related to not forwarding the report to the provider. While none of these deficiencies were significant, the large number showed a pattern of poor communication to patients of test results with complete notification letters. The following is an example: • In case 6, the provider endorsed laboratory test results eight days after the results became available. Furthermore, the provider did not include whether the results were within normal limits in the patient notification letter. We discuss this issue further in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians met with CIM’s chief support executive (CSE), clinical laboratory scientist (CLS), senior laboratory assistant, and phlebotomists. The CLS described the laboratory testing process workflow at CIM, including how CIM tracked pending STAT laboratory test results. OIG clinicians also met with a radiologic technician. CIM offers digital x-rays and on-site mobile imaging services for MRI, CT, ultrasound, and FibroScan.16 16 A CT is a computed, or computerized, tomography scan while an MRI is a magnetic resonance imaging scan. Both create detailed images of the organs and tissues to detect diseases and abnormalities. A FibroScan is a diagnostic imaging scan used to evaluate for liver scarring and fatty changes from liver disease. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 21 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 8 2 0 80.0% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 1 9 0 10.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 9 1 0 90.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 4 6 0 40.0% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive 6 3 0 66.7% the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing 5 4 0 55.6% staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory 9 0 0 100% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 7 3 0 70.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 7 1 2 87.5% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 8 2 0 pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 66.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 22 Recommendations • The department should develop strategies, such as an electronic solution, to ensure providers create patient notification letters when they endorse test results and ensure patient notification letters contain all elements required by CCHCS policy. The department should implement remedial measures as appropriate • Health care leadership should determine the root cause(s) of challenges to the completion and notification of STAT laboratory results and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 23 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services solely through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Not Applicable Case review found CIM needed improvement with this indicator during this cycle. CIM staff responded promptly to medical emergencies at the institution and performed well in the two CPR cases reviewed. However, we found the nursing staff needed improvement in completing thorough assessments, providing appropriate interventions when clinically indicated, and documenting thoroughly. In addition, while the nursing and medical leadership frequently conducted clinical reviews of urgent and emergent events, they did not identify the same deficiencies and opportunities for improvement the OIG clinicians identified. Considering all factors, the OIG rated this indicator inadequate. Case Review Results We reviewed 45 urgent or emergent events and found 50 emergency care deficiencies. Of those 50 deficiencies, 11 were significant.17 Emergency Medical Response OIG clinicians reviewed 13 events in eight cases requiring a medical response.18 CIM custody and health care staff generally responded promptly to emergencies throughout the institution and timely notified the TTA RN or clinic RN staff. However, we found two cases with delays in notifying 9-1-1 emergency services (EMS). The following are examples: • In cases 2 and 18, the patients both reported chest pain, but the RNs delayed notifying EMS in each case. In case 2, the RN initiated EMS approximately 20 minutes after the provider ordered the patient be transferred to the hospital. In case 18, the RN initiated EMS over 15 minutes from the time the provider ordered the patient be transferred to the hospital. 17 Deficiencies occurred in cases 1–3, 6, 7, 18, 19, 21, 22, and 47. Significant deficiencies occurred in cases 1–3, 6, 18, 21, and 22. 18 Medical response events occurred in cases 1–3, 6, 18, 19, 21, and 22. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 24 Cardiopulmonary Resuscitation Quality During this review period, OIG clinicians reviewed two cases in which staff initiated CPR.19 In both cases, the patients were found unresponsive and custody immediately activated EMS and initiated CPR prior to health care staff responding to the scene. Custody and medical staff worked cohesively to provide care, timely initiated application of the automated external defibrillator (AED), administered multiple doses of Naloxone, and provided other interventions.20 Provider Performance Providers performed satisfactorily in urgent and emergent situations as well as in after- hours care. We identified five deficiencies, none of which were significant.21 Providers were available for consultation with nurses when necessary and were involved in treatment decisions. They made accurate diagnoses and generally completed documentation. However, we found poor documentation as in the following example: • In case 3, the provider evaluated the patient, who presented with urethral bleeding and abnormal vital signs, including low blood pressure and elevated heart rate. The patient was at risk for significant blood loss due to chronic blood thinning medication. The provider did not document a progress note in detail for the findings, differential diagnosis, and a plan for continuity of care. Nursing Performance OIG clinicians identified 29 nursing performance deficiencies, eight of which were significant.22 We found nursing staff needed improvement in completing thorough assessments and providing appropriate interventions when clinically indicated.23 Examples are detailed below: • In case 2, custody staff activated a medical alarm for the patient, who complained of right flank pain.24 The RN transferred the patient to the clinic and consulted with the provider. However, the RN did not perform nursing assessments or interventions for the patient between 10:50 a.m. and 1:15 p.m. while in the clinic, did not reassess the patient or the patient’s pain scale level after administering Tylenol or prior to discharging the patient to the housing unit, and did not document the patient’s time of departure from the clinic. In addition, the nurse did not notify the provider for a further plan of care until over two hours after the patient arrived in the clinic. 19 CPR occurred in cases 4 and 5. 20 Naloxone is a medication used for the emergency treatment of known or suspected opioid overdose. According to the manufacturer, nasal naloxone doses can be safely administered every two to three minutes. CCHCS emergency medical training allows nurses to administer up to five nasal naloxone doses when an opioid overdose is suspected. 21 Provider performance deficiencies occurred in cases 1–3, 21, and 47. 22 Nursing performance deficiencies occurred in cases 1–3, 6, 7, 18, 19, 21, 22, and 47. Significant deficiencies occurred in cases 2, 3, 6, 18, 21, and 22. 23 Incomplete nursing assessments occurred in cases 2, 3, 6, 18, 19, 21, and 47. Inappropriate interventions occurred in cases 1–3, 6, 18, 19, 21, 22, and 47. 24 Flank pain refers to pain to the side of the body, specifically between the rib cage and the hip. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 25 • In another event in case 2, the RN assessed the patient, who walked into the clinic with a complaint of chest pain. The nurse consulted with the provider and received orders to administer nitroglycerin and transport the patient to the community hospital.25 However, the RN did not administer additional doses of nitroglycerin as per the provider’s order when the patient reported the first dose did not relieve the chest pain. In addition, the RN did not monitor vital signs every 15 minutes or place the patient on a cardiac monitor until EMS arrived approximately 50 minutes after the initial RN assessment. • In case 3, the patient walked into the clinic with a complaint of worsening testicular pain radiating to the left side of the groin and up the left side. The RN assessed the patient’s pain and consulted with the provider. However, the RN did not perform a physical assessment of the patient to include inspecting the patient’s groin area or left side of the body or assessing the patient’s gait, skin, and back or the hip range of motion. • In case 18, custody staff activated a medical alarm for the patient, who complained of chest pain radiating to the arm. This patient had a medical history of high blood pressure, mini-stroke, and an aneurysm.26 The RN transported the patient to the clinic for further evaluation and utilized the nursing chest pain protocol. The patient had moderate to severe chest pain not relieved with nitroglycerin and had an abnormal electrocardiogram (EKG).27 However, the RN did not administer a third dose of nitroglycerin when the patient continued to complain of chest pain and did not initiate EMS until 15 minutes after the provider ordered the higher level of care transport. • In case 21, custody staff assisted the patient in a wheelchair to the clinic after hours for right-sided abdominal pain. The RN assessed the patient and noted a bulge in the right groin area and complaints of moderate to severe cramping to the right groin. The RN attempted to call the medical provider of the day several times as well as the medical provider on call, but the RN did not receive a return call. The RN also notified the supervising RN (SRN). However, the RN discharged the symptomatic patient back to the housing unit instead of following the chain of command to speak to a provider for a plan of care prior to releasing the patient back to the housing unit. • In case 22, custody staff activated a medical alarm for the patient, who reported sustaining a fall due to unstable vital signs. The RN arrived to assess the patient, who complained of a headache. The patient had an elevated pulse and severely low blood pressure. The RN transported the patient to the clinic in a wheelchair where the patient’s blood pressure continued to decrease. The RN administered oxygen for the low oxygen saturation. The nurse initiated EMS, and the patient transferred to the community hospital 28 minutes after arriving in the clinic. The nurse documented the patient’s condition was consistent with nursing protocol and documented deferring the care to medical. However, the RN did not 25 Nitroglycerin is medication used to treat chest pain, which relaxes the blood vessels and decreases the heart’s workload and oxygen demand. 26 An aneurysm is a bulge or ballooning in the wall of an artery, which can potentially burst and cause bleeding or damage to the body. 27 An EKG is an electrocardiogram. This noninvasive test measures and records the electrical impulses from the heart and is used to help diagnose heart problems. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 26 consult with the provider for the patient’s unstable vital signs, listen to the patient’s lower lung sounds, or obtain an order to insert an IV and provide fluids to the patient prior to EMS arrival. Additionally, the RN did not document which nursing protocol they utilized. Nursing Documentation Nurses generally performed well in documenting an accurate timeline of events. Nurses intermittently performed thorough documentation of urgent and emergent events.28 We found a pattern of nurses not documenting complete vital signs, a thorough physical assessment, or not documenting medications administered on the medication administration record. Emergency Medical Response Review Committee OIG clinicians reviewed 25 urgent and emergent events in 13 cases in which patients transferred to a higher level of care. We found 15 deficiencies, two of which were significant.29 The SRNs, chief nurse executive (CNE), and the chief medical executive (CME) or designees frequently conducted clinical reviews. However, they omitted some clinical reviews and, in 12 of the 25 emergency events or unscheduled send outs, nursing and medical leadership did not recognize the same opportunities for improvement OIG clinicians identified. The following examples are below: • In case 2 on 7/2/24 and case 3 on 8/26/24, the provider evaluated the patients’ symptoms and subsequently transferred both patients to the community hospital. However, nursing and medical leadership or designees did not conduct clinical reviews for both unscheduled transfers to higher level of care. • Also, in case 2 on 5/3/24, the patient transferred to the community hospital for chest pain and high blood pressure evaluation. The nursing and medical leadership completed clinical reviews of the emergent event but did not identify the nurse did not perform an EKG, place the patient on a cardiac monitor, monitor the patient’s vital signs at least every 15 minutes, or reassess the patient’s chest pain level for 37 minutes prior to EMS arrival. Compliance testing showed the EMRRC often either did not complete the required checklists or did not timely complete reviews (MIT 15.003, 8.3%). This is discussed further in the Administrative Operations indicator. Clinician On-Site Inspection During the on-site inspection, OIG clinicians inspected and interviewed nursing staff and nursing supervisors in the TTA in D yard and the satellite TTAs in A, B, and C yards. The nursing staff would respond to emergencies in their respective yards and transport the patients to the main TTA or the “satellite” TTAs, where the ambulances would directly arrive to transport patients. The outside ambulances would arrive to the TTA satellites and main 28 Incomplete documentation occurred in cases 1–3, 6, 7, 18, 19, and 22. 29 Urgent and emergency events in which patients transferred to a high level of care occurred in cases 1–7, 18–22, and 47. Deficiencies occurred in cases 1–3, 6, 7, 18, 21, 22, and 47. Significant deficiencies occurred in case 2. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 27 TTA within 15 minutes for emergent transfers to the community hospital from the time of notification. The main TTA and the satellites were staffed with one RN during each shift, 24 hours per day. A provider was on site in D Yard from 7:00 a.m. to 11:00 p.m. A provider was on call from 11:00 p.m. to 7:00 a.m. The main TTA, in D Yard, was fully equipped to provide emergency care. This TTA had a crash cart, IVs, and a cardiac continuous monitor.30 The main TTA had four bays and an emergency response vehicle with no lights or sirens. The nurse reported the main TTA RN was responsible for evaluating all patients who returned from the emergency room, hospitalizations, and off-site specialty appointments. In addition, the main TTA RN was responsible for responding to alarms in the D Yard, OHU, culinary, firehouse, laundry, diving school program, administrative building, juice plant, and visiting area. The nurse reported, when they needed to respond to an emergency, they contacted the TTA or OHU SRN to cover the TTA during that time. The main TTA RN was the primary responder and did not have a licensed vocational nurse (LVN) or primary care registered nurse (PCRN) to assist since D Yard only contained the main TTA, OHU, and the mental health crisis bed (MHCB) unit. According to the CIM nursing staff, the satellite TTAs functioned like the main TTA but only provided basic life support (BLS) in emergency situations since the satellites did not have a crash cart, IVs, or a cardiac continuous monitor. A, B, and C Yards each had one satellite TTA. The satellites had one procedure room per respective yard. The morning shift satellite RNs participated in the huddles with the primary care teams during business hours. The satellite RNs responded to their respective yard emergencies with the LVNs and PCRNs during the morning shift. During the evening shift, the medical responders were the satellite RNs and LVNs. On the night shift, the health care responders were only the satellite RNs, which the RNs noted could be challenging if they had a patient already in the satellite TTA, in which case they would request custody to stay with the patient during the time they were responding to the emergency. The staff reported only one SRN on the night shift was stationed in the OHU in D Yard. If the patient was being transferred to the community hospital and needed continuous monitoring or IV fluids, the patient would be transported to the main TTA in D Yard; however, our clinical reviews did not corroborate such transfers occurred if the patient needed immediate intervention. The satellite RNs on the morning and evening shifts additionally assisted with patient walk- ins, add-ons, and follow-ups, and also with patient education for specialty procedures. The nurses reported, when chest pain emergencies occurred, they would contact the provider on site for the plan of care rather than initiate the chest pain nursing protocol since the provider was readily available. During business hours, the PCRNs would assist the satellite RNs if needed. The main TTA SRN reported an SRN, CNE, and CME or designees conducted clinical reviews on all unscheduled transports, unless the provider evaluated the patient and determined the patient needed to go to the hospital for laboratory tests. If, on the other hand, the RN co- consulted with the provider, then leadership would conduct a clinical review. The TTA SRN also performed sick call audits for A Yard to assist with the large volume. The TTA SRN reported D Yard previously had 800 patients housed in the outpatient setting; however, D 30 A crash cart is a mobile cabinet that contains essential equipment, tools, and medications used by medical staff to quickly treat life threatening emergencies. IV stands for intravenous. It is a medical procedure where fluids or medications are administered directly into a vein using an IV line. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 28 Yard would have an additional 50-bed MHCB unit opening approximately October 2025, which would change the population in D Yard to be solely MHCB and OHU patients. In 2023, staffing in the TTA decreased from two RNs to one RN per shift after the removal of the D yard outpatient population. The SRN also reported 11 fire crew incarcerated persons on grounds also responded to emergencies as needed. As mentioned above, the CNE reported the institution had what were termed satellite TTAs due to the unique layout of the institution and the proximity to the main TTA. The CNE reported CIM completed a time study in the past to evaluate the time for nursing staff in the main TTA to respond to the emergencies in A, B, C Yards and the time it took to transport the patient back to the main TTA. The time study revealed transferring the patient from A, B, and C Yards to the main TTA in D Yard delayed treatment and transport to the community hospital. The CNE also reported Chino Hospital was 10 minutes away, and Riverside University Health System was 30 minutes from the institution. The CNE reported the satellite TTAs functioned like an outpatient yard and provided BLS, nitroglycerin, and oxygen. The CNE also reported emergency medical response program directive prohibited staff from administering IVs on the yards. This raised the concern for nursing staff these satellite TTAs were not provided necessary equipment for emergency situations, despite the time study indication that patients received more timely emergent care by using these satellite locations. OIG clinicians also identified this concern in our review. Many emergency deficiencies the OIG cited are attributed to nursing staff in the satellite TTAs not providing necessary interventions, such as IVs or cardiac monitoring, because they did not have access to the necessary equipment. However, during our onsite interviews, we learned nursing leadership had already elevated these concerns to CCHCS. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 29 Recommendations • Medical and nursing leadership should determine the root cause(s) of challenges in completing thorough clinical reviews of urgent and emergent events in which patients transfer to the community hospital as well as in identifying opportunities for improvement. Leadership should implement remedial measures as appropriate. • CCHCS should reevaluate the necessity of equipment (cardiac monitor, crash cart, Omnicell, IVs, and IV fluids) required in the clinic satellite TTA areas as well as any licensing steps necessary to provide such equipment, as the institution utilizes these areas to provide urgent and emergent care to the patients. Having the necessary equipment allows for nursing and medical staff to provide the standard of care for urgent and emergent events and may potentially prevent negative outcomes for the patients. • CIM nursing leadership should determine any additional root cause(s) of challenges that prevent nurses from performing thorough assessments and reassessments and providing appropriate interventions for patients with urgent and emergent conditions. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 30 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Proficient (90.5%) Case review found CIM performed satisfactorily in health information management. Staff performed well in retrieving and scanning hospital discharge reports and diagnostic reports. However, case review found staff had opportunities for improvement in scanning specialty and hospital reports timely. Additionally, providers needed improvement in communicating diagnostic test results to patients with complete notification letters. After considering all factors, OIG rated the case review component of this indicator adequate. Compliance testing showed CIM performed very well in this indicator. Staff almost always scanned patient sick call requests and endorsed hospital discharge reports timely. Staff also performed very well in timely scanning hospital discharge reports and ensuring medical records are labeled and filed in the appropriate patient files. Lastly, staff generally scanned specialty reports into patients’ electronic health records within required time frames. Based on the overall Health Information Management compliance score result, the OIG rated this indicator proficient. Case Review and Compliance Testing Results We reviewed 1,104 events and identified 98 deficiencies related to health information management, three of which were significant.31 Hospital Discharge Reports CIM staff performed well in timely retrieving and scanning hospital discharge documents into patients’ electronic health records (MIT 4.003, 90.0%). Nearly all the hospital discharge reports contained discharge summaries with key elements, and providers reviewed these reports timely (MIT 4.005, 96.0%). OIG clinicians reviewed 30 off-site emergency department and hospital encounters and identified one minor and one significant deficiency. The significant deficiency is described below.32 31 Deficiencies occurred in cases 1–3, 6-23, 25, 26, 47, and 48. Significant deficiencies occurred in cases 1, 8 and 10. 32 The minor deficiency occurred in case 2, and the significant deficiency occurred in case 1. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 31 • In case 1, the patient was evaluated at the community hospital emergency department (ED) for possible seizures. However, CIM staff did not retrieve or scan the discharge report from the ED physician into the electronic health records system (EHRS) during our review period, despite this scanning being already overdue.33 Specialty Reports CIM staff performed sufficiently in retrieving and reviewing specialty reports. Compliance testing showed staff often scanned specialty service reports into the EHRS within required time frames (MIT 4.002, 80.0%). CIM staff always retrieved and reviewed high-priority specialty service reports (MIT 14.002, 100%), often retrieved and reviewed medium-priority specialty service reports (MIT 14.005, 86.7%), and inconsistently retrieved and reviewed routine-priority specialty service reports (MIT 14.008, 73.3%) within required time frames. OIG clinicians reviewed 87 specialty reports and identified 19 deficiencies, two of which were significant.34 The following is an example: • In case 10, the RN documented placing a seven-day Holter monitor on the patient and collecting the monitor to process the recordings.35 However, CIM staff did not retrieve and scan the results of the seven-day Holter monitor into EHRS during our review period, despite this scanning being already overdue. We discuss specialty reports further in the Specialty Services indicator. Diagnostic Reports CIM performed satisfactorily in retrieving and endorsing diagnostic reports timely. Compliance testing showed providers always endorsed laboratory reports within required time frames (MIT 2.005, 100%) and generally endorsed radiology reports within required time frames (MIT 2.002, 80.0%). Staff needed improvement in receiving the final pathology study within the required time frame (MIT 2.010, 70.0%). Providers often reviewed and endorsed pathology reports within required time frames (MIT 2.011, 87.5%) but never communicated results of the pathology study to patients with complete notification letters (MIT 2.012, zero). OIG clinicians identified 77 deficiencies with diagnostic reports, none of which were significant.36 Most deficiencies (72 out of 77 deficiencies) related to incomplete or missing patient test results notification letters. The following is an example: • In case 48, the provider endorsed the laboratory test results and created a test result patient notification letter in EHRS. However, the provider did not include whether the results were within normal limits in the letter. 33 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for storing the patient’s medical history. The health care staff use the system to communicate. This record stays with the patient throughout the patient’s time in department’s correctional system. 34 Deficiencies occurred in cases 3, 6, 8, 10, 12, 16, 19 22, 23, 25, and 48. Significant deficiencies occurred in cases 8 and 10. 35 A Holter monitor is a wearable device that records a patient’s cardiac electrical activity for set number of hours or days. 36 Deficiencies occurred in cases 1–3, 6, 7, 9–18, 20–22, 25, 26, 47, and 48. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 32 We discuss diagnostic reports in greater detail in the Diagnostic Services indicator. Urgent and Emergent Records OIG clinicians reviewed 45 emergency care events. Providers recorded their emergency care sufficiently, including off-site telephone encounters. Nurses documented well for urgent and emergent events. OIG clinicians identified three deficiencies in provider documentation, none of which were significant.37 The following is an example: • In case 3, the provider evaluated the patient, who was on a blood thinning medication and presented with urinary bleeding and abnormal vital signs, including low blood pressure and fast heart rate. The patient was at risk for significant blood loss due to the chronic blood thinning medication. However, the provider did not document a progress note for his findings, differential diagnosis, or plan of care. Scanning Performance CIM staff generally performed very well with the scanning process. Compliance testing showed staff almost always scanned health care services request forms into the EHRS within required time frames (MIT 4.001, 95.0%) and often timely scanned community hospital discharge documents (MIT 4.003, 90.0%). CIM staff almost always scanned hospital discharge reports with key elements, and the providers almost always reviewed the reports within the required time frame (MIT 4.005, 96.0%). CIM staff often properly scanned and labelled medical records in the correct patients’ files (MIT 4.004, 91.7%). CIM staff performed fairly well with scanning high-priority specialty reports within the required time frame (MIT 4.002, 80.0%). OIG clinicians identified 13 deficiencies related to delays in retrieving and scanning specialty and hospital reports. Four deficiencies related to not forwarding the reports to the provider for endorsement, and two deficiencies related to mislabeling reports. Of the six deficiencies, three were significant.38 The following is an example: • In case 8, the medical assistant sent a general message to the provider with the partial copy of “Cardiology Electrophysiology Pre-Procedure Instructions” from the cardiologist. However, CIM staff did not retrieve or scan the complete copy of the instructions into EHRS for the provider to review and sign. Clinician On-Site Inspection OIG clinicians discussed health information management processes with CIM’s medical leadership, medical records supervisor, office technicians (OTs), and providers. The supervisor described the workflow and explained the process of how they retrieved and uploaded specialty consultation reports into EHRS. The supervisor explained how CIM was expanding its capacity to directly access regional hospitals’ electronic health records to retrieve and scan hospital reports for the providers. 37 Deficiencies occurred in cases 1, 2, and 3. 38 Deficiencies occurred in cases 1–3, 8, 10, 12, 16, 19, 22, and 23. Significant deficiencies occurred in cases 1, 8, and 10. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 33 Compliance Score Results Table 8. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic 19 1 12 95.0% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 20 5 10 80.0% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 18 2 5 90.0% (4.003) During the inspection, were medical records properly scanned, labeled, 22 2 0 91.7% and included in the correct patients’ files? (4.004) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 24 1 0 96.0% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 90.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 34 Table 9. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse the 8 2 0 80.0% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing 5 4 0 55.6% staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 7 3 0 70.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 7 1 2 87.5% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 8 2 0 pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 5 0 0 100% frame? (14.002) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 13 2 0 86.7% frame? (14.005) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 11 4 0 73.3% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 35 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 36 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (52.9%) Overall, CIM performed poorly with respect to its health care environment. Medical supplies storage areas in the clinics contained unidentified, inaccurately labeled, or disorganized medical supplies. In addition, several clinics did not meet the requirements for essential core medical equipment and supplies. Staff also did not regularly sanitize or wash their hands during patient encounters. Lastly, emergency medical response bags (EMRBs) contained compromised medical supply packaging, had not been properly inventoried when seal tags changed, or did not have the required number of medical supplies. Based on the overall Health Care Environment compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Waiting Areas We inspected only indoor waiting areas because CIM had no outdoor waiting areas. Health care and custody staff reported the existing waiting areas contained sufficient seating capacity (see Photo 1). Patients waited either in the clinic waiting area or in individual modules (see Photo 2, next page). During our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Photo 1. Indoor waiting area (photographed on 11-20-24). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 37 Photo 2. Individual waiting modules (photographed on 11-19-24). Clinic Environment Seven of nine clinic environments were sufficiently conducive for medical care. They provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 77.8%). In two clinics, the blood draw stations were within close proximity to each other, which hindered auditory privacy. Of the eight applicable clinics we observed, five contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper examinations (MIT 5.110, 62.5%). The remaining three clinics had one or both of the following deficiencies: examination rooms lacked visual or auditory privacy, and we found both an examination table and chair with torn vinyl covers. Clinic Supplies None of the nine clinics followed proper medical supply storage and management protocols (MIT 5.107, zero). We found one or more of the following deficiencies in all nine clinics: compromised sterile medical supply packaging; expired medical supplies (see Photo 3, next page); unorganized, unidentified, or inaccurately labeled medical supplies; long-term storage of staff members’ food in the medical supply storage area; and staff members’ personal items and food stored with medical supplies (see Photo 4, next page). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 38 Photo 3. . Ex pired medical supplies found stored beyond manufacturers’ guidelines (photographed on 11-20-24). Photo 4. Staff’s personal food stored with medical supplies (photographed on 11-18-24). Three of the nine clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 33.3%). We found one or more of the following deficiencies in six clinics: examination table disposable paper, nebulization unit, peak flow meter, peak flow meter disposable tips, and lubricating jelly were missing; the clinic weight scale was not annually calibrated; staff did not always document the automated external defibrillator (AED) performance test results within the last 30 days; and the clinic daily glucometer quality control logs were either incomplete or contained inaccurate serial numbers. We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only two of the six applicable EMRBs passed our test (MIT 5.111, 33.3%). We found one or more of the following deficiencies with four EMRBs: staff did not ensure the EMRB’s compartments were sealed and intact; staff did not seal compartments when not in active use; staff had not inventoried the EMRBs when the seal tags were replaced; staff did not log EMRB daily glucometer quality control results; an EMRB was missing the required quantity of stored medical supplies; and staff inaccurately logged the EMRB’s glucometer serial number when performing the daily glucometer quality control. Medical Supply Management All medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, 100%). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 39 According to the Chief Executive Officer, health care leadership did not have any issues with the medical supply process. Health care and warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system in place. Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected two of nine clinics (MIT 5.101, 22.2%). We found one or both of the following deficiencies in seven clinics: the clinic did not maintain cleaning logs, and we found an unsanitary gurney, medical supply cart, clinic floor, and staff restroom. Staff in six of eight applicable clinics properly sterilized or disinfected medical equipment (MIT 5.102, 75.0%). In one clinic, we observed the clinician use the examination table without disposable paper during a patient encounter. In one other clinic, staff did not mention disinfecting the examination table as part of their daily start-up protocol. We found operational sinks and hand hygiene supplies in the examination rooms in seven of nine clinics (MIT 5.103, 77.8%). In two clinics, the patient restrooms lacked disposable hand towels. We observed patient encounters in seven applicable clinics. In all seven clinics, clinicians did not wash or sanitize their hands before and after examining their patients, before applying gloves, before performing blood draws, or before each subsequent re-gloving (MIT 5.104, zero). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of our medical inspection, CIM’s administrative team reported no ongoing health care facility improvement program construction projects. The institution’s health care management and plant operations manager reported all clinical area infrastructures were in good working order (MIT 5.999). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 40 Compliance Score Results Table 10. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately disinfected, 2 7 0 22.2% cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or disinfected as 6 2 1 75.0% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 7 2 0 77.8% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 0 7 2 0 hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 9 0 0 100% borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs of the medical 1 0 0 100% health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for managing and 0 9 0 0 storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 3 6 0 33.3% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 7 2 0 77.8% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 5 3 1 62.5% providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, and do they 2 4 3 33.3% contain essential items? (5.111) Does the institution’s health care management believe that all clinical areas This is a nonscored test. Please see the have physical plant infrastructures that are sufficient to provide adequate indicator for discussion of this test. health care services? (5.999) Overall percentage (MIT 5): 52.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 41 Recommendations • Health care leadership should determine the root cause(s) for staff not ensuring clinical areas are appropriately disinfected, cleaned, and sanitized and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried, stocked, or sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 42 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated staff performance in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals. Inspectors further confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (81.2%) Case review found CIM performed satisfactorily in the transfer-in and transfer-out process and with patients returning from the community hospital or emergency room. CIM performed excellently in ensuring medication continuity for patients transferring out of the institution and performed well in medication continuity for patients transferring into the institution and patients returning from the community hospital or emergency room. Additionally, when patients transferred into CIM and returned from the hospital or emergency room, nurses performed good assessments, and provider follow-up appointments occurred within time frames. CIM ensured hospital documents were scanned into patients’ electronic health records within required time frames and providers always reviewed hospital reports timely. However, we found opportunities for improvement in nurses documenting or communicating the patients’ pending specialty appointments to the receiving institution. Considering all factors, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, CIM’s overall performance improved for this indicator. CIM needed improvement in completing initial health screening forms thoroughly and ensuring medication continuity for newly transferred patients. However, the institution performed excellently in completing the assessment and disposition section of the screening process and ensuring transfer packets for departing patients included the required documents and medications. Based on the overall Transfers compliance score result, the OIG rated the compliance testing component of this indicator adequate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 43 Case Review and Compliance Testing Results OIG clinicians reviewed 42 events in 22 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 12 deficiencies, four of which were significant.39 Transfers In CIM had a mixed performance in the transfer-in process. Compliance testing showed nurses needed improvement with completing the initial health screening form thoroughly (MIT 6.001, 52.0%). However, nurses performed excellently in completing the assessment and disposition section of the healthcare screening form (MIT 6.002, 96.0%). In addition, compliance testing showed the providers performed very well in evaluating newly arrived patients within the required time frames (MIT 1.002, 92.0%). However, testing indicated CIM staff performed poorly in providing timely preapproved specialty services appointments when patients transferred into the institution (MIT 14.010, 45.0%). Compliance testing showed CIM performed very well in ensuring medication continuity for patient layovers (MIT 7.005, 88.0%). CIM also frequently provided medication continuity for patients who were newly transferred into the institution (MIT 6.003, 77.0%). Please refer to the Medication Management indicator for further details. While compliance testing results varied, OIG clinicians found CIM performed well in the transfer-in process. OIG clinicians reviewed six events in three cases in which patients transferred into CIM from other institutions. We identified three deficiencies, one of which was significant.40 In contrast to compliance testing, OIG clinicians found CIM performed excellently in providing timely preapproved specialty services appointments for patients newly transferred into CIM. We found nurses generally completed the initial health screening forms thoroughly and screened patients appropriately, providers evaluated the newly arrived patients timely, and patients almost always received their medications timely. Transfers Out CIM’s transfer-out process was satisfactory. OIG clinicians reviewed six transfer-out events and identified three deficiencies, one of which was significant.41 We found two deficiencies in which nursing did not document or communicate the patients’ pending specialty appointments to the receiving institution.42 The following details the one significant deficiency: • In case 32, the outpatient housing unit (OHU) RN performed a daily assessment on the patient. The patient was admitted to the OHU for acute changes in mental health status with Parkinsonian features that may have advanced to early dementia and other medical diagnoses. In addition, the patient had an indwelling catheter and pressure sores. The patient was pending transfer to another institution for a higher level of care. The OHU RN documented, at 7:00 39 Deficiencies occurred in cases 2, 6, 19, 21, 22, 27, 28, and 30–32. Significant deficiencies occurred in cases 2, 21, 28, and 32. 40 Transfer-in deficiencies occurred in cases 27 and 28. A significant deficiency occurred in case 28. 41 Transfer-out deficiencies occurred in cases 30, 31, and 32. A significant deficiency occurred in case 32. 42 Nurses did not document or communicate the patients’ pending specialty appointments in cases 30 and 31. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 44 a.m., custody removed the patient’s property and durable medical equipment (DME), and the patient departed CIM via ambulance transportation. The OHU RN also documented abnormal findings on the OHU assessment, including abnormal lung sounds, pink bloody urine, and two pressure ulcers. However, the RN did not indicate whether a medical hold was present or required, or whether the provider had been notified of the findings and had cleared the patient for transport. Secondly, the nurse documented the receiving institution accepted the transfer but did not document the communication provided, which should have included abnormal assessment findings, treatment plan, and a pending specialty urology appointment. In addition, the nurse did not verify which DME custody staff had removed, whether any DME was missing, or whether the RN had provided the transfer envelope with required documentation and contents to the patient escorts. Lastly, on the morning of transfer, the RN did not indicate whether the prescribed medications would expire within five days of transfer, whether staff sent a five-day supply of medications with the patient, or whether staff included KOP medications in the transportation envelope. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experience severe illness or injury and require more care, placing a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. OIG clinicians reviewed 25 events and identified six deficiencies, two of which were significant.43 The nurses generally performed good assessments, reviewed hospital recommendations, and notified the providers timely. Both compliance testing and clinicians found CIM performed excellently in providing follow- up appointments within required time frames to patients returning from hospitalizations and emergency room encounters (MIT 1.007, 100%). CIM performed very well in ensuring staff scanned hospital discharge documents into the patient’s electronic health record within three calendar days of discharge (MIT 4.003, 90.0%). Compliance testing also found providers almost always reviewed and endorsed hospital documents within required time frames (MIT 4.005, 96.0%). Similarly, OIG clinicians found CIM performed very well in ensuring staff scanned hospital discharge documents timely into the electronic health record, and the providers reviewed hospital documents timely. Compliance testing identified poor performance in ensuring medication continuity for patients returning from the hospital or emergency room (MIT 7.003, 43.5%). However, OIG clinicians found CIM performed well in medication continuity for hospital or emergency room returns. We identified two deficiencies, both of which were significant.44 This will be discussed further in the Medication Management indicator. 43 Deficiencies occurred in cases 2, 6, 19, 21, and 22. Significant deficiencies occurred in cases 2 and 21. 44 Significant deficiencies occurred in cases 2 and 21. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 45 Clinician On-Site Inspection CIM’s receiving and release (R&R) area was located on B Yard. The R&R was staffed with one RN on each of the three shifts, excluding weekends and holidays. We interviewed the R&R RN, who was a seasoned employee at CIM. The nurse was knowledgeable about the transfer process. CIM was the hub for Male to Community Reentry Program layovers to CIM for patients transferring down to the southern CDCR institutions.45 The nurse reported an average of 45 patients transferred into CIM weekly and an average of 10 patients transferred out weekly. The nurse reported the triage and treatment area (TTA) nurse assessed all patients who returned from the hospital or emergency room, reviewed hospital recommendations, and obtained medication orders as needed. In addition, the nurse reported the care teams on each respective yard conducted huddles during the weekdays to ensure they timely scheduled follow-ups and appropriately reconciled orders. Compliance On-Site Inspection and Discussion R&R nursing staff ensured all three applicable patients transferring out of the institution had the required medications, transfer documents, and assigned DME (MIT 6.101, 100%). 45 Male to Community Reentry Program (MCRP) is a voluntary program for male incarcerated persons who meet the eligibility criteria. Approved participants serve the end of their sentences in the community, in lieu of confinement in state prison. MCRP is designed to provide a range of community-based, rehabilitative services. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 46 Compliance Score Results Table 11. Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Did nursing staff complete the initial health screening and answer all screening 13 12 0 52.0% questions within the required time frame? (6.001) For endorsed patients received from another CDCR institution: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the patient to the TTA if TB signs and 24 1 0 96.0% symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 10 3 12 76.9% administered or delivered without interruption? (6.003) For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding transfer packet 3 0 1 100% required documents? (6.101) Overall percentage (MIT 6): 81.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 47 Table 12. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 23 2 0 92.0% patient seen by the clinician within the required time frame? (1.002) Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider within the 25 0 0 100% required time frame? (1.007) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 18 2 5 90.0% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 24 1 0 96.0% review the report within five calendar days of discharge? (4.005) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient 10 13 2 43.5% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 22 3 0 88.0% medications continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 6 4 0 60.0% administered or delivered without interruption? (7.006) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 9 11 0 45.0% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 48 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 49 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (53.4%) Case review found CIM performed satisfactorily in medication management. CIM performed excellently in medication continuity for patients transferring out of the institution and patients in the specialized medical housing unit. CIM performed well in ensuring medication continuity for new medications, transfer-in medications, and medications for patients returning from the hospital. However, we found opportunities for improvement in medication continuity for patients on chronic care medications. The OIG rated the case review component of this indicator adequate. Compliance testing showed CIM needed improvement in providing medication management services. CIM performed poorly in providing patients with chronic care medications, newly ordered medications, community hospital discharge medications, and specialized medical housing medications as well as with ensuring medication continuity for patients laying over at the facility. Based on the overall Medication Management compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 157 events in 35 cases related to medications and found 15 medication deficiencies, 10 of which were significant.46 New Medication Prescriptions Compliance testing showed new medications were intermittently not available or were not administered timely (MIT 7.002, 56.0%). In contrast, OIG clinicians found CIM performed well with timely administering new medication prescriptions to patients. We found one exception as detailed below: 46 Deficiencies occurred in cases 2, 5, 8, 13, 19–22, 24, 28, and 49. Significant deficiencies occurred in cases 2, 5, 8, 13, 20, 21, 22, 24, and 28. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 50 • In case 5, the patient was scheduled to receive a new keep on person (KOP) medication, Tamsulosin, to treat the symptoms of an enlarged prostate.47 However, the patient received the medication one month later. Chronic Medication Continuity Compliance testing revealed patients only sporadically received their chronic care medications within required time frames (MIT 7.001, 28.6%). OIG clinicians found 10 deficiencies, six of which were significant.48 The following are examples: • In case 8, the provider ordered Coumadin, a blood thinner, to be nurse administered on Monday, Wednesday, Friday, Saturday, and Sunday. However, the patient did not receive the chronic care medication one Saturday. • In case 13, the patient did not receive the KOP chronic care medication potassium chloride as scheduled, increasing the risk of the patient developing an electrolyte imbalance. The patient did not receive the medication until one month later. • In case 20, the patient was due to receive the KOP chronic care medication tiotropium, used to prevent constriction of the airways caused by chronic obstructive pulmonary disease (COPD); however, the LVN documented on the MAR "Not Done: ORDER INACTIVE." Subsequently, the patient did not receive the medication for the month of March 2024. The patient received the medication one month later. • In case 22, a dose increase was ordered for the patient’s chronic care KOP medication, tamsulosin. However, the patient received the updated medication dose almost one month late. Secondly, the patient’s chronic care KOP diabetes medication, metformin, was renewed; however, the patient received the medication, one month late. Lastly, the patient was scheduled to receive KOP blood pressure medication, but the patient received it one month late. • In case 24, the kidney transplant patient was scheduled to receive chronic care KOP antibiotic medication. However, the patient did not receive the medication until almost one month later. Hospital Discharge Medications Compliance testing revealed CIM performed poorly in ensuring medication continuity for patients returning from off-site hospitals or emergency rooms (MIT 7.003, 43.5%). However, OIG clinicians found CIM performed very well with hospital discharge medications. We found two deficiencies, both of which were significant and detailed below: 47 KOP means “keep on person” and refers to medications that a patient can keep and self-administer according to the directions provided. 48 Chronic care medication deficiencies occurred in cases 2, 8, 13, 19, 20, 22, and 24. Significant deficiencies occurred in cases 8, 13, 20, 22, and 24. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 51 • In case 2, the patient returned from a community hospitalization with a diagnosis of coronary artery disease.49 The hospital recommendations included to continue all prescription medications except carvedilol.50 However, recommended prescriptions were not renewed until three days after the patient returned to CIM from the hospital, resulting in a lapse in medication continuity for medications to treat high blood pressure, prostate cancer, lower urinary tract infection, high cholesterol, low potassium levels, acid reflux, folate, and vitamin D deficiencies. • In case 21, the patient returned from the hospital and was admitted to the outpatient housing unit (OHU). The patient was hospitalized for a ruptured appendix with an abdominal infection resulting in surgery. The hospital recommendations included a new antibiotic and to continue a medication to treat high cholesterol. The provider ordered the KOP antibiotic to start the same day the patient returned from the hospital; however, the patient did not receive the KOP medication until three days later, and only when the order was changed to nurse administered. In addition, the patient was to continue the chronic care medication to treat high cholesterol upon return from the hospital; however, the medication was not ordered upon the patient’s return to CIM, resulting in the patient receiving the medication three days late. Specialized Medical Housing Medications Compliance testing showed, when patients were admitted to the OHU, staff only sporadically administered medications timely (MIT 13.003, 33.3%). OIG clinicians found CIM staff performed excellently in providing OHU medications timely. We identified one deficiency, which was not significant.51 Transfer Medications Compliance testing showed CIM staff always ensured medications were in the transfer packets for patients transferring out of the institution (MIT 6.101, 100%). Compliance testing showed patients often received their medications within the required time frame when they transferred into the institution (MIT 6.003, 77.0%), and CIM performed very well in ensuring patients transferring from yard to yard received their medications without interruption (MIT 7.005, 88.0%). Lastly, compliance testing showed patients who had a layover at CIM intermittently received their medications timely (MIT 7.006, 60.0%). OIG clinicians found the institution performed very well in medication continuity for patients transferring out of CIM. We identified one transfer-in deficiency, which was significant and is detailed below: • In case 28, the RN evaluated a new arrival patient diagnosed with asthma. The nurse documented the patient arrived with KOP medications, to treat constipation and seasonal allergies. In addition, the nurse administered a maintenance inhaler and medication for seasonal allergies. However, the nurse 49 Coronary artery disease is a heart condition with the presence of plaque within the heart arteries, leading to reduced blood flow and increased risk for a heart attack. 50 Carvedilol is medication is used to reduce the workload on the heart by slowing the heart rate and lowering the blood pressure. 51 The deficiency occurred in case 49. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 52 did not ensure the patient had a rescue inhaler on person or administer a new rescue inhaler. The patient did not receive the rescue inhaler for the month of June 2024. Medication Administration Compliance testing showed nurses always administered tuberculosis (TB) medications as prescribed (MIT 9.001, 100%) and almost always monitored patients on TB medications per policy (MIT 9.002, 92.9%). Similarly, OIG clinicians identified no cases of patients receiving TB medications during the review period. Clinician On-Site Inspection During the on-site inspection, OIG clinicians met with the pharmacist and inspected the medication administration areas. The A Yard medication administration area was small and cluttered to be able to adequately accommodate the five medication nurses and five medication carts. The B and C Yards’ medication areas were clean, well-organized, and had adequate space for the medication nurses. Medication nurses were knowledgeable about the medication process. Medication nurses generally did not attend the morning huddles due to administering medications at the time huddles were conducted. However, nurses reported they would notify the provider if there were any medication issues. Nursing staff reported challenges with pharmacy staff delivering medications timely to the medication nurses, which resulted in less time to administer the KOP medications to the patients. For example, our clinicians witnessed pharmacy staff delivering medication for constipation with a start date of the date prior, which only gave the patient three days to pick up the medication instead of four days. According to nurses, this happened frequently. Medication nurses also reported the pharmacy should streamline their process with KOP medications for patients discharging from the OHU to the yards. Nurses reported KOPs were wasted when the patient was discharged from the OHU and reissued another pack of the same KOP medications. Nursing staff reported it was wasteful and added more to their workload in making sure the patients would come pick up their KOP medications. OIG clinicians reported the concerns above to the leadership team. Nursing staff reported nursing morale was mixed; however, most nurses expressed they were supported by leadership and enjoyed working at CIM. Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all of nine applicable clinic and medication line locations (MIT 7.101, 100%). Conversely, CIM appropriately stored and secured nonnarcotic medications in only two of nine applicable clinic and medication line locations (MIT 7.102, 22.2%). In seven locations, we observed one or more of the following deficiencies: nurses did not maintain unissued medication in its original labeled packaging; the treatment cart log was missing daily security check entries; the medication nurse did not follow the process in place to return medications with an expired pharmacy label that could be potentially restocked and reissued by the pharmacy; and the medication area lacked a clearly labeled designated area for refrigerated medications that were to be returned to the pharmacy. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 53 Staff kept medications protected from physical, chemical, and temperature contamination in only two of the 10 applicable clinic and medication line locations (MIT 7.103, 20.0%). In eight locations, we found one or more of the following deficiencies: staff did not store internal and external medications separately; the medication refrigerator was unsanitary; staff did not store nonrefrigerated medication within the correct temperature range at the time of our inspection; and staff members’ historical temperature log entries for the refrigerator were not within acceptable range. Staff successfully stored valid, unexpired medications in eight of the nine applicable medication line locations (MIT 7.104, 88.9%). In one location, nurses did not label the multiuse medication as required by CCHCS policy. Nurses did not exercise proper hand hygiene and contamination control protocols in any of six applicable locations (MIT 7.105, zero). Medication nurses neglected to wash or sanitize their hands when required. These occurrences included: before preparing and administering medications, before each subsequent regloving, and resanitizing and changing gloves when gloves were compromised. Staff in five of six applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 83.3%). In one location, medication nurses did not appropriately describe the process they followed when reconciling a newly received medication and the medication administration record (MAR) against the corresponding physician’s order. Staff in one of six applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 16.7%). In five locations, we observed one or more of the following deficiencies: medication nurses did not reliably observe patients while they swallowed direct observation therapy medications; medication nurses did not follow CCHCS care guide requirements when administering Suboxone medication; medication nurses did not properly disinfect the vial’s port prior to withdrawing medication; and a medication nurse improperly disposed of a controlled substance medication down the sink without another licensed nurse to witness. Pharmacy Protocols Pharmacy staff followed general security, organization, and cleanliness management protocols in CIM’s pharmacy (MIT 7.108, 100%) and properly stored nonrefrigerated medications (MIT 7.109, 100%). The institution did not properly store refrigerated or frozen medications in the pharmacy (MIT 7.110, zero). We found an unsanitary medication refrigerator. The pharmacist-in-charge (PIC) did not thoroughly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations (MIT 7.111, zero). Specifically, the PIC did not date a medication area inspection checklist (CDCR form 7477) in one location. We examined 24 medication error reports. The PIC timely and correctly processed all reports (MIT 7.112, 100%). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 54 Nonscored Tests The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Seven of eight applicable patients interviewed indicated they had access to their rescue medications. One patient reported they did not have their prescribed rescue inhaler because it was left in the yard after yard time. We promptly notified the Chief Executive Office of this concern, and health care management immediately issued a replacement rescue inhaler to the patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 55 Compliance Score Results Table 13. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames 6 15 4 28.6% or did the institution follow departmental policy for refusals or no‑shows? (7.001) Did health care staff administer, make available, or deliver new order prescription 14 11 0 56.0% medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 10 13 2 43.5% required time frames? (7.003) For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or delivered to N/A N/A N/A N/A the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 22 3 0 88.0% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 6 4 0 60.0% without interruption? (7.006) All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic medications 9 0 2 100% assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the assigned 2 7 2 22.2% storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of contamination in 2 8 1 20.0% the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in the 8 1 2 88.9% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and 0 6 5 0 medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 5 1 5 83.3% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 1 5 5 16.7% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 1 0 0 100% cleanliness management protocols in its main and remote pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 0 1 0 0 medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 0 1 0 0 medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 24 0 0 100% (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the OIG This is a nonscored test. Please see the indicator find that medication errors were properly identified and reported by the institution? (7.998) for discussion of this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator have immediate access to their KOP prescribed rescue inhalers and nitroglycerin medications? (7.999) for discussion of this test. Overall percentage (MIT 7): 53.4% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 56 Table 14. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 10 3 12 76.9% administered or delivered without interruption? (6.003) For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding transfer-packet 3 0 1 100% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 15 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 13 1 1 92.9% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 6 1 33.3% within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 57 Recommendations • Health care leadership should determine the challenges related to medication continuity for chronic care medications, new medications, hospital discharge medications, medications for patients in specialized medical housing unit, and medications for patients temporarily housed at CIM. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 58 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Proficient (98.8%) CIM performed outstandingly in preventive services. Staff performed exceptionally in administering tuberculosis (TB) medications to patients as prescribed, screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for patients ages 45 through 75, and offering immunizations to chronic care patients. They also performed very well in monitoring patients who were taking TB medications. Based on the overall Preventive Services compliance score result, the OIG rated this indicator proficient. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 59 Compliance Score Results Table 15. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 15 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 13 1 1 92.9% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 25 0 0 100% (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the patient 25 0 0 100% offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the patient N/A N/A N/A N/A offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was patient N/A N/A N/A N/A offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? (9.008) 12 0 13 100% Are patients at the highest risk of coccidioidomycosis (Valley Fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 98.8% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 60 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 61 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RN), licensed vocational nurses (LVN), psychiatric technicians (PT), certified nursing assistants (CNA), and medical assistants (MA). Our clinicians evaluated nurses’ performances in making timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance across many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable CIM’s overall nursing performance was satisfactory. Nurses responded promptly to emergencies and performed well in ensuring medication continuity for patients. Nurses provided satisfactory care for patients in the specialized medical housing unit (SMH) and outpatient setting, transferring into and out of the institution, and returning from the community hospital or emergency room. However, we identified opportunities for improvement for nurses in performing thorough assessments in the SMH and outpatient areas. In addition, we found the nursing staff needed improvement in performing thorough nursing assessments and interventions during emergent events. Although nursing leadership conducted clinical reviews for emergent events requiring a medical response, they often did not identify the same opportunities for improvement as OIG clinicians. Considering all factors, the OIG rated this indicator adequate. Case Review Results We reviewed 216 nursing encounters in 38 cases. Of the nursing encounters we reviewed, 76 were in the outpatient setting and 54 were sick call requests.52 We identified 96 nursing performance deficiencies, 16 of which were significant.53 52 Sick call events occurred in cases 1–3, 5–7, 14, 16, 18, 19, 21, 22, 33–46, and 48, 53 Deficiencies occurred in cases 1–3, 5–7, 18–22, 27, 28, 30–32, 35, 37, 44, and 46–50. Significant deficiencies occurred in cases 2, 3, 6, 7, 18, 19, 21, 22, and 32. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 62 Outpatient Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) elements. Nurses generally performed appropriate assessments and interventions. We identified 37 outpatient nursing deficiencies, seven of which were significant.54 The following cases showed room for improvement: • In case 2, the RN assessed the patient for a complaint of a bump on the left side of his head. The patient had elevated blood pressure and swelling to the back of the head. The patient reported decreased urine output and difficulty urinating as well as bloody amber urine. The patient also reported he had not been using his CPAP machine due to a missing cord. The nurse sent the patient to take his medications and return for a blood pressure recheck. About an hour later, the patient’s blood pressure was still elevated. However, the nurse did not obtain a urine dipstick test, describe the appearance or size of the bump or swelling on the left side of the head, and did not address the missing CPAP cord. In addition, the nurse did not notify or co-consult the provider regarding the patient’s continued elevated blood pressure, report of bloody amber urine, or swelling to the head prior to discharging the patient to the housing unit. • In case 3, the RN assessed the patient, who reported having had “very bad shivers,” head pain, a cough, phlegm, feeling cold even when fully covered and wearing a jacket, loss of appetite, being very weak when standing or walking, congested nostrils, and body aches for five days. Although the nurse performed a physical exam, the nurse did not assess the patient’s head, ears, eyes, nose, or throat to corroborate reported symptoms; assess the patient’s neck range of motion for stiffness, although the patient reported a headache; inquire about the location of the headache or the subjective characteristics of the pain; recheck the patient’s low blood pressure; provide COVID-19 or influenza testing; or co- consult with the provider for a plan of care. • In case 22, the RN assessed the patient for a complaint of dizziness described as “spinning-like” for three days. The nurse did not perform a complete physical assessment prior to referring the patient to the provider, which would have included the following: inquiry into related causes of the dizziness or what made the dizziness better; performing orthostatic vitals; review of current medications and compliance; assessment of the patient’s pupils as well as ears; listening to heart sounds; assessment of the patient’s skin; assessment of the patient’s extremity strength; and a description of the patient’s gait.55 Nurses triaged most sick call requests appropriately and generally provided appropriate nursing assessments and interventions. However, nurses did not always recognize urgent symptoms that warranted same day assessments. The following are examples: 54 Outpatient nursing deficiencies occurred in cases 1–3, 5, 7, 18–20, 22, 35, 37, 44, and 46. Significant deficiencies occurred in cases 2, 3, 7, and 19. 55 Orthostatic vitals means the blood pressure and pulse measurements are recorded in three separate positions: laying down, sitting, and standing. Positive orthostatic is when these measurements are abnormal, indicating possible fluid loss. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 63 • In case 7, the RN triaged a sick call request for a patient complaint of still having breathing problems with any type of exertion and concern of a heart blockage. The nurse documented on the sick call form “Pt was seen on 4/14/24 by an RN for the same problem see EHRS notes.” The nurse also documented on the form “File in chart only pls.” However, the patient had not, in fact, been evaluated on the prior day. Rather, the previous encounter for the same reason was from a month earlier. Consequently, the patient was not evaluated for the worsening complaint of breathing problems. • In case 19, the nurse triaged a sick call request for a patient complaint of extreme lower stomach pain, documented as possibly a bladder infection for about a week. However, the nurse did not schedule the patient for a same day appointment for the urgent complaint and symptoms. About five weeks later, another nurse triaged a sick call request with patient report of recent surgery for a burst appendix and complaint of worsening stomach pain. However, rather than schedule the patient to be seen the same day for the urgent complaint, the nurse referred the patient to be scheduled within one business day. Outpatient Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. CIM nursing staff generally documented care appropriately. Wound Care We reviewed seven cases in which nurses provided wound care to patients. We identified eight deficiencies, none of which were significant.56 The nurses generally performed wound care as ordered. However, we found opportunities for improvement in wound care assessments in the SMH, which is further discussed in the Specialized Medical Housing indicator. Emergency Services Nursing staff responded promptly to medical emergencies at the institution. We identified 50 urgent or emergent deficiencies. Of those 50, 29 deficiencies related to nursing performance, eight of which were significant.57 The nursing and medical leadership frequently conducted clinical reviews of the emergent events; however, they did not identify the same deficiencies OIG clinicians identified. We also found nursing staff needed improvement in thorough assessments, in providing appropriate interventions when clinically indicated, and documenting thoroughly. Please refer to the Emergency Services indicator for further details. 56 Patients received wound care in cases 3, 6, 10, 19, 21, 48, and 50. Deficiencies occurred in cases 3, 6, 19, 21, and 50. 57 Nursing performance deficiencies occurred in cases 1–3, 6, 7, 18, 19, 21, 22, and 47. Significant deficiencies occurred in cases 2, 3, 6, 18, 21, and 22. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 64 Hospital Returns OIG clinicians reviewed 25 events in which patients returned from an off-site hospitalization or emergency room. We identified six deficiencies, two of which were significant.58 Nurses performed good assessments, reviewed hospital recommendations, and notified providers timely. Please refer to the Transfers indicator for further details. Transfers We reviewed six cases that involved transfer-in and transfer-out processes.59 Nurses generally evaluated patients appropriately. Nurses always initiated provider appointments within appropriate time frames. However, nurses did not always document pertinent information when patients transferred out of the institution. Please refer to the Transfers indicator for further details. Specialized Medical Housing We reviewed 10 outpatient housing unit (OHU) cases with a total of 149 events, 37 of which were nursing events.60 In the OHU, OIG clinicians found nurses provided satisfactory care. However, we found opportunities for improvement in performing thorough nursing assessments and in initiating individualized care plans. OIG clinicians identified 20 nursing deficiencies, none of which were significant.61 For more specific details, please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed 26 nursing events in which patients returned from off-site specialty appointments and identified two deficiencies, neither of which were significant.62 CIM nurses frequently conducted thorough assessments, reviewed specialty recommendations, and initiated orders for provider follow-up appointments as required. Medication Management OIG clinicians reviewed 157 events in 35 cases related to medications and found 15 medication deficiencies, 10 of which were significant.63 We found most nurses administered patients’ medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection OIG clinicians interviewed nurses in the TTA, satellite TTAs, OHU, R&R, specialty, outpatient clinics, and medication areas. We attended organized huddles and found the clinic staff knowledgeable and familiar with their patient population. The primary care registered 58 Deficiencies occurred in cases 2, 6, 19, 21, and 22. Significant deficiencies occurred in cases 2 and 21. 59 Transfer-in cases occurred in cases 27, 28, and 29. Transfer-out cases occurred in cases 30, 31, and 32. 60 OHU nursing events occurred in cases 6, 21, 22, and 47–50. 61 OHU nursing deficiencies occurred in cases 6, 21, 22, and 47–50. 62 Deficiencies occurred in case 6 and 47, none of which were significant. 63 Deficiencies occurred in cases 2, 5, 8, 13, 19–22, 24, 28, and 49. Significant deficiencies occurred in cases 2, 5, 8, 13, 20–22, 24, and 28. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 65 nurses (PCRNs) also assisted the satellite RN (which they also referred to as the “man down/TTA RN”) as needed in emergent situations. The patient population at the time of the on-site inspection are as follows: A Yard: 947, B Yard: 607, C Yard: 725, and D Yard: 64. OIG clinicians were impressed by CIM’s A Yard population management meeting and the multiple disciplines that were present and contributed to the discussion. The population meeting was well-structured and organized. The staff at the A Yard population management meeting were knowledgeable about its patient population and coordinated the management of diabetic patients with dietary, mental health, and medical staff. In addition, the team reviewed the vaccine registry, provided updates for varicella screening appointments, and offered follow-up appointments for refusals. CIM’s C Yard had two PCRNs, one satellite TTA RN, and a mental health RN. The PCRN reported they triaged an average of 85 health care request forms on Mondays and assessed approximately 10 to 28 patients on each RN line per day. The PCRNs mainly assessed patients for care management every two to three months and as needed. At the time of the on-site inspection, no appointment backlogs existed for the RNs or MAs in A, B, C, and D Yards. We found most of the nursing staff interviewed had been working at CIM for many years and enjoyed the team collaboration at the institution. Nursing staff on C Yard reported two concerns they had regarding their safety. First, they expressed concern about when they had to go to the housing units to complete a refusal form with a patient due to the increased enhanced outpatient program (EOP) population—which can be a challenging population— and the decrease of custody staff in the units. Second, C Yard nurses expressed concern about the population of patients with a higher custody security need mixed with the general population freely walking around the yard, as well as the number of alarms occurring on that yard; however, nurses reported they had a good rapport with custody staff. The OIG clinician notified healthcare leadership of the staff concerns. The CIM CNE was seasoned in this position. The CNE acknowledged the OIG preliminary findings showed improvement needed in closing patient encounters for patients who were at the hospital for more than 24 hours to prevent confusion on medication orders. The CNE reported the SRNs audit the quality of nursing care for patients in the OHU, patients returning from off-site specialty appointments as well as from hospital and emergency room encounters, and patients with symptomatic and asymptomatic sick call requests. In these audits, they review the compliance and quality care components. The CNE learned from the OIG preliminary findings they needed to audit the walk-in encounters and ensure the nurses complete thorough assessments for the sick calls and for patients who would be transferred to the community hospital. The CNE expressed concern with the increase in high acuity patients in the OHU and the need for additional nursing positions; however, CCHCS determined the staffing level for the OHU was sufficient. The CNE also reported challenges with the increase in the workload for nurses due to the increase in the EOP population and EOP patients overdosing at CIM. Recommendations • Nursing leadership should determine the challenges to nurses performing thorough face-to-face assessments and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 66 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 67 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable As in Cycle 6, case review found CIM providers delivered good care for patients. Providers generally evaluated patients appropriately, diagnosed medical conditions correctly, and managed chronic conditions effectively. They referred patients to specialists as medically indicated and for a higher level of care when needed. However, providers needed improvement in generating complete patient test notification letters. After careful consideration of all factors, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 173 medical provider encounters and identified 33 deficiencies, 12 of which were significant. In addition, OIG clinicians examined the quality of care in 25 comprehensive case reviews.64 Of these 25 cases, we rated 23 adequate and two inadequate.65 Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound medical decisions for their patients. Most of the time, providers diagnosed medical conditions correctly, ordered appropriate tests, and referred their patients to specialists when needed. However, OIG clinicians identified 10 deficiencies related to poor medical assessment and decision-making, one of which was significant.66 The following is the significant deficiency: • In case 12, on multiple occasions, the provider documented the patient had elevated blood glucose levels after meals but did not make any adjustment to the diabetic medication regimen. Subsequently, the 64 Deficiencies occurred in cases 1–3, 5, 8, 12, 13, 16, 19, 20–22, 23, 25, 47, and 50. Significant deficiencies occurred in cases 12, 25, and 50. 65 We rated cases 12 and 25 inadequate. 66 Deficiencies occurred in cases 3, 5, 8, 12, 13, 16, 20, and 22. A significant deficiency occurred in case 12. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 68 patient’s HbA1c level progressed from 7.5 percent to 9.0 percent, indicating worsening diabetes.67 Review of Records Providers almost always timely reviewed medical records and addressed hospitalists’ recommendations for patients returning from hospitalizations. However, OIG clinicians identified one minor deficiency related to review of hospital records as follows: • In case 2, the provider evaluated the patient, who returned from the hospital for chest pain and hypertension. The provider documented the hospitalist’s report stating the patient had low heart rates in the 40s and the cardiologist’s recommendation to follow up in the outpatient cardiology clinic. However, the provider did not order a referral to the cardiology specialist and did not document a rationale for not following the recommendation. Emergency Care Providers usually managed patients in the TTA with urgent or emergent conditions appropriately. In addition, providers were usually available for consultation with TTA staff. OIG clinicians identified three deficiencies related to emergency care, none of which were significant.68 The following is an example: • In case 47, the patient, who was recently treated in the hospital for subdural hematoma requiring drainage, was experiencing similar symptoms of recurrent headache and nausea, which required emergent evaluation and possibly a head CT scan.69 The patient was inappropriately transferred to the hospital emergency room in a state vehicle instead of an ambulance. Chronic Care In most instances, providers appropriately managed patients’ chronic health conditions, such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. However, OIG clinicians identified four deficiencies, none of which were significant.70 The following is an example: • In case 19, the provider evaluated the patient at a chronic care appointment. The provider ordered a new proton pump inhibitor (PPI) medication, pantoprazole, for 90 days for this patient, who was asymptomatic with normal examination, without documenting a medical rationale for starting a new PPI medication.71 67 Hemoglobin A1c (HbA1c) is a blood test that measures the average plasma glucose over the previous 12 weeks. For most patients with diabetes, the HbA1c goal is 7 percent or less. Read more at https://www.cdc.gov/diabetes/diabetes-testing/prediabetes-a1c-test.html. 68 Deficiencies occurred in cases 3 and 47. 69 A subdural hematoma is a bleed inside the head and can be life-threatening, requiring immediate attention. 70 Deficiencies occurred in cases 2, 3, 19, and 23. 71 A proton pump inhibitor is a medication used to reduce stomach acid production. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 69 Specialty Services Providers appropriately referred patients for specialty consultations when medically indicated. When specialists made recommendations, providers mostly followed the recommendations and reviewed specialty reports timely. However, OIG clinicians identified nine deficiencies, six of which were significant, for providers not thoroughly reviewing the specialty reports.72 The following is an example: • In case 12, the provider evaluated the patient for follow-up from orthopedic surgery, ophthalmology, and infectious disease specialty appointments. The provider documented the patient had glaucoma with plans to continue eye drops. However, the patient was not using any eye drops for glaucoma. Furthermore, although the provider documented the infectious disease specialist’s recommendation for the patient to stop the antibiotic, cephalexin, the provider did not discontinue the antibiotic, putting the patient at risk for adverse side effects. We also discuss providers’ specialty performance in the Specialty Services indicator. Specialized Medical Housing Providers evaluated the patients in the outpatient housing unit (OHU) timely and appropriately. However, OIG clinicians identified four significant deficiencies with provider documentation and decision-making.73 The following is an example: • In case 25, the provider cloned clinical documentation extensively without updating the clinical changes. Furthermore, the provider did not address the multiple significant medical conditions. We also discuss further in the Specialized Medical Housing indicator. Documentation Quality Documentation is important because it shows the provider’s thought process during clinical decision-making. When contacted by nurses, providers frequently documented the interactions. OIG clinicians identified two undocumented interactions.74 The following is an example: • In case 2, the nursing staff co-consulted with the provider for the patient, who presented with unprovoked, non-radiating, reproducible chest pain. The provider ordered a ketorolac injection for pain. However, the provider did not document a progress note.75 72 Deficiencies occurred in cases 3, 12, and 50. Significant deficiencies occurred in cases 12 and 50. 73 Significant deficiencies occurred in case 25. 74 Deficiencies occurred in cases 1 and 2. 75 Ketorolac is a nonsteroidal anti-inflammatory medication used to reduce pain. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 70 Provider Continuity CIM offered good provider continuity. Providers were assigned to individual clinics taking care of specific patients. Provider Notification Letters Providers did not always send patient test results notification letters to patients. When they did, the letters did not always contain the four elements required by policy: the date of the test, the reviewing health care provider’s name, whether the results were within normal limits, and whether a provider follow-up appointment was required and would be scheduled. OIG clinicians identified 71 deficiencies concerning patient test result notification letters, but none of those deficiencies related to late endorsement of the results. We further discuss patient notification letters in Diagnostic Services and Health Information Management indicators. Clinician On-Site Inspection OIG clinicians attended morning huddles led by clinic providers and observed good attendance by patient care team members. OIG clinicians also attended a Population Management meeting with providers, the quality management team, nursing leadership, and medical assistants. We observed robust discussions among medical leadership and providers. The OIG physician met with the CME and the two chief physician and surgeons (CP&S) to discuss physician documentation expectations and workflow for clinic providers with medical leadership. The OIG physician also interviewed clinic providers. They expressed good support by medical leadership. However, they indicated their main challenge was the specialty medication and pharmacy availability, as many new, complex patients arrived at the institution after regular pharmacy hours, especially after transplant surgeries. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 71 Recommendations • Medical leadership should determine the root cause(s) of providers not thoroughly reviewing specialty service reports and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 72 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. At the time of our inspection, CIM’s specialized medical housing consisted of an outpatient housing unit (OHU). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (78.3%) Case review found CIM performed satisfactorily in this indicator. The providers and nurses generally provided good care. Patients received medications timely. However, we found a pattern with providers not following specialist recommendations. In addition, we found opportunities for improvement in nursing assessments and nurses initiating care plans at the time of admission to the OHU or during the OHU review period. Notably, these deficiencies did not cause significantly increased risk of harm to patients. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed CIM had a mixed performance in specialized medical housing. Nursing staff performed excellently in completing admission assessments timely, and providers performed satisfactorily in completing the history and physical examinations. In contrast, the institution needed significant improvement in timely administering medications for newly admitted patients. Based on the overall Specialized Medical Housing compliance score result, the OIG rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 10 OHU cases that included 47 provider events and 37 nursing events. Due to the frequency of nursing and provider contacts in the specialized medical housing unit, we bundle up to two weeks of patient care into a single event. We identified 29 deficiencies, five of which were significant.76 Provider Performance OHU providers generally delivered acceptable care. Compliance testing showed providers frequently completed admission history and physicals (H&Ps) timely (MIT 13.002, 80.0%). OIG clinicians found providers always completed H&Ps timely and generally made appropriate assessments and decisions. However, we found a pattern in which, when specialists evaluated patients, the providers did not always follow the specialists’ 76 Deficiencies occurred in cases 6, 21, 22, 25, and 47–50. Significant deficiencies occurred in cases 25 and 50. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 73 recommendations.77 Additionally, in one case, the same provider used the “copy and paste” function extensively throughout the patient’s documentation. We identified five deficiencies, all five of which were significant.78 The following are examples: • In case 25, the provider evaluated the patient for OHU placement follow-up and reviewed the pulmonology specialist recommendation stating the patient will require bronchoscopy as soon as possible. However, the provider requested bronchoscopy with medium-priority, instead of urgent-priority. Furthermore, the provider used “copy and paste” functionality extensively throughout the patient’s documentation and did not thoroughly review the patient’s chart. In one instance, the provider documented in the progress note about referring the patient to an on-site ophthalmologist even though in the EHRS, patient had already refused the on-site ophthalmologist appointment five days prior. • In case 50, the provider reviewed and signed the registered dietician report. However, the provider did not follow the recommendations and did not order two cartons of original boost nutritional supplement for one month for wound healing. Nursing Performance OIG clinicians found nurses performed timely admission assessments. Compliance testing showed OHU nursing staff performed excellently in completing timely admission assessments (MIT 13.001, 100%). We found OHU nurses conducted regular rounds and generally provided satisfactory care. However, OIG clinicians found opportunities for improvement in thorough nursing assessments. Also, we identified a pattern in which OHU nurses were not initiating individualized care plans at the time of admission or during the duration of the review period.79 OIG clinicians concluded, of the 29 deficiencies identified in the specialized medical housing cases, 20 directly related to the quality of nursing care, but none of these were significant.80 Examples are described below: • In cases 6, 22, 47, 48, 49 and 50, OHU nurses did not initiate individualized care plans at the time of admission or during the review period. • In case 21, from June 2024, through August 2024, the patient was housed in the OHU after undergoing surgery to remove the appendix. Although nurses frequently performed daily rounds, vital signs, and wound care, OHU nurses did not always assess the patient’s subjective pain levels. In addition, during this review period, nurses frequently did not assess the patient for abdominal symptoms, to include inquiring about the last bowel movement. Lastly, nurses frequently had conflicting documentation discrepancies in the appearance of the 77 In cases 22, 25, and 50, the provider did not follow the specialists’ recommendation. 78 Provider deficiencies occurred in cases 25 and 50. Significant deficiencies occurred in cases 25 and 50. 79 Interdisciplinary care plan is a formal, individualized treatment plan that identifies existing needs and recognizes potential needs or risks of a patient to also include setting specified goals and outcomes. According to CCHCS HCDOM 3.1.10 Specialized Health Care Housing, patients in the SMH shall have an interdisciplinary care plan completed with 72 hours of the patient’s admission and updated as the patient’s condition changes, treatments change, and interventions change. 80 Nursing deficiencies occurred in cases 6, 21, 22, and 47–50. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 74 wound, including the wound measurements, drainage, and the description of the wound edges. • In case 48, the OHU patient reported coughing up blood the night prior. However, the RN did not listen to lung sounds; assess the appearance of the patient’s mouth, mucous membranes, and throat; or notify the provider of the patient’s report. Medication Administration Compliance testing showed CIM performed poorly in ensuring patients admitted to the OHU received their medications within required time frames (MIT 13.003, 33.3%). This is discussed further in the Medication Management indicator. OIG clinicians identified one deficiency related to OHU medication continuity, which was not significant.81 Clinician On-Site Inspection At the time of the on-site inspection, the OHU had 45 beds and two negative-pressure rooms for respiratory isolation, and the census in OHU was 43. The OHU was divided into two stations; one station had 22 beds, and the other station had 23 beds. Each OHU station was staffed with one RN and one lead RN to cover both stations on the morning shift. The evening shift and night shift were staffed with two LVNS and one lead RN to cover both stations. Nursing staff reported sometimes they might have a certified nursing assistant (CNA) on staff, but often, the CNA was redirected to the mental health crisis bed (MHCB) area. The lead RN on all the shifts was also responsible for covering the MHCB stations. The RNs on each station were responsible for rounding, daily assessments, medication administration, wound care, admission and discharge assessments, and responding to emergencies in the unit. Nursing staff reported they did not initiate care plans in the OHU because it was an outpatient unit but did initiate care plans in the MHCB because it was an inpatient unit. The nursing staff reported the need for additional nursing support in the unit due to the presence of high-acuity patients requiring more nursing care. Nurses reported the OHU could have patients on IV antibiotics and patients requiring extensive wound care. This, therefore, increased the nurses’ responsibilities. The OHU and the MHCB shared one RN shift lead on each shift. CIM had a designated OHU provider, who made rounds with nursing staff and conducted daily morning huddles. The supervising registered nurse (SRN) reported assessing quality of nursing care by performing audits on admission assessments when patients returned from the hospital and off-site specialty appointments as well as for patients requiring wound care. The SRN reiterated the nurses did not initiate care plans for OHU patients. We interviewed the CNE, who reported the Health Care Department Operations Manual (HCDOM) referenced care plans for OHU patients and stated they would consult with CCHCS since CIM nursing staff had not previously initiated care plans for OHU patients. Compliance Testing Results 81 A medication deficiency occurred in case 49. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 75 On-Site Inspection and Discussion At the time of the compliance on-site inspection, the OHU maintained an operational call light system to ensure patients had access to care (MIT 13.101, 100%). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 76 Compliance Score Results Table 16. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial 10 0 0 100% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 8 2 0 80.0% required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 6 1 33.3% within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call 1 0 0 100% system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local 0 0 0 0 operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 78.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 77 Recommendations • Nursing leadership should determine the challenges to nurses performing thorough assessments and initiating individualized care plans. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 78 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (82.5%) Case review found CIM generally provided satisfactory specialty services for patients. Providers appropriately referred patients to specialists and followed up after specialty services. TTA providers and nurses also performed well in assessing patients who returned from specialty appointments. However, we found opportunities for improvement in scanning the reports and forwarding them to providers within required time frames. After considering all factors, the OIG rated the case review component of this indicator adequate. CIM performed variably in compliance testing for this indicator. Depending on the priority of the specialty service, access to specialty services ranged from needing improvement to excellent. Preapproved specialty services for newly arrived patients sometimes occurred within required time frames. Performances in retrieving specialty reports with prompt provider endorsements were mixed. Based on the overall Specialty Services compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 161 events related to specialty services, which included 135 specialty consultations and procedures as well as 26 nursing encounters. We identified 22 deficiencies, five of which were significant.82 Access to Specialty Services Compliance testing showed patients often received timely specialty services with high- priority referrals (MIT 14.001, 80.0%) and routine-priority referrals (MIT 14.007, 86.7%) within the required time frame. CIM also performed excellently in timely completing subsequent follow-up appointments to high-priority specialty services (MIT 14.003, 100%) and performed very well with subsequent follow-up appointments to medium-priority (MIT 14.006, 88.9%) and routine-priority (MIT 14.009, 88.9%) specialty services. However, CIM needed improvement in timely completing medium-priority referrals (MIT 14.004, 60.0%) and performed poorly in timely completing preapproved specialty services for patients transferring into CIM (MIT 14.010, 45.0%). In contrast, OIG clinicians did not find any deficiencies related to specialty appointment access. 82 Deficiencies occurred in cases 3, 6, 8, 10, 12, 16, 19, 23, 47, and 48. Significant deficiencies occurred in cases 8, 10, and 12. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 79 Provider Performance In general, providers referred patients appropriately, followed the specialists’ recommendations, and endorsed the specialty reports timely. Compliance testing showed timely follow-up appointments with providers after specialty consultations needed improvement (MIT 1.008, 73.1%). OIG clinicians identified three significant deficiencies related to providers not following specialists’ recommendations without documenting the medical rationale for doing so, and three deficiencies related to providers endorsing the specialists’ reports late.83 The following are examples: • In case 6, a CIM staff scanned the specialty report and forwarded it to the provider to review and sign. However, the provider endorsed the report eight days later. • In case 12, the ophthalmologist recommended to start glaucoma medication, latanoprost eye drops; however, the provider did not start the medication and did not document a medical rationale for not following the recommendation. Nursing Performance CIM specialty nurses reviewed specialty service requests and appropriately scheduled patients for specialty appointments. Nurses properly assessed patients after returning from specialty appointments, reviewed specialists’ recommendations, and communicated the recommendations to providers. OIG clinicians reviewed 26 nursing events in which patients returned from off-site specialty appointments and identified only two deficiencies, neither of which were significant.84 The following is an example: • In case 47, an RN evaluated the OHU patient, who had bilateral drains for a subdural hematoma, upon return from an off-site specialty neurology consult for a wound check. However, the RN did not describe the appearance of the patient’s scalp or wound site. Health Information Management Compliance testing showed providers always received and reviewed the high-priority specialty reports (MIT 14.002, 100%) and often received and reviewed the medium-priority specialty reports (MIT 14.005, 86.7%) timely. However, CIM needed improvement with receiving and reviewing routine-priority specialty reports (MIT 14.008, 73.3%) within required time frames. CIM staff generally scanned the specialty reports into the EHRS within the required time frame (MIT 4.002, 80.0%). OIG clinicians identified 11 deficiencies related to delays in retrieving and scanning the report, two of which were significant. Three deficiencies related to not forwarding the report to the providers for review.85 The following is an example: 83 Deficiencies occurred in cases 6, 12, and 48. Significant deficiencies occurred in case 12. 84 Deficiencies occurred in cases 6 and 48. 85 Deficiencies occurred in cases 3, 8,10, 12, 16, 19, and 23. Significant deficiencies occurred in cases 8 and 10. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 80 • In case 16, the ophthalmology specialist evaluated the patient for possible glaucoma, diabetes, and cataracts. However, CIM staff did not forward this specialty report to the provider to review and sign. We also discuss specialty reports management in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians met with medical and nursing leadership, providers, specialty nurses, and the utilization management (UM) nurse to discuss specialty services at CIM. Nursing staff reported challenges with available local specialty providers for soft contact lenses as well as an increased number of new arrivals, including patients arriving for layover and patients returning from the Male Community Reentry Program (MCRP), out to court from other institutions, post gender-affirming surgical care, and posttransplant care from nearby transplant centers. CIM offered on-site specialty services including optometry, ophthalmology, audiology, orthotics, hair electrolysis, gastroenterology (esophagogastroduodenoscopy and colonoscopy), wound care, physical therapy, and telemedicine specialty services.86 86 Hair electrolysis is a method used to remove hair. An esophagogastroduodenoscopy is a procedure using a camera to examine the esophagus and the stomach. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 81 Compliance Score Results Table 17. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 4 1 0 80.0% Service? (14.001) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 5 0 0 100% frame? (14.002) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 5 0 0 100% (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician Request for 9 6 0 60.0% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 13 2 0 86.7% frame? (14.005) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 8 1 6 88.9% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for 13 2 0 86.7% Service? (14.007) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 11 4 0 73.3% frame? (14.008) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 8 1 6 88.9% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 9 11 0 45.0% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Did the institution deny the primary care provider’s request for specialty 20 0 0 100% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 16 4 0 80.0% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 82.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 82 Table 18. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up visits 19 7 9 73.1% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 20 5 10 80.0% within five calendar days of the encounter date? (4.002) * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 83 Recommendations • Health care leadership should determine the root cause(s) of challenges to staff timely providing specialty appointments, including preapproved specialty appointments for transfer-in patients, and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 84 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (76.9%) CIM’s performance was satisfactory in this indicator. While CIM scored superlatively in most applicable tests, it needed improvement in some areas. The Emergency Medical Response Review Committee (EMRRC) rarely completed the required checklists. Staff did not conduct a live medical emergency response drill during the most recent quarter. In addition, physician managers rarely completed annual performance appraisals timely. These findings are set forth in the table on the next page. Based on the overall Administrative Operations compliance score result, the OIG rated the compliance testing component of this indicator adequate. Compliance Testing Results Nonscored Results At CIM, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Mortality Case Review reporting data. In our inspection, for 10 patients, we found no evidence in the submitted documentation that the preliminary mortality reports had been completed. These reports were overdue at the time of the OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 85 Compliance Score Results Table 19. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the This is a nonscored test. Please refer to the institution meet RCA reporting requirements? (15.001) discussion in this indicator. Did the institution’s Quality Management Committee (QMC) meet monthly? 6 0 0 100% (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did the incident 1 11 0 8.3% packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local operating N/A N/A N/A N/A procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 10 0 0 100% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 2 12 0 14.3% timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 17 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 2 0 1 100% (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100% valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement Agency (DEA) registration certificates, and did the pharmacy maintain valid 1 0 0 100% Automated Drug Delivery System (ADDS) licenses? (15.109) Did nurse managers ensure their newly hired nurses received the required 1 0 0 100% onboarding and clinical competency training? (15.110) Did the CCHCS Death Review Committee process death review reports This is a nonscored test. Please refer to the timely? Effective 05/2022: Did the Headquarters Mortality Case Review discussion in this indicator. process mortality review reports timely? (15.998) What was the institution’s health care staffing at the time of the OIG medical This is a nonscored test. Please refer to Table 3 inspection? (15.999) for CCHCS-provided staffing information. Overall percentage (MIT 15): 76.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 86 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 87 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 88 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for CIM Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 89 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 90 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 91 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 92 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 93 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating The OIG medical inspection unit individually examines all the case review and compliance inspection findings under each specific methodology. We analyze the case review and compliance testing results for each indicator and determine separate overall indicator ratings. After considering all the findings of each of the relevant indicators, our medical inspectors individually determine the institution’s overall case review and compliance ratings. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 94 Appendix B: Case Review Data Table B–1. CIM Case Review Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 4 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services – CPR 1 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 14 Specialty Services 4 50 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 95 Table B–2. CIM Case Review Chronic Care Diagnoses Diagnosis Total Anemia 11 Anticoagulation 5 Arthritis/Degenerative Joint Disease 7 Asthma 2 COPD 8 COVID-19 2 Cancer 4 Cardiovascular Disease 7 Chronic Kidney Disease 3 Chronic Pain 10 Cirrhosis/End Stage Liver Disease 5 Coccidioidomycosis 1 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 15 Gastroesophageal Reflux Disease 12 Gastrointestinal Bleed 1 HIV 2 Hepatitis C 8 Hyperlipidemia 23 Hypertension 22 Mental Health 16 Seizure Disorder 1 Sleep Apnea 5 Substance abuse 14 Thyroid Disease 4 189 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 96 Table B–3. CIM Case Review Events by Program Program Total Diagnostic Services 240 Emergency Care 83 Hospitalization 51 Intrasystem Transfers In 6 Intrasystem Transfers Out 6 Outpatient Care 385 Specialized Medical Housing 149 Specialty Services 184 1,104 Table B–4. CIM Case Review Sample Summary Total MD Reviews Detailed 25 MD Reviews Focused 5 RN Reviews Detailed 15 RN Reviews Focused 25 Total Reviews 70 Total Unique Cases 50 Overlapping Reviews (MD & RN) 20 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 97 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 98 Appendix C: Compliance Sampling Methodology California Institution for Men Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least one Patients condition per patient — any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003 – 006 Nursing Sick Call 32 Clinic • Clinic (each clinic tested) (6 per clinic) Appointment List • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 25 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 35 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 9 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 99 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 32 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 35 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 25 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for • Any misfiled or mislabeled document any tested identified during incarcerated OIG compliance review person (24 or more = No) MIT 4.005 Returns From 25 CADDIS off-site • Date (2 – 8 months) Community Hospital admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101 – 105 Clinical Areas 9 OIG inspector • Identify and inspect all on-site clinical MITs 5.107 – 111 on-site review areas Transfers MITs 6.001 – 003 Intrasystem Transfers 25 SOMS • Arrival date (3 – 9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 4 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 100 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 • See Access to Care Medication • At least one condition per patient — any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 25 OIG Q: 4.005 • See Health Information Management Community Hospital (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 10 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med Areas by test on-site review line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical Preparation and by test on-site review areas that prepare and administer Administration Areas medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 24 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 8 On-site active • KOP rescue inhalers & nitroglycerin KOP Medications medication listing medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 101 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 15 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to Annual Screening inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to Vaccinations inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to Screening inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to institution inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to institution inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2 – 8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 102 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 003 Specialized Health 10 CADDIS • Admit date (2 – 8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101 – 102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001 – 003 High-Priority 5 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care / addiction medication, narcotic treatment program, and transgender services • Randomize MITs 14.004 – 006 Medium-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 103 Quality No. of Indicator Sample Category Samples Data Source Filters Specialty Services (continued) MITs 14.007 – 009 Routine-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize MIT 14.010 Specialty Services 20 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 20 InterQual • Review date (3 – 9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Administrative Operations MIT 15.001 Adverse/sentinel N/A Adverse/sentinel • Adverse/Sentinel events events events report (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB N/A at this LGB meeting • Quarterly meeting minutes institution minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 104 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations (continued) MIT 15.103 Death Reports 10 Institution-list of • Most recent 10 deaths deaths in prior Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 14 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 17 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site certification • All staff Response tracking logs • Providers (ACLS) Certifications • Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications MIT 15.109 Pharmacy and All On-site listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee training logs 12 months) Orientations MIT 15.998 CCHCS Mortality 10 OIG summary log: • Between 35 business days & Case Review deaths 12 months prior • California Correctional Health Care Services mortality reviews Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 105 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7, California Institution for Men | 106 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: January 2026 Cycle 7 Medical Inspection Report for California Institution for Men OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA January 2026 OIG