California Institution for Women Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, California Institution for Women | 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 6 Population-Based Metrics 9 HEDIS Results 9 Recommendations 12 Indicators 15 Access to Care 15 Diagnostic Services 21 Emergency Services 26 Health Information Management 30 Health Care Environment 36 Transfers 43 Medication Management 50 Prenatal and Postpartum Care 59 Preventive Services 63 Nursing Performance 66 Provider Performance 72 Specialized Medical Housing 77 Specialty Services 82 Administrative Operations 87 Appendix A: Methodology 90 Case Reviews 91 Compliance Testing 94 Indicator Ratings and the Overall Medical Quality Rating 95 Appendix B: Case Review Data 96 Appendix C: Compliance Sampling Methodology 100 California Correctional Health Care Services’ Response 108 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | iv Illustrations Tables 1. CIW Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. CIW Master Registry Data as of April 2024 7 3. CIW Health Care Staffing Resources as of April 2024 8 4. CIW Results Compared With State HEDIS Scores 11 5. Access to Care 18 6. Other Tests Related to Access to Care 19 7. Diagnostic Services 24 8. Health Information Management 33 9. Other Tests Related to Health Information Management 34 10. Health Care Environment 41 11. Transfers 47 12. Other Tests Related to Transfers 48 13. Medication Management 56 14. Other Tests Related to Medication Management 57 15. Prenatal and Postpartum Care 61 16. Preventive Services 64 17. Specialized Medical Housing 80 18. Specialty Services 84 19. Other Tests Related to Specialty Services 85 20. Administrative Operations 88 A–1. Case Review Definitions 91 B–1. CIW Case Review Sample Sets 96 B–2. CIW Case Review Chronic Care Diagnoses 97 B–3. CIW Case Review Events by Program 98 B–4. CIW Case Review Sample Summary 98 Figures A–1. Inspection Indicator Review Distribution for CIW 90 A–2. Case Review Testing 93 A–3. Compliance Sampling Methodology 94 Photographs 1. Indoor Waiting Area 36 2. Individual Waiting Module 37 3. Expired Medical Supply Dated March 17, 2024 38 4. Physical Therapy Ice Packs Stored With Staff Members' Personal Food Items 38 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 that 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 Women, 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 October 2023 to March 2024.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of CIW in September 2024. OIG inspectors monitored the institution’s delivery of medical care that occurred between October 2023 and March 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 CIW adequate. quality at CIW adequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 57 cases, which contained 1,323 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 that may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in September 2024, to verify their initial findings. OIG physicians rated the quality of care for 29 comprehensive case reviews. Of these 29 cases, our physicians rated none proficient, 27 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 379 patient records and 1,259 data points and used the data to answer 100 policy questions. In addition, we observed CIW’s processes during an on-site inspection in May 2024. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 14 health care indicators.5 5 The indicator for Reception Center did not apply to CIW. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CIW Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 CIW during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 11 of the 14 indicators applicable to CIW. Of these 11 indicators, OIG clinicians rated two proficient, eight adequate, and one inadequate. OIG physicians also rated the overall adequacy of care for each of the 29 detailed case reviews they conducted. Of these 29 cases, 27 were adequate, and two were inadequate. In the 1,323 events reviewed, we identified 227 deficiencies, 43 of which 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 CIW: • Staff provided good access to care with most provider appointments occurring timely, including outpatient, after hospitalization, after specialty, or after TTA events. Nursing clinic appointments always occurred timely. • Staff completed almost all specialty appointments as requested. In addition, they retrieved and scanned all specialty reports timely. • Staff frequently completed diagnostic tests within requested time frames. Our clinicians found the following weaknesses at CIW: • Providers needed to improve communication of diagnostic test results to patients through complete patient test results letters and timely endorsement of specialty service reports. • Staff performed poorly in medication management making frequent medication reconciliation errors for patients returning from hospitals. Delays in medication continuity occurred for patients transferring into CIW. In the specialized medical housing unit, staff did not issue rescue inhalers to their patients. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 6 Compliance Testing Results Our compliance inspectors assessed 11 of the 14 indicators applicable to CIW. Of these 11 indicators, our compliance inspectors rated two proficient, six adequate, and three inadequate. We tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. CIW showed a high rate of policy compliance in the following areas: • Staff performed exceptionally in scanning community hospital discharge reports and requests for health care services into patients’ electronic medical records within required time frames. • CIW showed perfect performance in offering and providing preventive services for their patients, such as influenza vaccination, colorectal cancer screening, and breast cancer screening. Staff also performed outstandingly in providing and monitoring patients taking tuberculosis (TB) medications. • Nursing staff processed sick call request forms, performed face-to-face evaluations, and completed nurse-to-provider referrals within required time frames. In addition, CIW housing units contained adequate supplies of health care request forms. CIW showed a low rate of policy compliance in the following areas: • Staff sporadically maintained medication continuity for chronic care patients, patients discharged from the hospital, and patients admitted to specialized medical housing. Furthermore, staff intermittently maintained medication continuity for patients who transferred into the institution or had a temporary layover at CIW. • Nursing staff did not regularly inspect emergency medical response bags (EMRBs). • Healthcare staff did not follow hand hygiene precautions before or after patient encounters, or during medication administration. • Medical clinics contained multiple expired medical supplies. Institution-Specific Metrics The California Institution for Women is located in the city of Corona in Riverside County. CIW’s mission is to provide a safe and secure environment for its incarcerated female population. The institution houses general population patients as well as patients with special needs, such as pregnancy, psychiatric care, and medical problems. CIW runs clinics in which health care staff members handle nonurgent requests for medical services. The institution also conducts patient screenings in its receiving and release (R&R) clinical area, treats patients requiring urgent or emergent care in its triage and treatment area (TTA), and houses patients requiring inpatient care in its licensed correctional treatment center (CTC). In its outpatient housing unit (OHU), CIW treats Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 7 patients who require assistance with the activities of daily living but do not require a higher level of inpatient care. CCHCS has designated CIW as an intermediate care prison. To provide the most cost-effective care, intermediate care institutions are predominantly located in urban areas, close to tertiary care centers and specialty care providers likely to be used by a patient population with higher medical needs. As of January 14, 2025, the department reported on its public tracker 62 percent of CIW’s incarcerated population is fully vaccinated for COVID-19 while 67 percent of CIW’s staff is fully vaccinated for COVID-19.7 In April 2024, the Health Care Services Master Registry showed CIW had a total population of 1,159. A breakdown of the medical risk level of the CIW population as determined by the department is set forth in Table 2 below.8 Table 2. CIW Master Registry Data as of April 2024 Medical Risk Level Number of Patients Percentage* High 1 149 12.9% High 2 179 15.4% Medium 513 44.3% Low 318 27.4% Total 1,159 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 4-29-24. 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, CIW had no executive leadership vacancies, 0.8 primary care provider vacancies, no nursing supervisor vacancies, and 27.6 nursing staff vacancies. Table 3. CIW Health Care Staffing Resources as of April 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 6.8 20.5 217.1 249.4 Filled by Civil Service 5.0 6.0 20.5 189.5 221.0 Vacant 0 0.8 0 27.6 28.4 Percentage Filled by Civil Service 100% 88.2% 100% 87.3% 88.6% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 0 0 40.0 40.0 Percentage Filled by Registry 0 0 0 18.4% 16.0% Total Filled Positions 5.0 6.0 20.5 229.5 261.0 Total Percentage Filled 100% 88.2% 100% 105.7% 104.7% Appointments in Last 12 Months 0 2.0 3.0 43.0 48.0 Redirected Staff 88.2 0 0 0 88.2 Staff on Extended Leave ‡ 0 0 0 7.0 7.0 Adjusted Total: Filled Positions –83.2 6.0 20.5 222.5 165.8 Adjusted Total: Percentage Filled –1,664% 88.2% 100% 102.5% 66.5% * 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 April 29, 2024, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 CIW’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. 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)—CIW’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. CIW had a 57 percent influenza immunization rate for adults 18 to 64 years old and an 80 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 90 percent.10 Cancer Screening Statewide comparative data was available for breast cancer, cervical cancer, and colorectal cancer screening. When compared with statewide Medi-Cal programs— California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CIW had a 92 percent breast cancer screening rate and an 83 percent colorectal cancer screening rate, indicating very good performance on these two screening measures. CIW had a 55 percent cervical cancer screening rate, which was 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 10 worse than California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal). Prenatal and Postpartum Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CIW’s prenatal care was 100 percent and postpartum care was 88 percent, indicating better performance than the three Medi-Cal programs. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 11 Table 4. CIW Results Compared With State HEDIS Scores CIW 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%) ‡,§ 5% 36% 31% 22% HbA1c Control (< 8.0%) ‡ 83% – – – Blood Pressure Control (< 140/90) ‡ 99% – – – Eye Examinations 80% – – – Influenza – Adults (18 – 64) 57% – – – Influenza – Adults (65 +) 80% – – – Pneumococcal – Adults (65 +) 90% – – – Breast Cancer Screening (50–74 ) 92% 56% 77% 77% Cervical Cancer Screening 55% 57% 75% 75% Colorectal Cancer Screening 83% 37% 68% 70% Prenatal Care 100% 89% 91% 95% Postpartum Care 88% 82% 79% 82% Notes and Sources * Unless otherwise stated, data were collected in May 2024 by reviewing medical records from a sample of CIW’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, 2022 – June 30, 2023 (published March 2024); https://www.dhcs.ca.gov/dataandstats/reports/Documents/Medi-Cal-Managed-Care-Technical- Report-Volume-1.pdf. ‡ For this indicator, the entire applicable CIW 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 12 Recommendations As a result of our assessment of CIW’s performance, we offer the following recommendations to the department: Access to Care • Health care leadership should determine the root cause(s) of challenges to timely providing provider follow-up appointments for chronic care and after specialty consultations and should implement remedial measures as appropriate. Diagnostic Services • The department should develop and implement strategies, such as an electronic solution, to ensure providers create patient letters that contain all elements required by CCHCS policy when they endorse test results. • Health care leadership should ascertain the root cause(s) of the untimely provision of STAT laboratory services as well as the untimely provider acknowledgment and nursing staff notification of STAT laboratory results and should implement remedial measures as appropriate. Health Care Environment • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement appropriate remedial measures. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement appropriate remedial measures. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and sealed and should implement appropriate remedial measures. Transfers • Health care leadership should identify the challenges to medication continuity for patients returning from hospitalizations or emergency rooms. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop strategies to ensure nursing staff completely answer and address required initial health screening questions. Leadership should implement remedial measures or education as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 13 Medication Management • Medical and nursing leadership should identify the challenges to ensuring hospital discharge and newly arrived patients receive their medications accurately, timely, and without interruption. Leadership should implement remedial measures as appropriate. • Pharmacy, medical, and nursing leadership should develop and implement measures to ensure supplemental doses can be accurately recorded in the patients’ medication administration record (MAR). • Nursing leadership should develop and implement strategies to ensure nursing staff correctly follow the prescriber’s ordered parameters prior to administering medications. • The institution should develop and implement measures to ensure staff timely make available and administer medications to patients, or document refusals in the MAR summaries, as described in CCHCS policy and procedures including refusals and no-shows. Prenatal and Postpartum Care • Health care leadership should ascertain causes related to the untimely scheduling of or provision of patients’ obstetrics (OB) appointments and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of staff not documenting the weight, blood pressure, and fundal height of patients at each clinic OB appointment and should implement remedial measures as appropriate. Preventive Services • Health care leadership should determine the root cause(s) of challenges to timely providing pap smears and should implement appropriate remedial measures. • Health care leadership should determine the root cause(s) for challenges to timely providing immunizations to chronic care patients and should implement appropriate remedial measures. Provider Performance • Medical leadership should ascertain the challenge(s) to providers performing pertinent examinations and timely endorsements of specialty service reports and should implement appropriate remedial measures. Specialized Medical Housing • Nursing leadership should determine the root cause(s) of challenges preventing nurses from performing thorough initial assessments and Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 14 ensuring nursing care plans address patient needs. Leadership should implement remedial measures as appropriate. Specialty Services • Health care leadership should ascertain the root cause(s) related to untimely providing and scheduling patients’ high-priority specialty service appointments and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of challenges to timely providing preapproved specialty appointments for transfer-in patients and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 15 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 Adequate (84.6%) Case review found CIW performed excellently in this indicator. Nursing appointments occurred timely, and most provider appointments, including outpatient, after hospitalization, after specialty consultation, or after a TTA event, occurred within required time frames. Considering all aspects, the OIG rated the case review component of this indicator proficient. In this cycle, compliance testing showed CIW performed well with access to care. Nurses always reviewed all patient sick call requests and frequently completed face-to-face encounters within required time frames. CIW always ensured housing units offered health care services forms for patients. Furthermore, providers always timely evaluated newly transferred patients and patients returning from hospitalizations. However, completion of chronic care follow-up appointments with providers needed improvement, and providers intermittently evaluated patients returning from specialty services appointments within required time frames. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results Our clinicians reviewed 521 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events that required the institution to generate appointments. We identified only two deficiencies related to Access to Care, both of which were significant.11 Access to Care Providers Compliance testing showed CIW often timely completed nurse-to-provider appointments (MIT 1.005, 80.0%). However, staff needed improvement with timely completing chronic care follow-up appointments with providers (MIT 1.001, 64.0%). In contrast, OIG clinicians reviewed 129 clinic provider appointments and did not identify any deficiencies. 11 The two significant deficiencies occurred in cases 6 and 8. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 16 Access to Specialized Medical Housing Providers CIW performed well with access to specialized medical housing providers. OIG clinicians reviewed 31 provider encounters and did not identify any deficiencies related to provider appointments. Access to Clinic Nurses Compliance testing showed nurses always reviewed nurse sick call requests on the same day they were received (MIT 1.003, 100%). The nurses also frequently completed face-to- face encounters within the required one business day (MIT 1.004, 90.0%). OIG clinicians reviewed 146 nursing encounters and did not identify any deficiencies related to clinic nurse access. Access to Specialty Services Compliance testing revealed variable completion of initial high-priority specialty appointments (MIT 14.001, 60.0%), initial medium-priority specialty appointments (MIT 14.004, 93.3%), and initial routine-priority specialty appointments (MIT 14.007, 100%) within required time frames. However, staff performed excellently in completing follow- up specialty appointments, as compliance testing showed all follow-up high-priority, medium-priority, and routine-priority specialty appointments occurred within required time frames (MIT 14.003, 100%, MIT 14.006, 100%, and MIT 14.009, 100%). OIG clinicians reviewed 147 specialty events and identified only one significant deficiency related to delayed specialty appointments. This deficiency is discussed in the Provider Performance indicator.12 Follow-Up After Specialty Services Compliance testing revealed CIW needed improvement with completing provider appointments after specialty services (MIT 1.008, 53.1%). OIG clinicians did not identify any missed or delayed provider appointments. Follow-Up After Hospitalization Compliance testing showed all provider appointments after hospitalization occurred within required time frames (MIT 1.007, 100%). OIG clinicians reviewed 36 hospital returns and identified two missed appointments as follows: • In case 6, the nurse requested a provider follow-up appointment in five days for the patient returning from community hospital. However, the appointment did not occur. • In case 8, a nurse requested a provider follow-up appointment in five days for the patient returning from a community emergency department. However, the appointment did not occur. 12A deficiency occurred in case 25. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 17 Follow-Up After Urgent or Emergent Care (TTA) CIW providers always evaluated their patients following a TTA event, as medically indicated. OIG clinicians reviewed 64 TTA events and did not identify any deficiencies. Follow-Up After Transferring Into CIW Compliance testing showed provider appointments frequently occurred for newly arrived patients (MIT 1.002, 90.0%). OIG clinicians evaluated nine transfer-in events and did not identify any missed or delayed provider appointments. Clinician On-Site Inspection CIW had three main clinics: 1, 2, and 3. Clinic staff reported each clinic was assigned one provider and an office technician, each of whom attended the morning huddles and scheduled provider appointments. Each provider evaluated about eight patients per day. At the time of the on-site inspection, CIW had 147 provider appointments backlogged for the three main clinics. OIG clinicians attended morning huddles for clinics 1 and 2. The patient care team discussed specialty appointments with recommendations, patient glucose logs, hospital returns, and medication refusals. Nurses informed providers of scheduled clinic appointments, expiring medications, and new arrivals from other institutions. OIG clinicians discussed the two missed provider appointments referenced above in cases 6 and 8 with the office technician supervisor. The supervisor explained that, in each case, the medical assistant escorted the patient to the examination room and obtained vital signs; however, the record contained no explanation why the provider did not see the patient or write a note. Compliance On-Site Inspection and Discussion Patients had access to health care services request forms in all six housing units inspected (MIT 1.101, 100%). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 18 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 16 9 0 64.0% 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 18 2 5 90.0% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 30 0 0 100% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 27 3 0 90.0% 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 1 25 80.0% 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 0 0 30 N/A specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 16 0 1 100% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 17 15 13 53.1% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 6 0 0 100% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 84.6% * 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 19 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 15 5 0 75.0% 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 9 6 0 60.0% Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 9 0 6 100% 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 14 1 0 93.3% 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? 6 0 9 100% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 15 0 0 100% 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 6 0 9 100% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 20 Recommendations • Health care leadership should determine the root cause(s) of challenges to timely providing provider follow-up appointments for chronic care and after specialty consultations and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 21 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 Adequate (76.0%) Case review found CIW performed well in this indicator. Staff completed all radiology tests and most laboratory tests within requested time frames. Providers did not always thoroughly communicate test results to their patients; however, these deficiencies were minor. Taking all factors into consideration, the OIG rated the case review component of this indicator adequate. CIW’s overall compliance testing score improved for this indicator in Cycle 7. Staff performed very well to excellently in timely completing laboratory and radiology tests and timely retrieving pathology reports. Providers also often reviewed and endorsed diagnostic test results within required time frames. However, staff needed improvement in timely completing STAT tests and in acknowledging or notifying STAT laboratory results timely. In addition, providers performed variably in generating complete patient notification test result letters with all required elements. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 234 diagnostic events and identified 20 deficiencies, three of which were significant. Of the 20 deficiencies, 15 related to health information management and five to test completion.13 Test Completion Compliance testing showed staff frequently completed radiology tests within the required time frames (MIT 2.001, 90.0%). OIG clinicians reviewed 43 radiology tests and did not identify any missed or delayed tests. 13 Diagnostic deficiencies occurred in cases 3, 5, 6, 8-11, 16, 18, 19, 26-28, 30, and 57. Significant deficiencies occurred in cases 5, 26, and 30. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 22 Compliance testing showed staff always completed laboratory tests timely (MIT 2.004, 100%). However, OIG clinicians reviewed 177 laboratory tests and identified five deficiencies related to untimely specimen collection.14 The following are examples: • In case 18, a provider requested laboratory tests be completed in three days. However, the medical staff completed the tests in four days. • In case 30, a provider requested laboratory tests, including a hepatitis C viral test, be completed on the following day. However, the medical staff did not complete this test until 21 days later. Compliance testing revealed staff needed improvement in completing STAT laboratory tests within required time frames (MIT 2.007, 62.5%). OIG clinicians did not have any STAT laboratory tests to review in their case samples. OIG clinicians reviewed nine electrocardiograms (EKGs) and found staff performed all as requested.15 Health Information Management Compliance testing showed CIW staff retrieved all pathology reports timely (MIT 2.010, 100%). OIG clinicians also found all laboratory test results and most radiology reports were retrieved timely, except for one ultrasound report. We reviewed five pathology events and identified one missed pathology report.16 We further discuss the missed ultrasound and pathology reports in the Health Information Management indicator. Regarding endorsement of results, compliance testing showed the providers often endorsed radiology reports and always endorsed laboratory results timely (MIT 2.002, 80.0% and MIT 2.005, 100%). The providers also always endorsed pathology reports (MIT 2.011, 100%) and often endorsed STAT laboratory results (MIT 2.009, 87.5%) within specified time frames. OIG clinicians identified five deficiencies related to late endorsements.17 The following are examples: • In case 8, CIW staff scanned a pathology report of a fluid drainage into the EHRS; however, the provider did not endorse the report until 15 days later.18 • In case 16, the provider did not endorse laboratory tests results until 18 days after the results were available. 14 Deficiencies occurred in cases 10, 18, 27, 30, and 57. 15 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. 16 Deficiencies occurred in case 25 and 26. 17 Deficiencies occurred in cases 8, 9, 11, and 16. 18 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for storing the patient’s medical history and health care staff communication. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 23 Compliance testing revealed providers rarely acknowledged STAT test results and nursing staff rarely notified providers of STAT test results within required time frames (MIT 2.008, 12.5%). Compliance testing showed providers inconsistently sent complete patient notification test result letters for radiology results (MIT 2.003, 60.0%), laboratory results (MIT 2.006, 80.0%), or pathology results (MIT 2.012, 40.0%) within required time frames. OIG clinicians found on two occasions, the providers did not send letters informing patients of radiology results, and on one occasion, the provider did not send the letter informing the patient of a pathology result.19 The following are examples: • In case 28, a provider endorsed an arterial ultrasound result but did not send a patient result letter. • In case 30, a provider endorsed a pathology report of a tongue lesion but did not send a patient result letter. OIG clinicians also found five examples of patient letters with at least one of the required elements missing. The following is an example: • In case 3, a provider sent a letter informing the patient of laboratory results but did not include all the required elements, such as whether the tests were within normal limits. Clinician On-Site Inspection OIG clinicians met with the laboratory supervisor and radiology supervisor. They reported CIW had two full-time phlebotomists, who perform about 30 laboratory tests per day, and two full-time x-ray technicians, who perform general x-rays on site. Monthly mobile imaging units offer mammogram, ultrasound, CT, and MRI services on site.20 OIG clinicians discussed the late collections of laboratory tests with the laboratory supervisor. The supervisor explained the late collections were due to a staff shortage, as the senior laboratory technician was out on extended leave and subsequently retired. 19 Deficiencies occurred in cases 28 and 30. 20 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. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 24 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 9 1 0 90.0% 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 6 4 0 60.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 10 0 0 100% 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 8 2 0 80.0% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive 5 3 0 62.5% the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing 1 7 0 12.5% staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory 7 1 0 87.5% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 10 0 0 100% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 4 6 0 40.0% pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 76.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 25 Recommendations • The department should develop and implement strategies, such as an electronic solution, to ensure providers create patient letters that contain all elements required by CCHCS policy when they endorse test results. • Health care leadership should ascertain the root cause(s) of the untimely provision of STAT laboratory services as well as the untimely provider acknowledgment and nursing staff notification of STAT laboratory results and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 26 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 Adequate Not Applicable In this cycle, case review found CIW provided sufficient care. Nursing staff responded promptly to emergency events and usually provided appropriate care. In addition, providers made appropriate medical decisions. CIW nursing and provider leadership always conducted clinical reviews of their unscheduled higher level of care transfers; however, on a few occasions, they missed opportunities to improve their nurses’ care. Although we identified some opportunities for improvement in CIW’s urgent and emergent care, the deficiencies we found did not impact patient outcomes. The OIG rated this indicator adequate. Case Review Results We reviewed 94 urgent and emergent events and found 45 emergency deficiencies. Of these 45 deficiencies, three were significant.21 Emergency Medical Response Our clinicians reviewed 30 emergency events requiring responses from first medical responders and found CIW performed well. Custody and health care staff responded to emergencies throughout the institution. In addition, the staff timely activated emergency medical services (EMS) as necessary. Cardiopulmonary Resuscitation (CPR) Quality During this period, we reviewed only one case in which CPR was initiated. Custody and medical staff worked cohesively to provide care, moved the patient to the TTA for additional interventions, and appropriately transferred the patient to a higher level of care. An opportunity for improvement was identified and is detailed below: 21Deficiencies occurred in cases 1-4, 7, 8, 14, 16-18, and 22- 25. Significant deficiencies occurred in cases 2, 8, and 14. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 27 • In case 4, custody staff initiated CPR, administered naloxone, and activated emergency medical services.22 The patient responded to naloxone and improved; however, in this case, the nurses never obtained a complete set of vital signs. Provider Performance CIW providers performed well in urgent and emergent situations, and in after-hours care. Although they made accurate diagnoses, on two occasions, TTA nurses consulted providers, but the providers did not document the communication. Nursing Performance CIW’s nurses performed well in urgent and emergent events. They responded to emergencies promptly and generally provided appropriate care. Occasionally, we found incomplete nurse assessments and documentation; however, nurses usually formulated appropriate plans of care. We identified the following examples of opportunities for nursing improvement: • In case 2, a nurse evaluated the patient for chest pain. The nurse administered nitroglycerin but did not administer aspirin as warranted. In addition, the nurse did not document the times of nitroglycerin administration. • In case 8, a nurse evaluated the pregnant patient after a fall onto her stomach. The nurse did not subjectively assess the patient for contractions and did not describe the appearance of the patient’s abdomen. Emergency Medical Response Review Committee The EMRRC met monthly and discussed emergency responses and unscheduled send- outs. Compliance testing found most incident packages were deficient due to cases not being reviewed within the required time frame or being incomplete (MIT 15.003, 33.3%). Our clinicians identified 28 urgent or emergent events that resulted in patients being transferred to a higher level of care. CIW nursing and provider leadership consistently conducted clinical reviews of all these events; however, on a few occasions, they did not identify opportunities for improvement. Examples are listed below: • In case 2, the nurse did not administer aspirin as directed in the CCHCS chest pain protocol. • In case 24, an LVN consulted a TTA RN when the diabetic patient had chest pain and an elevated blood pressure result. Instead of responding to the patient with the urgent cardiac symptoms, the RN inappropriately instructed 22 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 five nasal naloxone doses when an opioid overdose is suspected. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 28 the LVN to transport the patient to the TTA, which caused a delay in RN assessment and interventions. Clinician On-Site Inspection During the clinician on-site inspection, we inspected the TTA, which had two examination rooms with a nursing station in the middle of the two rooms. One of the rooms contained an infant warmer and supplies for an emergency delivery. Our clinicians interviewed two RNs, who indicated CIW’s TTA was very busy with emergency responses.23 While discussing the emergency response process, the RNs indicated LVNs served as the first medical responders on the morning and afternoon shifts; however, on the night shift, the TTA RNs were the first medical responders. According to the RNs, even when the LVNs responded first, the TTA RNs always responded to each emergency. Nurses reported having received new employee training on emergency deliveries; however, in their five combined years of time in the TTA, they had not experienced an emergency delivery on their shifts. One of the TTA nurses interviewed indicated they personally felt more emergency delivery training should be provided to the nursing staff. The TTA nurses described being very busy evaluating the high volume of patients returning from off-site specialist appointments during the morning shift, which ranged from 11 to 35 patients on business days. OIG clinicians also spoke with a physician assigned to work in the TTA. The provider had recently transferred from another institution and expressed his enjoyment working in the TTA and at CIW. According to CIW leadership, after business hours and on the weekends, the provider would commonly receive around 30 calls from TTA staff each day. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 29 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 (92.5%) Case review found CIW performed well in this indicator. Staff retrieved all specialty reports and laboratory tests as well as most hospital records, radiology results, and pathology reports within required time frames. However, our inspection revealed a pattern of late endorsements of specialty reports and incomplete or missing patient test result notification letters. Taking all factors into consideration, the OIG rated the case review component of this indicator adequate. Compliance testing showed CIW performed excellently in this indicator. Staff always scanned patients’ requests for medical care as well as scanned and retrieved hospital discharge records within required time frames. CIW satisfactorily scanned specialty reports and ensured staff labeled and filed medical records in the appropriate patient files. Based on the overall compliance score result, the OIG rated the compliance component of this indicator proficient. Case Review and Compliance Testing Results OIG clinicians reviewed 1,323 events and identified 26 deficiencies related to health information management, seven of which were significant.24 Hospital Discharge Reports Compliance testing showed CIW staff always scanned hospital discharge records timely (MIT 4.003, 100%). In addition, the hospital discharge reports always included key elements, and the providers always endorsed hospital discharge reports timely (MIT 4.005, 100%). OIG clinicians reviewed 36 off-site emergency department and hospital encounters and identified only one hospital discharge summary that was not retrieved as follows: 24 Deficiencies occurred in cases 2, 3, 5-9, 11, 16, 19, 26, 28, 30, and 55. Significant deficiencies occurred in cases 2, 5, 6, 7, and 26. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 31 • In case 2, the patient was discharged from a community hospital with a diagnosis of anemia; however, CIW staff did not retrieve the hospital discharge summary. Specialty Reports Compliance testing showed the institution frequently retrieved and scanned specialty reports within the required time frames (MIT 4.002, 83.3%), and the providers often endorsed high-priority and medium-priority but only intermittently endorsed routine- priority specialty reports timely (MIT 14.002, 80.0%, MIT 14.005, 83.3% and MIT 14.008, 53.3%). OIG clinicians reviewed 147 specialty appointments and found staff retrieved all specialty reports timely. For specialty report endorsements, we identified eight deficiencies related to late endorsements.25 The following are examples: • In case 6, an obstetrician evaluated the patient, and staff scanned the report into the EHRS; however, the provider did not endorse the report until 14 days later. • In case 55, an endocrinologist evaluated the patient, and staff scanned the report into the EHRS; however, the provider did not endorse the report until 26 days later. Diagnostic Reports Compliance testing showed CIW providers always endorsed laboratory test results within required time frames (MIT 2.005, 100%). The providers also endorsed most radiology reports timely (MIT 2.009, 87.5%), but providers acknowledged nursing staff provided STAT laboratory results sporadically within required time frames (MIT 2.008, 12.5%). OIG clinicians found staff timely retrieved all laboratory tests and all radiology reports, except for one report: • In case 5, the patient had an off-site fetal ultrasound; however, the medical staff did not retrieve the report. Compliance testing showed staff retrieved and endorsed all pathology reports timely (MIT 2.010, 100% and MIT 2.011, 100%). OIG clinicians reviewed five pathology events and identified one missed pathology report: • In case 26, the patient underwent a craniotomy with resection of a brain mass, and the surgeon sent the mass for pathology evaluation.26 However, by the end of the review period, the institution still had not retrieved the pathology report. OIG clinicians identified five deficiencies related to late endorsement of laboratory results. We also identified eight deficiencies, demonstrating a pattern, involving 25 Deficiencies occurred in cases 5-8, 16, and 55. 26 Craniotomy is a surgery to remove part of the skull bone and access the brain. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 32 incomplete or missing patient notification letters, none of which were significant. Please refer to the Diagnostic Services indicator for additional information. Urgent and Emergent Records OIG clinicians reviewed 64 emergency care events and did not identify any deficiencies regarding documentation. Both the nurses and providers recorded these events excellently. Scanning Performance Compliance testing showed staff always scanned patient health care request forms (MIT 4.001, 100%) and often properly scanned, labeled, and filed medical documents timely and in the correct patients’ files (MIT 4.004, 79.2%). OIG clinicians did not identify any deficiencies related to mislabeled or misfiled medical documents. Legibility OIG clinicians found staff completed legible handwritten nursing assessments of the sick call requests. Clinician On-Site Inspection OIG clinicians discussed health information management processes with the CIW health information management supervisor, who stated the staff had a tracking process for specialty consultations and hospital records to ensure staff retrieved these documents timely. The medical records supervisor acknowledged the missed pathology report and stated the institution had implemented a new process to retrieve pathology reports from off-site specialists and hospitals. Specifically, staff will use the EHRS to create a standard mechanism to track for the receipt of all off-site pathology reports. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 20 0 10 100% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 25 5 15 83.3% 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? 17 0 0 100% (4.003) During the inspection, were medical records properly scanned, labeled, 19 5 0 79.2% 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 17 0 0 100% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 92.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 1 7 0 12.5% staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 10 0 0 100% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 4 6 0 40.0% 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 12 3 0 80.0% 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 10 2 3 83.3% 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 8 7 0 53.3% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 35 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 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 compliance rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (73.0%) Overall, CIW’s performance with health care environment needed improvement. Medical supplies storage areas contained expired, inaccurately labeled, and disorganized medical supplies. Several clinics did not meet the requirements for essential core medical equipment and supplies. In addition, staff did not regularly sanitize or wash their hands during patient encounters. Lastly, emergency medical response bag (EMRB) logs were missing staff verification or inventory was not performed when seal tags were changed. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Waiting Areas We only inspected indoor waiting areas as CIW had no outdoor waiting areas. Health care and custody staff reported the existing waiting areas contained sufficient seating capacity. Dependent on the population, patients waited either in the clinic waiting area or in individual modules (see Photo 1, this page, and Photo 2, next page). During our inspection, we did not observe overcrowding in any clinic indoor waiting area. Photo 1. Indoor waiting area (photographed on 5-14-24). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 37 Photo 2. Individual waiting module (photographed on 5-16-24). Clinic Environment All 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, 100%). Of the 13 clinics we observed, 11 contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 84.6%). In two clinics, the examination rooms either lacked visual or audio privacy for conducting clinical examinations. Clinic Supplies Six of the 13 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 46.2%). We found one or more of the following deficiencies in seven clinics: expired medical supplies (see Photo 3, next page); unorganized or inaccurately labeled medical supplies; cleaning materials stored with medical supplies; medication stored with medical supplies; 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 38 Photo 3. Expired medical supply dated March 17, 2024 (photographed on 5-14-24). Photo 4. Physical therapy ice packs stored with staff members' personal food items (photographed on 5-13-24). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 39 Five of the 13 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 38.5%). The remaining eight clinics lacked medical supplies, contained improperly calibrated equipment, or contained nonfunctional equipment. The missing items included disposable paper for the examination table and a nebulization unit. The staff had not properly calibrated several automated external defibrillators (AED). We found a nonfunctional otoscope and two nonfunctional ophthalmoscopes, and the Snellen eye chart lacked a clearly established and identifiable distance line on the floor or wall. Staff also had not properly logged the results of the AED or defibrillator performance test within the last 30 days. We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only three of the eight EMRBs passed our test (MIT 5.111, 37.5%). We found one or more of the following deficiencies with five EMRBs: staff failed to ensure the EMRB’s compartments were sealed and intact; staff had not inventoried the EMRBs when the seal tags were replaced; and staff failed to log EMRB daily glucometer quality control results. In addition, the psychiatry inpatient unit did not have a treatment cart available at the time of our inspection. Medical Supply Management All the medical supply storage areas located outside the medical clinics stored medical supplies appropriately (MIT 5.106, 100%). According to the chief executive officer (CEO), the institution did not have any concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system. Infection Control and Sanitation Staff appropriately disinfected, cleaned, and sanitized nine of 10 applicable clinics (MIT 5.101, 90.0%). In one clinic, we found an unsanitary gurney. Staff in 10 of 13 clinics properly sterilized or disinfected medical equipment (MIT 5.102, 76.9%). In three clinics, staff did not mention disinfecting the examination table as part of their daily start-up protocol. We found operating sinks and hand hygiene supplies in the examination rooms in 12 of 13 clinics (MIT 5.103, 92.3%). The patient restroom in one clinic lacked disposable hand towels. We observed patient encounters in eight clinics. In five of the eight clinics, staff did not wash their hands before or after examining their patients, or before applying gloves (MIT 5.104, 37.5%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 40 Physical Infrastructure CIW’s health care management and plant operations manager reported a minor infrastructure issue in the CTC and TTA hall, where the flooring was bubbling and needed repair to improve the safety of the walkway in the clinic. The institution reported the initial groundbreaking date was postponed due to delay of the materials ordered by the contractor. At the time of inspection, the institution reported the expected start date was July 8, 2024, and projected to be completed by July 22, 2024. CIW’s health care management did not believe this negatively impacted the institution’s current ability to provide good patient care (MIT 5.999). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 41 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, 9 1 3 90.0% 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 10 3 0 76.9% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 12 1 0 92.3% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 3 5 5 37.5% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 13 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 6 7 0 46.2% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 5 8 0 38.5% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 10 0 3 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 11 2 0 84.6% 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 3 5 5 37.5% 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): 73.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 42 Recommendations • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement appropriate remedial measures. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement appropriate remedial measures. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and sealed and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 43 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; and inspectors 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 Inadequate (49.2%) In Cycle 7, case review found CIW performed excellently when patients transferred from CIW to another institution. In contrast, we identified some opportunities for improvement when patients arrived at CIW from another institution and when patients transferred back from a community hospital. However, the majority of significant deficiencies related to medication continuity and are further discussed in the Medication Management indicator. Taking all things into consideration, the OIG rated the case review component of this indicator adequate. The compliance testing score for this indicator declined in Cycle 7. CIW performed excellently in ensuring departing patients’ transfer packets included required documents and medications. In contrast, CIW performed poorly in completing initial health screening forms and the assessment and disposition sections of the screening process. The institution also needed improvement in medication continuity for patients newly transferred into CIW. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 44 Case Review and Compliance Testing Results OIG clinicians reviewed 92 events in 20 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 29 deficiencies, 15 of which were significant.27 Transfers In CIW’s transfer-in process had a mixed performance. OIG clinicians reviewed 15 events in nine cases in which patients transferred into the facility from another institution. We identified six deficiencies, four of which were significant.28 Compliance testing revealed CIW nurses performed poorly in completing both the assessment and disposition sections of the initial health screening form (MIT 6.002, 30.4%). Furthermore, nursing staff did not accurately and thoroughly complete the initial health screenings within the required time frame in 24 of 25 cases (MIT 6.001, 4.0%). In contrast, our clinicians found nurses thoroughly and accurately completed the initial health screenings in seven of the nine cases reviewed. Compliance testing revealed opportunities for improvement in medication compliance when patients transferred to CIW (MIT 6.003, 62.5%). Additional information can be found in the Medication Management indicator. Case review found significant medication-related deficiencies in two examples below: • In case 25, the patient had missing keep on person (KOP) chronic care medications. Although the pharmacy refilled the missing medications, the nurses incorrectly returned them to the pharmacy and documented the patient had not requested the medications.29 • In case 32, the diabetic patient transferred to CIW and had missing KOP chronic care medications, including diabetic and blood pressure medications. The medications were automatically refilled, but the nurses did not issue them. Instead, the nurses either documented the patient had not requested a refill or the medication was a duplicate. As a result, some of the missing medications were not issued to the patient until a month later. Transfers Out CIW performed excellently in the transfer-out process. OIG clinicians reviewed four cases in which patients transferred from CIW to another institution. They found nurses performed thorough departure assessments, and documentation was complete. Furthermore, nurses ensured medication continuity. Similarly, compliance testing found patients who transferred out of the institution always had their medications and required documents (MIT 6.101, 100%). 27 Deficiencies occurred in cases 1, 2, 5, 6, 8, 23-25, 31, and 32. Significant deficiencies occurred in cases 2, 5, 6, 8, 23, 25, and 32. 28 Deficiencies occurred in cases 5, 25, 31 and 32. Significant deficiencies occurred in cases 5, 25, and 32. 29 KOP means “keep on person” and refers to medications that a patient can keep and self-administer according to the directions provided. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 45 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. 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. Compliance testing found CIW performed outstanding in providing follow-up appointments within required time frames to patients returning from hospitalizations and emergency room encounters (MIT 1.007, 100%). In addition, CIW also performed excellently in timely collecting and scanning community hospital discharge summaries (MIT 4.005, 100%). Our clinicians reviewed 71 hospital related events within 21 cases and identified 23 deficiencies, 11 of which were significant.30 In four cases, nurses incorrectly reconciled medications, and in one case medication continuity was interrupted when chronic care medication doses were missed.31 Two significant deficiencies occurred when hospital records were either never scanned or scanned late into the patients’ medical records.32 Another significant deficiency occurred when a provider failed to ensure antibiotics were reconciled correctly, and the patient did not receive the remaining antibiotics.33 Findings are also discussed in the Medication Management indicator. The following significant deficiencies are detailed below: • In case 2, the patient returned from a hospital admission, and the remaining three doses of antibiotic (Levaquin) were not ordered. • In case 23, a nurse evaluated the patient after a hospitalization; however, the nurse did not initiate a provider follow-up in the time frame requested, did not acknowledge the recommendations to stop medications, and did not document the details of a localized skin abnormality. Clinician On-Site Inspection OIG clinicians toured the receiving and release (R&R) area and spoke with an RN working in the area and the supervising registered nurse (SRN). The RN reported an RN staffed the R&R each shift during business days. We also learned the R&R nurse reconciled KOP prescribed medications but depended on custody staff to return medications to the patients in their respective housing units. We also learned missing KOPs were reported to the local pharmacy staff, who usually filled these medications and distributed the missing medications to the administration areas for patients to pick up, instead of waiting for the refill to arrive from the CDCR-Central Fill Pharmacy.34 We also 30 Significant deficiencies occurred in cases 2, 6, 8, 23, and 25. 31 Medication deficiencies occurred in cases 1, 2, 8, 24, and 25. 32 Hospital records were either never scanned or scanned late into the patients’ medical record occurred in cases 2 and 6. 33 A significant provider deficiency occurred in case 2. 34 The California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) department ensures the furnishing or dispensing of medication from the Correctional Pharmacy and the CDCR-Central Fill Pharmacy. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 46 learned all pregnant and transgender patients were transferred to CIW from the other women’s institution, Central California Women’s Facility (CCWF). We further learned TTA RNs evaluated all patients returning from a community hospital or emergency room and consulted with a provider to ensure continuity of medications. Compliance On-Site Inspection and Discussion R&R nursing staff always ensured patients transferring out of the institution had the required medications, transfer documents, and assigned durable medical equipment (DME) (MIT 6.101, 100%). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 47 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 1 24 0 4.0% 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 7 16 2 30.4% 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 6 9 62.5% 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 2 0 0 100% required documents? (6.101) Overall percentage (MIT 6): 49.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 48 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 18 2 5 90.0% 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 16 0 1 100% 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? 17 0 0 100% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 17 0 0 100% 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 2 13 2 13.3% 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 3 7 0 30.0% 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 10 8 0 55.6% 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 49 Recommendations • Health care leadership should identify the challenges to medication continuity for patients returning from hospitalizations or emergency rooms. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop strategies to ensure nursing staff completely answer and address required initial health screening questions. Leadership should implement remedial measures or education as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 50 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 Inadequate Inadequate (61.9%) In this cycle, case review found CIW overall needed improvement in this indicator. CIW performed well ensuring continuity of most chronic care and new medication orders. However, when patients returned from a community hospital, CIW frequently had reconciliation errors, which led to disruptions in medication continuity. In addition, when patients transferred to CIW without their keep on person (KOP) medications, we identified delays in medication continuity.35 In the specialized medical housing areas, patients were not issued their rescue inhaler medication, and nurses did not always follow the prescriber parameters for administering medications. Lastly, case review compared Cycle 6 findings and found an increase in both overall and significant deficiencies this cycle. Considering all factors, the OIG rated the case review component of this indicator inadequate. Compliance testing showed CIW needed improvement in this indicator. CIW scored low in providing patients with chronic care medications, newly prescribed medications as ordered, community hospital discharge medications, and medications for patients temporarily housed at the institution. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 37 cases related to pharmacy and medication management and found 39 deficiencies, 14 of which were significant.36 35 KOP means “keep on person” and refers to medications that a patient can keep and self-administer according to the directions provided. 36 Deficiencies occurred in cases 1-3, 5, 6, 8, 12, 14, 15, 18, 22-25, 32, and 55. Significant deficiencies occurred in cases 2, 5, 12, 18, 23, 25, 32, and 55. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 51 New Medication Prescriptions Compliance testing showed CIW needed improvement in ensuring patients received newly prescribed medications (MIT 7.002, 68.0%). In contrast, case review found only one deficiency which is detailed below: • In case 6, the patient received a newly prescribed KOP antibiotic one day late. Chronic Medication Continuity During this review period, CIW had a mixed performance in continuity for chronic medications. Compliance testing found only few occasions in which staff made chronic care medications available to, and issued them to, patients within required time frames (MIT 7.001, 33.3%). In contrast, our clinicians found most patients received their chronic care medications timely.37 Hospital Discharge Medications Compliance found CIW only occasionally ensured medications were available, administered, or delivered to their patients within required time frames (MIT 7.003, 13.3%). Similarly, case review found on nine occasions within five cases, patients returning after a community hospital admission or emergency room encounter experienced lapses in medication continuity. On several occasions, nurses did not reconcile medications correctly, which resulted in lapses of medication continuity or in the patient receiving incorrect doses of medication. Examples are detailed below: • In case 2, the patient returned from a community hospital admission for asthma exacerbation. A rescue inhaler was ordered but not issued to the patient until five days later. In addition, a blood pressure medication (diltiazem) was ordered four days late, and a medication to prevent blood clots (Xarelto) was not ordered. • In case 8, the patient returned after a planned cesarean section. The hospital’s discharging provider recommended the patient be continued on calcium acetate and ferrous sulfate but recommended to discontinue prescribed prenatal vitamins. The CIW provider neither followed the hospital provider’s recommendations nor documented the reasons for deviating from these recommendations.38 • In case 25, the patient returned after a community hospital admission. The hospital discharging provider recommended the patient take 5mg of prednisone daily. However, a nurse incorrectly initiated an order for 10mg of prednisone daily, which was double the dose recommended. 37 Patients did not timely receive chronic care medications in cases 6, 12, 14, 22, and 25. 38 Calcium acetate is a medication used to treat high levels of phosphorus in the blood. Ferrous sulfate is a medication used to treat and prevent iron deficiency anemia. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 52 Specialized Medical Housing Medications Compliance testing found, when patients were admitted to the specialized medical housing (SMH) areas, staff only sporadically made available and administered medications timely, and nurses did not document reasons when patients refused medications (MIT 13.003, 30.0%). In addition, in 14 of the 21 cases, the pharmacy did not make the patient’s chronic care medication available prior to exhaustion (MIT 7.001, 33.3%). Our clinicians identified nine deficiencies, two of which were significant.39 The following are examples: • In case 25, on multiple occasions in March 2024, the LVNs did not obtain a blood pressure reading prior to administering the blood pressure medication as per the provider’s order to ensure the blood pressure reading was within the range to administer the medication or the LVNs administered the blood pressure medication when the blood pressure reading did not warrant the administration of the medication. • In case 55, in the December 2023 and January 2024, the provider ordered blood pressure medication(s) with parameters to hold the medication if the blood pressure is below a specific range. However, the nurses intermittently did not hold the medication(s) as ordered or obtain a blood pressure prior to administering the medication(s). Our findings are also discussed in the Specialized Medical Housing indicator. Transfer Medications CIW performed well in ensuring patients who transferred from one housing unit to another within CIW received their medications without interruption (MIT 7.005, 88.0%). Both case review and compliance found CIW performed excellently when patients transferred from CIW to another institution. Case review found patients received their nurse administered medication prior to transfer, and in the one eligible case, compliance testing showed staff placed appropriate medications in the transfer envelope (MIT 6.101, 100%). However, when patients transferred into CIW from other institutions, both compliance and case review found opportunities for improvement. Compliance testing revealed many patients experienced interruptions in medication continuity (MIT 6.003, 62.5%). Case review similarly found in three cases, patients arrived at CIW without their scheduled KOP medications.40 The pharmacy refilled the medications; however, in all three cases, the nurses did not issue the medications. Additional information is discussed in the Transfers indicator. An example is detailed below. • In case 5, on January 29, 2024, nurses did not issue KOP prenatal vitamins and ferrous sulfate. Instead, the nurse documented “not done, task duplication.” On February 12, 2024, nurses issued prescribed prenatal vitamins, 14 days late. The patient did not receive ferrous sulfate prior to departure on March 7, 2024. 39 Deficiencies occurred in cases 3, 22, 25, and 55. Significant deficiencies occurred in cases 25 and 55. 40 Transfer-in medication deficiencies occurred in cases 5, 25, and 32. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 53 Medication Administration Compliance testing found nurses nearly always administered TB medication as prescribed (MIT 9.001, 95.2%). The nurses also usually monitored these patients correctly (MIT 9.002, 90.5%). Clinician On-Site Inspection During the on-site inspection, our clinicians met with the pharmacist in charge (PIC) and nursing supervisors and discussed pharmacy and medication management topics. We also toured the main yard and enhanced outpatient program (EOP) medication administration areas. A nurse reported, one week prior to our inspection, the main clinic’s KOP medication process had changed to allow earlier notification to patients. According to the nurse, patients were previously added to the KOP pick-up list three or four days after the medications were to be issued; however, with their new process, nurses did not delay in adding the patient names on the first day due. The nurse explained custody staff also helped ensure patients reported to the medication administration area. When the patients did not pick up their medication by the morning of the fourth day, a final notification was provided to custody staff, who then made an announcement to the patients. When patients did not report to pick up or refused medications by 10:00 a.m on the fourth day, custody staff would remotely disable the patient’s electronic tablet until the patient’s resolves the medication issue with the medication nurses. In the main clinic’s medication administration area, nurses indicated pharmacy staff would often drop off KOP medications several days before the medications were due; however, in the EHRS, the nurses were not notified or tasked until the date the medication was ordered to begin. Therefore, the nurses were required to find space to store and organize the medications. In addition, the nurses indicated patients would intermittently lose their KOP medications and request refills early. The nurse stated they would contact the pharmacy, who would issue enough medications to last until the patient’s next 30-day refill would be delivered. However, the nurses did not have an order for the specific doses being issued. Therefore, the nurses had to either document on the existing order, which indicated a 30-day supply was being issued, or not document at all. Both options inaccurately skewed the documentation. In addition, the clinicians learned, in the main clinic, nurses did not always perform a finger stick blood glucose (FSBG) prior to administering regular insulin. According to the nurse, if the patient was deemed “trustworthy” in self-testing, the nurses would instead use the patient’s glucometer FSBG results without independent verification by finger stick. The nurse also indicated providers did not always order a FSBG test. When the OIG clinician asked the nursing and physician leadership their expectations, they indicated nurses administering insulin should always perform a FSBG test prior to administering regular insulin. OIG clinicians also went to the EOP housing area, which included the medication administration room in the same building. The nurses indicated they did not have any concerns and did not need to distribute a KOP list to custody staff because their unit only had 68 patients, who were compliant. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 54 Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in 11 of 12 applicable clinic and medication line locations (MIT 7.101, 91.7%). In one location, the supervising nurse did not describe the appropriate narcotic medication discrepancy reporting process. CIW appropriately stored and secured nonnarcotic medications in nine of 13 clinic and medication line locations (MIT 7.102, 69.2%). In two locations, nurses did not maintain unissued medication in its original labeled packaging. In one location, nurses did not follow the appropriate process to return medications with expired pharmacy labels that potentially could be restocked or reissued by the pharmacy. In addition, the medication area lacked a clearly labeled designated area for refrigerated medications to be returned to the pharmacy. The remaining clinic’s treatment cart log was missing daily security check entries. Staff kept medications protected from physical, chemical, and temperature contamination in eight of the 13 clinic and medication line locations (MIT 7.103, 61.5%). In four locations, staff did not separate the storage of internal and external medications. In one location, staff did not record the refrigerator temperature. Staff successfully stored valid, unexpired medications in eight of the 13 medication line locations (MIT 7.104, 61.5%). In four locations, nurses did not label the multiple-use medication as required by CCHCS policy. In one location, nurses did not store solutions in the original packaging as recommended by the manufacturer. Nurses exercised proper hand hygiene and contamination control protocols in two of five applicable locations (MIT 7.105, 40.0%). In three locations, nurses neglected to wash or sanitize their hands when required. These occurrences included before preparing and administering medications as well as before each subsequent re-gloving. Staff in four of five applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 80.0%). In one location, medication nurses did not correctly describe the process they must follow when reconciling newly received medications and the medication administration record (MAR) against the corresponding physician’s order. Staff in two of five medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 40.0%). In two clinics, we observed a medication nurse who did not follow the CCHCS care guide when administering Suboxone medication. In one location, medication nurses did not reliably observe patients while they swallowed direct observation therapy medications. Pharmacy Protocols CIW followed all general security, organization, and cleanliness management protocols in its pharmacy (MIT 7.108, 100%). In the pharmacy, staff did not properly store nonrefrigerated medications (MIT 7.109, zero). We found several medications were not maintained in their original labeled packaging at the time of inspection. The institution Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 55 properly stored all refrigerated and frozen medications in the pharmacy (MIT 7.110, 100%). The pharmacist-in-charge (PIC) correctly accounted for all narcotic medications stored in CIW’s pharmacy (MIT 7.111, 100%). We examined 25 medication error reports. The PIC timely or correctly processed only 19 of these 25 reports (MIT 7.112, 76.0%). In four reports, the PIC did not initiate the medication error follow-up form timely. For the remaining two reports, the PIC did not recommend changes to prevent the same errors from occurring in the future. Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. The OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in the restricted housing unit to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Both applicable patients interviewed indicated they had access to their rescue medications (MIT 7.999). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 56 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 7 14 4 33.3% 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 17 8 0 68.0% 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 2 13 2 13.3% 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 3 7 0 30.0% 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 11 1 4 91.7% 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 9 4 3 69.2% 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 8 5 3 61.5% 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 5 3 61.5% 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 2 3 11 40.0% medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 4 1 11 80.0% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 2 3 11 40.0% 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 0 1 0 0 medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 19 6 0 76.0% (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): 61.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 57 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 6 9 62.5% 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 2 0 0 100% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 20 1 0 95.2% 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 19 2 0 90.5% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 6 14 0 30.0% 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 58 Recommendations • Medical and nursing leadership should identify the challenges to ensuring hospital discharge and newly arrived patients receive their medications accurately, timely, and without interruption. Leadership should implement remedial measures as appropriate. • Pharmacy, medical, and nursing leadership should develop and implement measures to ensure supplemental doses can be accurately recorded in the patients’ medication administration record (MAR). • Nursing leadership should develop and implement strategies to ensure nursing staff correctly follow the prescriber’s ordered parameters prior to administering medications. • The institution should develop and implement measures to ensure staff timely make available and administer medications to patients, or document refusals in the MAR summaries, as described in CCHCS policy and procedures including refusals and no-shows. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 59 Prenatal and Postpartum Care This indicator evaluates the institution’s capacity to provide timely and appropriate prenatal, delivery, and postnatal services to pregnant patients. This includes the ordering and monitoring of indicated screening tests, follow-up visits, referrals when necessary to higher levels of care such as high-risk obstetrics clinic, and postnatal follow-up. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (76.7%) Case review found CIW provided satisfactory prenatal and postpartum care. Although CIW did not have an on-site obstetrician, off-site and telemedicine obstetricians effectively provided perinatal care.41 Nursing staff timely addressed patients’ complaints and needs. Patients also generally received their diagnostic tests, vaccinations, and specialty appointments timely. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing similarly showed CIW’s performance was satisfactory in this indicator. Prenatal obstetric appointments occurred timely for most patients, and patients received appropriate housing, vitamins, and meal supplementation. Postpartum obstetric appointments always occurred within required time frames. However, timely patient encounters with obstetric providers only occasionally occurred. In addition, staff needed improvement in documenting blood pressure, weight, and fundal height during each obstetric appointment. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed four peripartum cases and rated all four cases adequate. OIG clinicians reviewed 55 events related to prenatal or postpartum care and identified six deficiencies, none of which were significant.42 Prenatal Care Compliance testing showed most initial appointments with the providers for pregnant patients occurred timely (MIT 8.001, 90.0%), and staff frequently ordered the recommended vitamins and nutritional supplements (MIT 8.003, 90.0%). However, obstetrics providers only occasionally evaluated these patients according to the recommended pregnancy encounter guidelines (MIT 8.004, 40.0%). OIG clinicians reviewed four cases and found the patients were taking the recommended prenatal vitamins. Off-site obstetricians from a community medical group and a telemedicine obstetrician from the other women’s institution, Central California 41 Perinatal care includes prenatal, delivery, and postpartum care. 42 Deficiencies occurred in cases 6, 7, and 8. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 60 Women’s Facility (CCWF), provided prenatal care. The obstetricians evaluated the patients regularly, and the medical staff addressed all the obstetricians’ recommendations. Staff completed prenatal ultrasounds at acceptable intervals based on patient risk factors. Patients also received their diagnostic tests, vaccinations, and specialty appointments timely. Prenatal care nurses appropriately assessed the patients and documented well. OIG clinicians identified three nursing deficiencies related to prenatal care.43 The following is an example: • In case 6, a nurse assessed the patient after an off-site obstetric assessment and documented fetal heart tones detected; however, the nurse did not document the fetal heart rate. Postpartum Care Compliance testing showed patients always received their six-week postpartum obstetric appointment (MIT 8.007, 100%). OIG clinicians reviewed three postpartum cases: one patient had a vaginal delivery, and two patients had cesarean deliveries. The obstetricians evaluated the patients timely after their deliveries, and the nurses also assessed the patients regularly and performed wound care as medically indicated. We identified three nursing deficiencies related to postpartum care.44 The following is an example: • In case 8, a nurse performed daily wound checks after a cesarean delivery and documented the skin had a new pink area; however, the nurse did not notify a provider of the skin changes. Clinician On-site Inspection During the OIG review period, CIW did not have an on-site obstetrician. Off-site and telemedicine obstetricians provided prenatal and postpartum care for patients. During the OIG clinician on-site inspection, our clinicians met a recently hired part-time on-site obstetrician. We attended a well-organized clinic huddle, where medical staff discussed significant overnight events, scheduled patients’ appointments, and reviewed diagnostic tests, such as obstetric ultrasounds. At the time of the clinician inspection, CIW had eight pregnant patients. Most of the pregnant patients arrived at CIW in their third trimester. Staff reported the obstetrician monitored the progressions of their pregnancies and transferred the patients to the community hospital for deliveries. Emergent deliveries rarely occurred at CIW; however, the obstetric staff and TTA nurses had received basic training for emergent deliveries, if needed. 43 Deficiencies occurred in cases 6, 7, and 8. 44 Deficiencies occurred in cases 6 and 8. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 61 Compliance Score Results Table 15. Prenatal and Postpartum Care Scored Answer Compliance Questions Yes No N/A Yes % For patients identified as pregnant, did the institution timely offer initial 9 1 0 90.0% provider visits? (8.001) Was the pregnant patient timely issued a comprehensive accommodation chrono for a lower bunk and lower-tier housing and did the patient receive 10 0 0 100% the correct housing placement? (8.002) Did medical staff promptly order recommended vitamins, extra daily 9 1 0 90.0% nutritional supplements and food for the patient? (8.003) Did timely patient encounters occur with an OB physician or OB nurse practitioner in accordance with the pregnancy encounter guidelines? 4 6 0 40.0% (8.004) Were the results of the patient’s initial prenatal screening tests timely 0 0 10 N/A completed and reviewed? (8.005) Was the patient’s weight, fundal height, and blood pressure documented at 4 6 0 40.0% each clinic OB visit? (8.006) Did the patient receive her six-week postpartum obstetric visit? (8.007) 6 0 4 100% Overall percentage (MIT 8): 76.7% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 62 Recommendations • Health care leadership should ascertain causes related to the untimely scheduling of or provision of patients’ obstetrics (OB) appointments and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of staff not documenting the weight, blood pressure, and fundal height of patients at each clinic OB appointment and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 63 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 (86.5%) CIW performed well in this indicator. Staff performed excellently in screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for patients from ages 45 through 75, and offering mammograms for female patients from ages 50 through 74. In addition, they showed very good to outstanding performance in administering and monitoring patients taking TB medications. However, staff needed improvement in offering pap smears and performed poorly in offering required immunizations to chronic care patients. Based on the overall compliance score result, the OIG rated this indicator proficient. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 64 Compliance Score Results Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 20 1 0 95.2% 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 19 2 0 90.5% 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 25 0 0 100% offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was patient 17 8 0 68.0% offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? (9.008) 5 8 12 38.5% 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): 86.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 65 Recommendations • Health care leadership should determine the root cause(s) of challenges to timely providing pap smears and should implement appropriate remedial measures. • Health care leadership should determine the root cause(s) for challenges to timely providing immunizations to chronic care patients and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 66 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’ performance 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 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 The overall CIW nursing care was appropriate and timely. Nurses responded quickly to emergencies, performed excellently in timely triaging sick call requests, thoroughly prepared their patients for transfer, and usually provided appropriate care plans. Our clinicians identified opportunities for nurses to improve their medication reconciliation and ensure patients receive their medication timely and safely. Nurses had a similar number of events and deficiencies in this cycle as they did in the previous cycle. Taking all into consideration, the OIG rated nursing performance adequate. Case Review Results We reviewed 402 nursing encounters in 57 cases. Of the nursing encounters we reviewed, 157 events occurred in the outpatient setting, and 72 were sick call requests. We identified 115 nursing performance deficiencies, 10 of which were significant.45 Outpatient Nursing Assessment, Interventions and Documentation 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 assessed sick call requests timely and initiated face-to-face appointments within policy guidelines and as clinically indicated. On most occasions, nurses’ interventions were appropriate; however, we identified a pattern of sick call 45Deficiencies occurred in cases 1-8, 14-25, 31, 37, 38, 42-45, 47, 49, 50, 52, 55, and 56. Significant deficiencies occurred in cases 2, 8, 14, 15, 23, 25, and 56. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 67 nurses performing incomplete assessments. Additionally, we found nursing documentation was occasionally either incomplete or inconsistent. Although both presented opportunities for improvement, neither significantly impacted the patients’ care. Examples are as follows: • In case 1, a sick call nurse evaluated the patient for complaints of back pain. The nurse did not subjectively assess when the patient’s pain began or perform a thorough pain assessment. Furthermore, the nurse did not assess the patient’s range of motion. • In case 14, the nurse documented the patient’s vital signs were within normal range but did not document the numerical results. • In case 37, a sick call RN evaluated the patient for ankle pain and swelling. The nurse did not document the degree of swelling and did not assess circulation and sensation of the extremity. Case Management OIG clinicians reviewed six cases in which diabetic patients were evaluated by an RN care manager.46 At CIW, RNs frequently evaluated patients when their diabetic laboratory results (HgA1c) were abnormal. In addition, for patients who had their own glucometers, our clinicians found nurses frequently collected patients’ finger stick blood glucose (FSBP) logs and issued diabetic supplies. An opportunity for improvement is detailed below: • In cases 22 and 23, RN care managers documented collecting their patients’ FSBG written log results; however, the nurses did not review and assess the written results. Wound Care We reviewed six cases in which nurses documented the patient had a wound and found eight deficiencies, none of which were significant. Most of the deficiencies occurred when nurses either did not assess the wound or did not provide thorough documentation. An example is listed below: • In case 7, the nurse did not assess this patient’s cesarean section incision. Emergency Services CIW’s nursing staff responded promptly to emergency events and usually provided appropriate care. Additional information can be found in the Emergency Services indicator. 46 A care manager assessed patients in cases 10, 11, 13, 16, 22, and 23. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 68 Hospital Returns We reviewed 71 events involving returns from off-site hospitals or emergency rooms and identified seven nursing deficiencies, one of which was significant.47 The nurses usually performed sufficient assessments; however, we identified a pattern of deficiencies when nurses did not reconcile medications appropriately, which we detailed further in the Transfers and Medication Management indicators. Transfers We reviewed 12 cases involving transfer-in and transfer-out processes. Our clinicians found nurses performed good assessments on seven of the nine patients who transferred into CIW. One transfer-in case the nurses did not document some of the patient’s medications did not arrive with the patient, did not document if the KOP medications were issued to the patient for self administration, document the patient’s durable medical equipment, or obtain the patient’s weight. In the other transfer-in case, the nurse did not obtain a finger stick blood glucose reading for the diabetic patient. When patients departed from CIW, nurses performed excellently in ensuring patients were screened and received their medications prior to their departure. Please refer to the Transfers indicator for further details. Specialized Medical Housing We reviewed nine cases with a total of 39 nursing events, and identified 18 nursing deficiencies, four of which were significant.48 All the significant nursing deficiencies occurred in two OHU cases and related to incomplete assessments. Please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed 147 events and identified 15 cases in which nurses evaluated these patients after an off-site specialist appointment. We identified five deficiencies, within three cases.49 Most deficiencies related to incomplete assessments. Please refer to the Specialty Services indicator for additional details. Medication Management OIG clinicians examined 148 events within 37 cases involving medication management and found 39 deficiencies, 14 of which were significant.50 Both case review and compliance rated medication management inadequate. OIG clinicians found nurses were responsible for most of the severe deficiencies when nurses incorrectly reconciled medications, did not obtain the patient’s blood pressure prior to administering medications, or did not issue medications. Please refer to the Medication Management indicator for additional details. The following is an example: 47 Deficiencies occurred in cases 2, 8, and 23-25. A significant deficiency occurred in case 23. 48 Deficiencies occurred in cases 3, 7, 21, 22, 25, 55, and 56. Significant deficiencies occurred in cases 25 and 56. 49 Nursing deficiencies occurred in cases 8, 18, and 25. 50 Deficiencies occurred in cases 1-3, 5, 6, 8, 12, 14, 15, 18, 22-25, 32, and 55. Significant deficiencies occurred in cases 2, 5, 12, 18, 23, 25, 32, and 55. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 69 • In case 2, the patient returned from a community hospital admission for an asthma exacerbation with a recommendation to continue an antibiotic. The nurse contacted the provider on-call and informed the provider of the recommendation to continue an antibiotic; however, the nurse did not initiate the order. Clinician On-Site Inspection During the on-site inspection, our clinicians met with the chief nurse executive (CNE) and SRNs. While in the clinics, we participated in the morning huddle and spoke with clinic RNs and LVNs in the medication administration areas. The nurses provided detailed responses and seemed knowledgeable about their job expectations. Many of the nursing staff had worked at CIW for several years and indicated they enjoyed their positions. In the medical clinic, an RN care manager stated she frequently evaluated diabetic patients who had a hemoglobin A1c laboratory result above eight, provided education, issued diabetic supplies, and received the patients’ finger stick result logs or diaries weekly.51 The nurses in the medication administration area indicated several patients had their own glucometers and recorded the results for their care team’s review. The medication nurses expressed challenges in creating an accurate list of patients with KOP medications to pick up. The medication nurses indicated they could generate a list that reflected patients who had KOP medication due; however, they had to manually reconcile which of these medications had been delivered by pharmacy. Otherwise, patients’ names would indicate they had a KOP medication available for pickup, but the pharmacy may not have delivered this medication. According to the nurses, if the pharmacist system showing medication delivered could automatically sync with the list of patients with KOP medications for pickup, the nurses could both post and provide a more accurate KOP list to custody of patients with medications ready for pickup. This would prevent patients from coming to pick up medications because their names were on the KOP medication list, but the medications had not yet been delivered. During discussions with the nursing leadership team, we found the two directors of nursing (DONs) and CNE knowledgeable and committed to improving the quality of their patients’ care. They were prepared for the clinicians’ on-site inspection, discussed cases professionally, and indicated they recognized areas in which they could implement improvement. The CNE had transferred from California Rehabilitation Center (CRC) and expressed that CIW was a busy and sometimes challenging institution. In addition, she indicated, compared with CRC, CIW nurses required additional training related to women’s needs; however, despite the additional training requirement, they did not have the necessary staff to provide coverage. In addition, she stated CIW was frequently piloting new programs, and CIW nurses have been reassigned to assist in projects outside of CIW, which sometimes posed staffing challenges. The CNE indicated staff morale was impacted by the loss of team members who passed away from COVID-19 as well as the inconsistent nursing leadership prior to her arrival; however, she expressed her commitment in supporting her staff. 51 Hemoglobin A1c is a blood test that measures the average plasma glucose over the previous 12 weeks. For most patients with diabetes, the A1c goal is 7 percent or less. https://www.cdc.gov/diabetes/diabetes- testing/prediabetes-a1c-test.html Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 70 During the clinician on-site inspection, the nursing and provider leadership teams appeared to have a strong, collaborative working relationship. During our discussions about specific patients or a process, the nurse and physician leadership team were cohesive and focused on how they could collectively deliver the care their patients needed. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 71 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 72 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 Case review found CIW providers generally delivered good care. Providers made appropriate assessments and decisions, managed chronic medical conditions effectively, and reviewed medical records thoroughly. However, we identified patterns of missing physical examinations and late endorsements of specialty reports, along with patient test result notification letter deficiencies. Considering all aspects, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 183 medical provider encounters and identified 24 deficiencies, nine of which were significant.52 OIG physicians also rated the overall adequacy of care for each of the 29 comprehensive case reviews.53 Of these 29 cases, we rated 27 adequate and two inadequate. Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound medical plans for their patients. However, OIG clinicians identified seven deficiencies related to a lack of 54 pertinent physical examinations. The following are examples: • In case 2, a provider evaluated the patient after a recent hospitalization for pneumonia but did not perform a lung examination. 52 Deficiencies occurred in cases 1, 2, 3, 6, 7, 12, 15-18, 24, and 25. Significant deficiencies occurred in cases 2, 3, 12, 16, 17, and 25. 53 We reviewed 25 detailed cases and four perinatal cases. 54 Deficiencies occurred in cases 2, 3, 17, 18, and 24. Significant deficiencies occurred in cases 2 and 17. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 73 • In case 17, a provider evaluated the patient for a TTA follow-up for laceration of the right thumb and right knee pain. However, the provider did not examine the patient’s right thumb or right knee. • In case 18, a provider evaluated the patient for recent hospitalization for heart failure. The provider documented performing musculoskeletal, neurological, and skin examinations but did not perform a heart or lung examination. Providers generally diagnosed medical conditions correctly, ordered appropriate tests, and coordinated effective treatment plans for their patients. However, OIG clinicians identified two significant deficiencies related to inadequate treatment plans as follows: • In case 12, a nurse consulted a provider for a patient with complaints of excessive menstrual bleeding, dizziness, and fatigue. However, the provider did not evaluate the patient urgently or refer the patient to a specialist. • In case 16, a medical assistant messaged a provider of a worsened asthma control test (ACT); however, the provider did not respond to the message or evaluate the patient. Outpatient Review of Records Providers performed adequately in reviewing hospital records and addressing the hospitalists’ recommendations. However, OIG clinicians identified two significant deficiencies related to inadequately reconciling medications after hospitalizations: • In case 2, the hospitalist diagnosed the patient with bronchitis and recommended the patient take an oral antibiotic for three days. The on-call provider documented the patient should take the antibiotic for three days but did not order the antibiotic. • Also in case 2, the patient was taking a blood thinner for a prior pulmonary embolism. The patient subsequently returned from a community hospital with the hospitalist’s recommendation to continue taking the blood thinner. However, the provider did not prescribe the medication. Providers generally reviewed diagnostic tests on time and addressed abnormal results appropriately. However, we identified one significant deficiency related to inadequately addressing an abnormal laboratory result: • In case 3, a provider endorsed the laboratory test result showing anemia (low level of red blood cells). However, the provider did not address the anemia or follow up with the patient timely. Providers generally performed well in reviewing medical records for patients transferring into CIW and ordering diagnostic tests and specialty appointments as indicated. However, in one case, the provider did not timely order a pre-approved specialty appointment as follows: • In case 25, the transfer-in patient with a kidney transplant and chronic kidney disease had a pre-approved follow-up appointment with a Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 74 nephrologist within one month.55 The provider acknowledged the nephrology appointment but did not order the follow-up appointment until three weeks later. The nephrologist did not evaluate the patient until seven weeks later. Providers generally performed well in reviewing the medication administration record (MAR) and renewing their patients’ medications timely. Emergency Care Providers generally made appropriate triage decisions and treatment plans for patients with urgent or emergency medical conditions in the TTA. The providers generally documented the required progress notes for the TTA events. OIG clinicians identified 56 two deficiencies related to missing progress notes. Chronic Care Providers performed well in managing chronic medical conditions such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. For patients with diabetes, the providers regularly monitored the patients’ blood glucose levels and adjusted diabetic medications as medically indicated. For patients with cardiovascular disease, the providers prescribed antiplatelet medications and cholesterol lowering medications to reduce the risk of heart attack or stroke. Providers also performed well in ensuring preventive tests, such as mammograms and pap smears, were completed timely. Specialty Services Providers appropriately referred and generally reviewed specialty reports in a timely manner. Although we identified eight deficiencies related to late endorsements of specialty service reports, providers addressed most the specialists’ recommendations timely.57 We discuss further in the Health Information Management Indicator. Outpatient Documentation Quality Providers generally documented outpatient encounters on the same day of the encounter. 58 Our clinicians identified three deficiencies related to missing progress notes. The following is an example: • In case 6, a nurse consulted a provider about the patient complaining of discomfort while swallowing. The provider ordered an antibiotic but did not document a progress note. 55 A nephrologist is a medical provider who specializes in diagnosing, treating, and managing kidney condition and diseases. 56 Deficiencies occurred in cases 1 and 7. 57 Deficiencies occurred in cases 5-8, 16, and 55. Three deficiencies were significant and occurred in cases 6 and 7. 58 Deficiencies occurred in cases 6, 16, and 17. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 75 Patient Notification Letter Providers generally sent patient letters to thoroughly communicate diagnostic test results to their patients. However, OIG clinicians identified eight minor deficiencies related to missing or incomplete patient letters.59 We discuss these deficiencies further in the Diagnostic Services indicator. Clinician On-Site Inspection The OIG clinician met and interviewed CIW’s chief medical executive (CME), chief physician and surgeon (CP&S), and providers. Medical leadership reported CIW had six full-time providers with one and a half vacancies. The providers expressed enthusiasm about their work and were generally satisfied with nursing, diagnostics, and specialty services. The providers reported the difficulty with the after-hours on-call coverage, as providers may receive about 30 calls from nursing staff each call night. Two providers from another institution also take overnight calls to help CIW providers. Sixteen of the 24 provider deficiencies belonged to one provider. The OIG clinician discussed this provider’s performance with the CME. The CME agreed with the deficiencies, was aware of the provider’s poor performance, and had implemented training, monitoring, and improvement measures. However, the provider abruptly retired. 59 The deficiencies occurred in cases 3, 6, 19, 28, and 30. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 76 Recommendations • Medical leadership should ascertain the challenge(s) to providers performing pertinent examinations and timely endorsements of specialty service reports and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 77 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, CIW’s specialized medical housing consisted of a correctional treatment center (CTC) and the outpatient housing unit (OHU). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (78.0%) CIW performed satisfactorily in this indicator. Nurses routinely rounded on their patients and usually documented their findings. Providers performed timely initial assessments and evaluated their patients regularly. Our clinicians found most of the significant deficiencies occurred within one OHU case. CIW showed some opportunities for improvement in initial nursing assessments, incomplete care plans, and medication administration within provider ordered parameters. Taking all things into consideration, the OIG rated the case review component of this indicator adequate. Compliance testing showed a mixed performance in this indicator. Staff variably completed timely admission assessments and history with physical examinations. The institution maintained operational call light systems in specialized medical housing units. However, CIW needed significant improvement in medication administration. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results We reviewed nine cases in the OHU and CTC, which included 31 provider events and 39 nursing events. Due to the frequency of nursing and provider contacts in specialized medical housing, we frequently bundle two weeks of patient care into a single event. We identified 28 deficiencies, six of which were significant.60 Provider Performance Compliance testing showed providers completed timely history and physicals (H&P) most of the time (MIT 13.002, 75.0%). OIG clinicians reviewed four OHU and four CTC 60 Deficiencies occurred in cases 3, 7, 21, 22, 25, 55, and 56. Significant deficiencies occurred in cases 25, 55, and 56. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 78 admissions and identified one deficiency related to an incomplete physical examination.61 Otherwise, the providers’ performed thorough H&P examinations, made sound medical plans, and reviewed test results and specialty reports timely. Nursing Performance During our period of review, nurses performed three CTC and three OHU initial assessments, all of which occurred timely.62 Compliance testing showed nurses also performed well in ensuring timely admission assessments (MIT 13.001, 85.0%). Although nurses performed timely assessments, our clinicians found opportunities for improvement when the CTC and OHU nurses performed incomplete admission assessments and incomplete individualized care plans that did not address the patient’s medical needs.63 In addition, we identified two cases in which nurses administered medications without first obtaining the patient’s blood pressure or inappropriately administered a medication when the patient’s blood pressure result warranted the medication be held based on the parameters ordered.64 An example is detailed below: • In case 25, the patient began dialysis and was admitted to the OHU for blood pressure stabilization and pain management. The nurse’s admission assessment was incomplete and did not include a care plan for the patient’s newly placed central venous catheter.65 In addition, the nurses occasionally administered blood pressure medications when it was not warranted or without first assessing the patient’s blood pressure. Medication Administration Compliance testing found patients admitted to CIW’s SMH often did not receive their medications on time, the pharmacy did not timely make the medications available, or nurses did not document the patient’s reason when the patient refused medications (MIT 13.003, 30.0%). Our clinicians identified nine deficiencies, two of which occurred when patients newly admitted to SMH did not receive their prescribed rescue inhalers.66 Additional information can be found in the Medication Management indicator. Clinician On-Site Inspection OIG clinicians toured CIW’s 16-bed OHU and eight-bed CTC. The OHU morning shift nurse had worked at CIW for 14 years, with several of these years working in the OHU. The OHU RN indicated medications were administered by an RN unless an LVN was available; however, an LVN was only staffed in the OHU on the afternoon and evening shifts. OHU staff conducted a daily huddle, and a consistent medical provider was normally assigned to care for the patients. 61 The deficiency occurred in case 3. 62 Nurses performed initial assessments in cases 3, 7, 21, 22, 25, and 55. 63 Incomplete initial nursing assessments occurred in cases 3, 7, 21, 55, 22, and 25. 64 Nurses inappropriately administered medications in cases 25 and 55. 65 A central venous catheter (CVC) is a tube inserted into a vein to provide access to the large vein above the heart. CVCs are used to administer treatment, obtain blood samples, and provide nutrition to the patient. 66 Newly admitted SMH patients were not issued their prescribed rescue inhalers in cases 3 and 22. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 79 Three registered nurses, one of whom was assigned a “lead” position, worked during each shift in the CTC. In addition, the unit was staffed with a licensed vocational nurse and a psychiatric technician. One medical provider was consistently assigned to care for the CTC’s patients. The nursing team also cared for patients housed in the CTC for mental health diagnosis. The nurses indicated they would frequently be assigned to care for both medical and mental health patients. Weekly, the medical and nursing executives conducted grand rounds and daily huddles in the unit.67 Compliance On-site Inspection and Discussion During the on-site inspection, the CTC and OHU had functional call light communication systems (MIT 13.101, 100%). In addition, staff maintained a patient safety check log as specified in the institution’s local operating procedure in the psychiatric inpatient program unit (MIT 13.102, 100%). 67 Grand rounds involve a meeting in which health care leadership and the patient care teams discuss patient care conditions and management. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 80 Compliance Score Results Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial 17 3 0 85.0% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 15 5 0 75.0% 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 6 14 0 30.0% within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call 2 0 1 100% 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 1 0 2 100% operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 78.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 81 Recommendations • Nursing leadership should determine the root cause(s) of challenges preventing nurses from performing thorough initial assessments and ensuring nursing care plans address patient needs. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 82 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 Proficient Adequate (79.9%) Case review found CIW performed very well in this indicator. Staff completed specialty appointments as requested while also retrieving and scanning all specialty reports timely. Nursing and providers offered good care related to specialty services; however, we identified some late provider endorsements of specialty reports. Considering all aspects, the OIG rated the case review component of this indicator proficient. Compliance testing showed a satisfactory performance in this indicator. Access to specialists ranged from excellent to needing improvement, depending on the specialty appointment priority. Specialty service follow-up appointments always occurred timely. However, preapproved specialty referrals for newly arrived patients only intermittently occurred within required time frames. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 147 events related to specialty services and identified 15 deficiencies in this category, three of which were significant.68 Access to Specialty Services Compliance testing showed variable performance in timely completing initial high- priority, medium-priority, and routine-priority specialty appointments (MIT 14.001, 60.0%, MIT 14.004, 93.3%, and MIT 14.007, 100%). However, staff completed all follow-up specialty appointments within required time frames (MIT 14.003, 100%, MIT 14.006, 100%, and MIT 14.009, 100%). For patients transferring into CIW with pre-approved specialty requests, compliance testing showed just more than half of the specialty appointments occurred timely (MIT 14.010, 55.6%). In contrast, OIG clinicians found all specialty appointments occurred within required time frames, except in one case as the provider did not timely order a 68 Deficiencies occurred in cases 5-8, 16, 25, and 55. Significant deficiencies occurred in cases 6 and 7. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 83 pre-approved specialty request for a transfer-in patient. This deficiency is discussed in the Provider Performance indicator. Provider Performance CIW providers referred patients to specialists appropriately and addressed specialists’ recommendations timely. OIG clinicians also found CIW providers delivered exceptional care for patients on medication assisted treatment (MAT) with substance use disorders. Nursing Performance Overall, CIW’s nursing performance for specialty care was good. TTA nurses appropriately assessed patients who returned from specialty appointments. TTA and telemedicine nurses generally documented accurately and ordered provider follow-up appointments within recommended time frames. OIG clinicians identified five deficiencies related to incomplete nursing assessments, none of which were significant.69 The following is an example: • In case 18, a nurse assessed the patient after a cardiac catheterization and documented a leg artery was used for the catheterization. However, the nurse did not assess the leg artery site. Health Information Management Compliance testing showed staff acceptably retrieved and scanned specialty reports within the required time frames (MIT 4.002, 83.3%). Providers performed variably in timely reviewing and endorsing high-priority (MIT 14.002, 80.0%), medium-priority (MIT 14.005, 83.3%), and routine-priority reports (MIT 14.008, 53.3%). OIG clinicians found all specialty reports were retrieved and scanned within required time frames. However, we identified eight deficiencies related to late endorsements, three of which were significant.70 These deficiencies are discussed in the Health Information Management indicator. Clinician On-Site Inspection The specialty services supervisor reported specialty nurses utilize a tracking tool for completing specialty appointments and retrieving specialists’ reports. Specialty nurses also track provider endorsements of specialty reports and, on every Monday, provide a list of missed endorsements to the CME and CP&S. Riverside University Health System (RUHS), which has large multi-specialty groups, provides most of the off-site specialty services. After specialty appointments, the RUHS specialists also arrange follow-up appointments as needed. CIW specialty nurses were able to access RUHS medical records to obtain specialty reports. 69 Deficiencies occurred in cases 8, 18, and 25. 70 Deficiencies occurred in cases 5-8, 16, and 55. Significant deficiencies occurred in cases 6 and 7. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 84 Compliance Score Results Table 18. 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 9 6 0 60.0% 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 12 3 0 80.0% 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? 9 0 6 100% (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 14 1 0 93.3% 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 10 2 3 83.3% 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? 6 0 9 100% (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 15 0 0 100% 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 8 7 0 53.3% 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? 6 0 9 100% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 10 8 0 55.6% 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 1 2 0 33.3% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 2 0 1 100% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 79.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 85 Table 19. 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 17 15 13 53.1% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 25 5 15 83.3% 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 86 Recommendations • Health care leadership should ascertain the root cause(s) related to untimely providing and scheduling patients’ high-priority specialty service appointments and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of challenges to timely providing preapproved specialty appointments for transfer-in patients and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 87 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 (75.0%) CIW’s performance was satisfactory in this indicator. While CIW scored well in most applicable tests, it needed improvement in several areas. The Emergency Medical Response Review Committee (EMRRC) did not complete the required checklists or review the cases within required time frames. In addition, staff conducted a medical emergency response drill with several missing required emergency response drill forms. Additionally, physician managers did not complete all provider clinical performance appraisals timely. Lastly, the nurse educator did not ensure all newly hired nurses received the required onboarding training timely. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator adequate. Compliance Testing Results Nonscored Results The OIG did not have any applicable adverse sentinel events requiring root cause analysis during the inspection period (MIT 15.001). The institution reported no patient deaths during the inspection period (MIT 15.998). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 88 Compliance Score Results Table 20. 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 4 8 0 33.3% 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 4 0 0 100% 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 2 1 0 66.7% 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 N/A N/A N/A N/A 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 0 6 1 0 timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 11 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 5 0 2 100% 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 0 1 0 0 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): 75.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 89 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 90 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 CIW Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 91 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 92 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 93 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 94 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 95 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 96 Appendix B: Case Review Data Table B–1. CIW Case Review Sample Sets Sample Set Total Anticoagulation 1 CTC/OHU 3 Diabetes 4 Emergency Services – CPR 1 Emergency Services – Non-CPR 3 High Risk 7 Hospitalization 5 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 Perinatal Services 4 RN Sick Call 18 Specialty Services 5 Total 57 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 97 Table B–2. CIW Case Review Chronic Care Diagnoses Sample Set Total Anemia 16 Anticoagulation 2 Arthritis/Degenerative Joint Disease 18 Asthma 11 Cancer 3 Cardiovascular Disease 7 Chronic Kidney Disease 4 Chronic Pain 18 Cirrhosis/End-Stage Liver Disease 2 COPD 8 COVID-19 4 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 13 Gastroesophageal Reflux Disease 18 Gastrointestinal Bleed 1 Hepatitis C 7 Hyperlipidemia 22 Hypertension 21 Mental Health 33 Migraine Headaches 8 Seizure Disorder 3 Sleep Apnea 2 Substance Abuse 18 Thyroid Disease 10 Total 251 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 98 Table B–3. CIW Case Review Events by Program Diagnosis Total Diagnostic Services 290 Emergency Care 94 Hospitalization 71 Intrasystem Transfers In 15 Intrasystem Transfers Out 7 Outpatient Care 476 Prenatal & Postpartum Care 55 Specialized Medical Housing 86 Specialty Services 229 1,323 Table B–4. CIW Case Review Sample Summary Sample Set Total MD Reviews Detailed 29 MD Reviews Focused 3 RN Reviews Detailed 20 RN Reviews Focused 26 Total Reviews 78 Total Unique Cases 57 Overlapping Reviews (MD & RN) 21 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 99 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 100 Appendix C: Compliance Sampling Methodology California Institution of Women 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 30 Clinic • Clinic (each clinic tested) (6 per clinic) Appointment List • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 17 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 45 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 8 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 101 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 17 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 17 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 13 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 2 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 102 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 17 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 25 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 1 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 103 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries 5 OB Roster • Delivery date (2 – 12 months) • Most recent deliveries (within date range) Pregnant Arrivals 5 OB Roster • Arrival date (2 – 12 months) • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 21 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 25 SOMS • Arrival date (at least 2 yrs. prior to inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear 25 SOMS • Arrival date (at least three yrs. prior to 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 104 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 20 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 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 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 105 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 18 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 3 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 0 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 4 LGB meeting • Quarterly meeting minutes 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 106 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations (continued) MIT 15.103 Death Reports 0 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 7 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 11 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 0 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: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 107 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7, California Institution for Women | 108 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024. Report Issued: June 2025 Cycle 7 Medical Inspection Report for California Institution for Women OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA June 2025 OIG