California Men’s Colony Prison Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, California Men’s Colony | 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 11 Indicators 13 Access to Care 13 Diagnostic Services 20 Emergency Services 25 Health Information Management 31 Health Care Environment 37 Transfers 44 Medication Management 51 Preventive Services 59 Nursing Performance 62 Provider Performance 68 Specialized Medical Housing 73 Specialty Services 79 Administrative Operations 85 Appendix A: Methodology 89 Case Reviews 90 Compliance Testing 93 Indicator Ratings and the Overall Medical Quality Rating 94 Appendix B: Case Review Data 95 Appendix C: Compliance Sampling Methodology 99 California Correctional Health Care Services’ Response 107 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | iv Illustrations Tables 1. CMC Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. CMC Master Registry Data as of May 2024 7 3. CMC Health Care Staffing Resources as of May 2024 8 4. CMC Results Compared With State HEDIS Scores 10 5. Access to Care 17 6. Other Tests Related to Access to Care 18 7. Diagnostic Services 23 8. Health Information Management 34 9. Other Tests Related to Health Information Management 35 10. Health Care Environment 42 11. Transfers 48 12. Other Tests Related to Transfers 49 13. Medication Management 56 14. Other Tests Related to Medication Management 57 15. Preventive Services 60 16. Specialized Medical Housing 77 17. Specialty Services 82 18. Other Tests Related to Specialty Services 83 19. Administrative Operations 87 Table A–1. Case Review Definitions 90 Table B–1. CMC Case Review Sample Sets 95 Table B–2. CMC Case Review Chronic Care Diagnoses 96 Table B–3. CMC Case Review Events by Program 97 Table B–4. CMC Case Review Sample Summary 97 Figures A–1. Inspection Indicator Review Distribution for CMC 89 A–2. Case Review Testing 92 A–3. Compliance Sampling Methodology 93 Photographs 1. Outdoor Patient Wating Area 37 2. Individual Waiting Modules 38 3. Indoor Patient Waiting Area 38 4. Expired Medical Supply Dated April 2024 39 5. Expired Medical Supply Dated November 30, 2023 39 6. Long-Term Storage of Staff’s Food in the Medical Supply Storage Area 39 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 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: July 2025 Cycle 7, California Men’s Colony | 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 Men’s Colony, 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. The case reviews include death reviews between June 2023 and January 2024, anticoagulation reviews between October 2023 and March 2024. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of CMC in October 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 CMC adequate. quality at CMC adequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 60 cases, which contained 1,089 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 October 2024 to verify their initial findings. The OIG physicians rated the quality of care for 25 comprehensive case reviews. Of these 25 cases, our physicians rated all 25 adequate. 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 352 patient records and 1,091 data points, and we used the data to answer 91 policy questions. In addition, we observed CMC’s processes during an on-site inspection in June 2024. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 13 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to CMC. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CMC 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: July 2025 Cycle 7, California Men’s Colony | 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 CMC during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to CMC. Of these 10 indicators, OIG clinicians rated all 10 adequate. The OIG physicians also rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, all 25 were adequate. In the 1,089 events reviewed, we identified 308 deficiencies, 61 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CMC: • Patients received excellent outpatient provider and nurse access. • Staff performed excellently in the transfer-in process, including transfer medications. • Providers often appropriately managed patients with urgent or emergent conditions. • Providers and nurses delivered good care for correctional treatment center (CTC) patients. Our clinicians found the following weaknesses at CMC: • Providers needed improvement in endorsing laboratory test results timely and often did not send or sent incomplete test result notification letters to patients. • Nurses needed improvement in performing complete pain assessments and focused abdominal assessments when clinically indicated. • Nurses needed improvement in thoroughly documenting emergency events. 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: July 2025 Cycle 7, California Men’s Colony | 6 Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CMC. Of these 10 indicators, our compliance inspectors rated two proficient, two adequate, and six inadequate. We tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. CMC showed a high rate of policy compliance in the following areas: • Staff performed excellently in offering immunizations, providing preventive services, and transferring patients with a high risk of contracting coccidioidomycosis (Valley Fever) out of the CMC. • Nursing staff and provider performance was outstanding in completing nursing and provider assessments of patients admitted to the specialized medical housing unit. CMC revealed a low rate of policy compliance in the following areas: • Providers did not often communicate results of diagnostic tests timely with complete test result notifications letters. Most patient letters communicating these results were missing the date of the diagnostic service, the date of the results, and whether the results were within normal limits. • Nursing staff did not regularly inspect emergency medical response bags. • Health care staff did not follow hand hygiene precautions before or after patient encounters, or during medication administration. • CMC staff frequently failed to maintain medication continuity for chronic care patients, patients discharged from the hospital, and patients admitted to the specialized medical housing unit. In addition, CMC maintained poor medication continuity for patients who transferred into the institution or had a temporary layover at CMC. Institution-Specific Metrics California Men’s Colony (CMC) is located northwest of the city of San Luis Obispo, in San Luis Obispo County. The institution had two separate housing facilities, commonly referred to as “East” and “West.” CMC closed its West facility on October 27, 2023. Medical staff members run multiple clinics where patients are seen for nonurgent care. East facility houses medium security and general population patients, and is divided into five facilities, including a triage and treatment area (TTA) where medical staff members see patients requiring urgent and emergent care, and a correctional treatment center (CTC) which provides inpatient care. The department has designated CMC as an intermediate care prison; these institutions are predominantly located in urban areas, close to tertiary care centers and specialty care providers for the most cost-effective care. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 7 As of January 22, 2025, the department reports on its public tracker that 71 percent of CMC’s incarcerated population is fully vaccinated for COVID-19, while 62 percent of CMC’s staff is fully vaccinated for COVID-19.7 In May 2024, the Health Care Services Master Registry showed that CMC had a total population of 2,318. A breakdown of the medical risk level of the CMC population as determined by the department is set forth in Table 2 below.8 Table 2. CMC Master Registry Data as of May 2024 Medical Risk Level Number of Patients Percentage* High 1 148 6.4% High 2 288 12.4% Medium 1,188 51.3% Low 694 29.9% Total 2,318 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 5-20-24. 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: July 2025 Cycle 7, California Men’s Colony | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, CMC had one vacant executive leadership position, 1.7 nursing supervisor vacancies, and 41 nursing staff vacancies. CMC had no primary care provider vacancies and reported a surplus of 1.5 primary care providers. Table 3. CMC Health Care Staffing Resources as of May 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 9.5 20.2 222.3 257.0 Filled by Civil Service 4.0 11.0 18.5 181.3 214.8 Vacant 1.0 –1.5 1.7 41.0 42.2 Percentage Filled by Civil Service 80.0% 115.8% 91.6% 81.6% 83.6% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 0 0 25.0 25.0 Percentage Filled by Registry 0 0 0 11.2% 9.7% Total Filled Positions 4.0 11.0 18.5 206.3 239.8 Total Percentage Filled 80.0% 115.8% 91.6% 92.8% 93.3% Appointments in Last 12 Months 0 0 1.0 20.0 21.0 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 1.0 1.0 7.0 9.0 Adjusted Total: Filled Positions 4.0 10.0 17.5 199.3 230.8 Adjusted Total: Percentage Filled 80.0% 105.3% 86.6% 89.7% 89.8% * 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 May 20, 2024, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 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 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 CMC’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. Currently, only two HEDIS measures are available for review: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control and colorectal cancer screening rates for patients ages 45 to 75. CMC’s results compared favorably with those found in State health plans for these measures. 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)—CMC’s percentage of patients with poor HbA1c control was significantly lower, indicating very good performance for this measure. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. CMC had a 48 percent influenza immunization rate for adults 18 to 64 years old and a 74 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 94 percent.10 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CMC had a 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: July 2025 Cycle 7, California Men’s Colony | 10 90 percent colorectal cancer screening rate, indicating very good performance for this measure. Table 4. CMC Results Compared with State HEDIS Scores CMC 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%) ‡,§ 8% 36% 31% 22% HbA1c Control (< 8.0%) ‡ 82% – – – Blood Pressure Control (< 140/90) ‡ 90% – – – Eye Examinations 78% – – – Influenza – Adults (18 – 64) 48% – – – Influenza – Adults (65 +) 74% – – – Pneumococcal – Adults (65 +) 94% – – – Colorectal Cancer Screening 90% 37% 68% 70% Notes and Sources * Unless otherwise stated, data were collected in June 2024 by reviewing medical records from a sample of CMC’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 CMC 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: July 2025 Cycle 7, California Men’s Colony | 11 Recommendations As a result of our assessment of CMC’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 the timely provision of chronic care and hospital follow-up appointments with providers and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) of challenges to the timely provision of nurse face-to-face assessments after sick call requests and should implement remedial measures as appropriate. Diagnostic Services • Medical leadership should determine the root cause(s) of the challenges to providers timely endorsing test results and creating patient test result letters with all elements required by CCHCS policy. Medical leadership should implement remedial measures as appropriate. Health Information Management • Health care leadership should identify challenges to scanning, labeling, and filing medical records properly 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 necessary remedial measures. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement necessary 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 for staff failing to properly complete the monthly logs and should implement necessary remedial measures. Transfers • Nursing leadership should identify strategies to ensure nursing staff completely answer and address required initial health screening questions. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 12 • Healthcare leadership should identify the challenges to maintaining medication continuity for patients transferring into the institution without their medications and should implement remedial measures as appropriate. Medication Management • Medical and nursing leadership should determine the challenges to ensuring chronic care patients, hospital discharge patients, and newly arrived patients receive their medications timely and without interruption. Leadership should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for nursing staff not documenting patient refusals and no-shows in the medication administration record (MAR), as described in CCHCS policy and procedures, and should implement remedial measures as appropriate. Nursing Performance • Nursing leadership should determine the causes that prevent CMC nurses from scheduling patients for a same-day evaluation when patients complain of urgent symptoms and should implement remedial measures as appropriate, which may include training staff. • Nursing leadership should determine the causes that prevent CMC nurses from performing thorough pain and abdominal assessments when patients present with related symptoms and should implement remedial measures as appropriate, which may include training staff. Specialty Services • Health care leadership should determine the root cause(s) of challenges to ensuring follow-up provider appointments with patients after specialty encounters occur within required time frames and should implement necessary remedial measures. • Health care leadership should determine the root cause(s) of challenges for staff timely retrieving and scanning specialty reports, as well as providers timely endorsing specialty reports, and should implement necessary remedial measures. • Health care leadership should determine the root cause(s) of challenges to ensuring staff schedule newly transferred patients with preapproved specialty services within specified time frames the providers order and should implement necessary remedial measures. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 13 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (75.5%) Case review found CMC provided good access to care during Cycle 7. Appointments with clinic providers, nurses, and specialists generally occurred timely. CMC also offered excellent provider access for correctional treatment center (CTC) patients. Patients received timely follow-up appointments after a hospitalization or a triage and treatment area (TTA) event. While we found some access deficiencies, we did not identify any significant patterns. After considering all aspects, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed performance in this indicator. Nursing staff always reviewed patient sick call requests timely but only sometimes completed face-to-face encounters after triage of sick call requests as required by policy. Providers often evaluated newly transferred patients within required time frames. However, providers sporadically evaluated patients with chronic care conditions, patients returning from specialist appointments, and patients returning from hospitalizations within required time frames. CMC also did not maintain a good process to ensure housing units adequately stored health care services request forms. 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 252 provider, nursing, emergency (TTA), specialty, and hospital events that required CMC staff to generate appointments. We identified 18 deficiencies related to Access to Care, six of which were significant.11 Access to Care Providers CMC’s performance varied with access to clinic providers. Compliance testing revealed chronic care follow-up appointments occurred occasionally within ordered time frames (MIT 1.001, 52.0%). However, provider appointments ordered by nurses frequently occurred on time (MIT 1.005, 85.0%), and provider follow-up appointments after a sick 11 Deficiencies occurred in cases 2, 10–12, 16, 18, 25, 26, 28, 30, 51, 58, and 59. Significant deficiencies occurred in cases 2, 16, 25, 30, and 59. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 14 call encounter always occurred on time (MIT 1.006, 100%). The OIG clinicians reviewed 125 provider encounters in clinics and identified only two deficiencies related to provider access, one of which was significant as follows:12 • In case 25, a provider ordered the follow-up appointment to occur in 60 days. However, the appointment had not occurred as ordered by the end of our review period, at which time the appointment was already 15 days late. Access to Specialized Medical Housing Providers CMC provided excellent access to providers in the CTC. Compliance testing showed providers always completed the required history and physical examinations timely (MIT 13.002, 100%). The OIG clinicians reviewed 56 provider encounters and identified no access deficiencies. Access to Clinic Nurses Access to sick call nurses varied. While compliance testing showed nurses reviewed all sick call requests on the same day they were received (MIT 1.003, 100%), nurses only sometimes performed face-to-face patient assessments within one business day (MIT 1.004, 63.3%). The OIG clinicians reviewed 88 outpatient nursing encounters and identified only three deficiencies related to nursing access, one of which was significant as follows:13 • In case 2, the primary care registered nurse (RN) attempted to assess the patient for a 30-day interfacility follow-up appointment and documented, “per custody, patient did not receive a ducat. Appointment will be rescheduled.” Staff did not reschedule the appointment properly; consequently, the appointment occurred nearly 30 days late. Access to Specialty Services CMC performed well in referrals to specialty services. Compliance testing showed staff generally completed initial specialty appointments within required time frames for high- priority (MIT 14.001, 77.8%), medium-priority (MIT 14.004, 86.7%), and routine-priority (MIT 14.007, 86.7%) referrals. CMC staff also completed specialty follow-up appointments as requested, with most high-priority (MIT 14.003, 88.9%) and medium-priority (MIT 14.006, 87.5%) appointments occurring timely, as well as all routine-priority (MIT 14.009, 100%) appointments occurring timely. The OIG clinicians reviewed 126 specialty encounters and identified 11 deficiencies related to specialty provider access, two of which were significant.14 The following is an example: • In case 30, the patient underwent outpatient surgery for persistent nasal bleeding and was scheduled for a follow-up appointment with his surgeon in one week. However, the follow-up appointment did not occur. 12 Deficiencies occurred in cases 18 and 25. 13 Deficiencies occurred in cases 2, 11, and 51. 14 Deficiencies occurred in cases 10, 12, 26, 28, 30, 58, and 59. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 15 The other deficiency is described in the Specialty Services indicator. Follow-Up After Specialty Services Compliance testing revealed provider appointments after specialty encounters often occurred untimely at CMC, with just over half the appointments completed within required time frames (MIT 1.008, 54.6%). OIG clinicians identified two significant deficiencies related to clinic provider appointments as described below: • In case 16, the patient returned from a high-priority appointment with the orthopedic surgeon. Staff scheduled the patient for a 14-day follow-up appointment with his CMC provider, instead of a five-day follow-up appointment as required by CCHCS policy. • In case 30, the patient returned from a high-priority appointment with an ENT specialist.15 Staff should have scheduled the patient for a five-day follow-up appointment with his CMC provider. However, staff did not order the follow-up appointment. Follow-Up After Hospitalization Compliance testing revealed patients generally received a follow-up appointment with their provider after a hospital discharge (MIT 1.007, 75.0%). OIG clinicians did not identify any access deficiencies with provider appointments for patients after hospitalizations. Follow-Up After Urgent or Emergent Care (TTA) CMC provided excellent access to care for patients following a TTA event. OIG clinicians assessed 24 TTA events and did not identify any access deficiencies. Follow-Up After Transferring Into the CMC Newly arrived patients to CMC received good access to care. Compliance testing showed providers frequently evaluated patients within required time frames (MIT 1.002, 83.3%). The OIG clinicians did not identify any deficiencies related to new patient arrivals in the four cases we reviewed.16 Clinician On-Site Inspection During our on-site inspection, we met with health care leadership, providers, and ancillary staff. In previous cycles, CMC consisted of an East and a West facility; however, CMC reported closing its West facility on October 27, 2023. As a result, the East facility contained all patient housing units and clinics. CMC staff maintained one multi-provider outpatient clinic, a medical correctional treatment center (CTC), a mental health CTC, and a restricted housing unit. In addition, staff operated a TTA, temporarily located in the outpatient clinic during renovation of the centrally located TTA. All CMC medical providers worked a Monday through Friday schedule, except one provider who worked 15 An ENT specialist is an Ear, Nose, and Throat specialist. 16 OIG clinicians reviewed cases 2 and 31–33. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 16 two days a week to cover for absent providers. A provider usually evaluated eight to 10 patients per day. Staff reported no backlog in the outpatient clinics at the time of our inspection. CMC also conducted telemedicine appointments and various on-site specialty appointments. Some CMC on-site specialists also provided care for patients at other institutions. Compliance On-Site Inspection and Discussion Four of six housing units randomly tested at the time of inspection had access to health care services request forms (CDCR Form 7362) (MIT 1.101, 66.7%). In two housing units, custody officers did not have a system in place for restocking the forms. The custody officers reported reliance on medical staff to replenish the forms in the housing units. In addition, one of the two housing units had no forms available at the time of inspection. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 17 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 13 12 0 52.0% 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 20 4 1 83.3% 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 19 11 0 63.3% 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 17 3 10 85.0% 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 5 0 25 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 9 3 1 75.0% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 12 10 17 54.6% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 4 2 0 66.7% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 75.5% * 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: July 2025 Cycle 7, California Men’s Colony | 18 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 N/A N/A N/A N/A required 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 N/A N/A N/A N/A to 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the 10 0 0 100% 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 7 2 0 77.8% Request for Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 8 1 0 88.9% 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 13 2 0 86.7% 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? 7 1 7 87.5% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 13 2 0 86.7% for Service? (14.007) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care 5 0 10 100% 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: July 2025 Cycle 7, California Men’s Colony | 19 Recommendations • Health care leadership should determine the root cause(s) of challenges to the timely provision of chronic care and hospital follow-up appointments with providers and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) of challenges to the timely provision of nurse face-to-face assessments after sick call requests and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 20 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (56.9%) Case review found CMC performed satisfactorily in delivering diagnostic services to patients. Staff completed most tests as requested and promptly managed STAT test results. However, we identified a pattern of late provider endorsement of test results. In addition, providers often either did not send test result notification letters or sent incomplete test result notification letters to patients. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. CMC’s overall compliance testing scored low for diagnostic services. Staff performed excellently in completing all radiology tests, while also often timely completing routine- priority laboratory tests and reviewing laboratory test results. However, they only sometimes timely retrieved and reviewed pathology reports, and inconsistently generated patient test result letters with all required elements. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 229 diagnostic events and identified 122 deficiencies, 15 of which were significant and related to health information management.17 For health information management, we consider test reports that were never retrieved or reviewed to be as severe a problem as tests that were never performed. We discuss this further in the Health Information Management indicator. Test Completion CMC performed well in completing diagnostic tests. Compliance testing showed staff completed all radiology services (MIT 2.001, 100%) and most laboratory services (MIT 2.004, 80.0%) within required time frames. Similarly, OIG clinicians only identified four minor deficiencies related to diagnostic test completion.18 17 Diagnostic deficiencies occurred in cases 1, 2, 10–17, 19, 21, 22, 24–30, and 57–59. Significant deficiencies occurred in cases 13, 24, 30, 57, and 58. 18 Deficiencies occurred in cases 24 and 25. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 21 OIG clinicians reviewed three STAT diagnostic tests, all of which were completed timely.19 Compliance testing did not have any STAT laboratory tests in their samples (MIT 2.007, N/A). Health Information Management CMC staff retrieved diagnostic test results promptly and forwarded them to providers for review. In compliance testing, providers generally endorsed laboratory results timely (MIT 2.005, 80.0%). However, providers only intermittently endorsed radiology reports (MIT 2.002, 70.0%) and pathology reports (MIT 2.011, 62.5%) within specified time frames. OIG clinicians identified 118 deficiencies, 15 of which were significant.20 The following are examples: • In case 13, providers endorsed laboratory test results 14, 17, 27, and 31 days late. • In case 57, staff completed laboratory tests for the patient. The results were available within a week, and staff forwarded them to the primary provider. However, the provider endorsed the results more than four months later, after the patient had been transferred to another institution. • In case 58, staff completed laboratory tests for the patient on four separate occasions. Each time, the results were available for review the following day. However, a provider did not endorse the results until four weeks later. As in Cycle 6, creating patient notification letters remained a challenge for providers at CMC. Compliance testing showed providers sometimes sent complete patient test result letters for radiology tests (MIT 2.003, 50.0%), rarely sent complete patient test result letters for laboratory tests (MIT 2.006, 10.0%), and never sent complete patient test result letters for pathology tests (MIT 2.012, zero). In 90 of the 118 deficiencies, OIG clinicians identified the patient test result letters were either missing a required element or were never sent to the patient.21 While none of these deficiencies were significant, the large number showed a pattern of poor letter communication of test results between providers and patients. The following are examples: • In case 2, a provider endorsed a throat culture result but did not generate a patient notification letter. • In case 10, a provider endorsed the pathology report for the patient’s liver biopsy. However, the provider did not send the patient a notification letter. 19 STAT tests occurred in cases 10, 24, and 30. 20 Deficiencies occurred in cases 1, 2, 10–17, 19, 21, 22, 24–30, and 57–59. Significant deficiencies occurred in cases 13, 24, 30, 57, and 58. 21 Deficiencies occurred in cases 1, 2, 10–12, 14–17, 19, 21, 22, and 24–30. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 22 • In case 11, a provider sent the patient a results notification letter. However, the letter did not state the date of the testing or whether the results were normal. • In case 21, a provider sent the patient a notification letter for the results of an ultrasound. However, the letter did not state whether the results were normal. • In case 24, a provider sent the patient a notification letter for a chest X-ray. However, the letter did not include the date of the X-ray or whether the results were normal. • In case 30, a provider endorsed laboratory test results 10 days late and generated a patient notification letter that did not include the date of the test. Clinician On-Site Inspection We interviewed the diagnostic services supervisor and staff. The main laboratory at CMC was located just outside the institution. Phlebotomists reported to the laboratory each morning and prepared for their daily assignments. Phlebotomists then entered CMC and proceeded to the various patient areas. CMC employed three laboratory technicians, one of whom was a registry employee. The high cost of living in the local community contributed to laboratory staff turnover at CMC. Depending on a patient’s location, laboratory staff or a nurse would collect STAT laboratory specimens. Staff would then contact a courier to transport the specimen. The diagnostic services supervisor described how couriers had challenges delivering specimens to a contracted laboratory quickly because of CMC’s location. Even with the additional time allowance for rural institutions, CMC usually retrieved STAT laboratory results late. When laboratory staff left for the day, they would notify the medical CTC charge nurse of any pending STAT results and forward the nurse’s contact information to the processing laboratory. A typical turnaround time for STAT laboratory results was eight hours. CMC radiology services included plain films, ultrasounds, CT scans, and MRIs.22 Radiology staff reported FibroScan studies would be available in the near future.23 CMC also anticipated the installation of new radiology equipment, which would enable faster processing and direct transfer of images. 22 A CT is a computed, or computerized, tomography scan. An MRI is a magnetic resonance imaging scan. Both create detailed images of the organs and tissues to detect diseases and abnormalities. 23 A FibroScan is a diagnostic imaging test used to evaluate for liver scarring and fatty changes from liver disease. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 23 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 7 3 0 70.0% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 5 5 0 50.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 8 2 0 80.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 8 2 0 80.0% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 1 9 0 10.0% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive N/A N/A N/A N/A the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory N/A N/A N/A N/A results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 6 4 0 60.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 5 3 2 62.5% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 8 2 0 pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 56.9% 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: July 2025 Cycle 7, California Men’s Colony | 24 Recommendations • Medical leadership should determine the root cause(s) of the challenges to providers timely endorsing test results and creating patient test result letters with all elements required by CCHCS policy. Medical leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 25 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 Cycle 7, CMC showed improvement in emergency care. Although the OIG clinicians reviewed fewer cases than in Cycle 6, the number of overall emergency events was similar. In addition, although the case samples contained fewer urgent and emergent events in Cycle 7, we reviewed six times the number of CPR cases in this cycle than in Cycle 6, increasing the opportunity for deficiencies. Yet, in Cycle 7, we identified fewer overall deficiencies than in Cycle 6. Notably, although we found two more significant deficiencies occurred in Cycle 7 than in Cycle 6, both related to clinical reviews rather than patient care. Moreover, we found no patterns or trends identified in emergency care that were cause for concern. Taking these factors into account, the OIG rated this indicator adequate. Case Review Results The OIG clinicians reviewed 24 urgent or emergent events and found 18 deficiencies within various aspects of overall emergency care. Of these 18 deficiencies, seven were significant.24 Emergency Medical Response CMC custody staff and health care staff responded promptly to all medical alarm activations throughout the institution. However, on one occasion, a patient with chest pain walked to the TTA as instructed by the psychiatric technician (PT), rather than the PT activating a medical alarm.25 In addition, custody and health care staff almost always initiated emergency medical services (EMS) promptly. On one occasion, the TTA nurse did not consider activating EMS when patient symptoms warranted transfer to a higher level of care, as described below: 24 Deficiencies occurred in cases 1, 3–6, 8–10, 25, 26, and 30. Significant deficiencies occurred in cases 1, 6, 8, and 25. 25 This medical alarm activation deficiency occurred in case 1. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 26 • In case 25, staff activated a medical alarm for this patient in respiratory distress. The patient had an elevated heart rate, increased respirations, low oxygen saturation, and left leg swelling, which are classic signs of a pulmonary embolism.26 However, the nurse did not timely notify the provider or activate EMS. Cardiopulmonary Resuscitation Quality CMC custody staff and medical staff worked collaboratively to provide emergency care. OIG clinicians reviewed six cases in which CPR was initiated.27 In five of the six CPR cases, we identified opportunities for improvement, two of which were significant and are described below: • In case 6, nursing staff provided emergency care for the patient, who was found hanging, unresponsive, and not breathing. The TTA RN documented the patient had red-colored gastric contents coming out of the mouth, but did not initiate suction to clear the airway. In addition, although the supervising registered nurse (SRN) inserted an oral airway adjunct, nursing staff did not apply oxygen.28 Furthermore, the nurses did not apply a cervical collar to stabilize the patient’s neck during emergency care. • In case 8, staff activated a medical alarm for the unresponsive patient. However, nurses did not timely administer oxygen. Provider Performance CMC providers performed excellently in urgent and emergent situations, and in after- hours care. Providers were available for consultation with nurses when necessary and were involved in treatment decisions. Providers made accurate diagnoses and generally completed documentation. OIG clinicians reviewed 24 emergency events and identified only one minor provider deficiency as follows: • In case 25, a nurse consulted with a provider regarding the patient’s symptoms of shortness of breath and chest discomfort, along with a low oxygen saturation and an elevated heart rate. The provider ordered an oral dose of an anxiety medication. However, the provider should have also considered alternative cardiopulmonary diagnoses, given the patient’s age, medical history, and clinical presentation. In addition, the provider should have considered more urgent transfer to a higher level of care. Nursing Performance CMC nurses generally performed good nursing assessments and interventions in emergency events. Of the 18 emergency care deficiencies identified, 11 related to nursing, 26 A pulmonary embolism is a life-threatening condition caused by a blood clot blocking an artery in the lung. 27 Staff performed CPR in cases 4–9. CPR deficiencies occurred in cases 4–6, 8, and 9. 28 An oral airway device is a medical device used to maintain or open a patient’s airway when the patient is unresponsive and not breathing. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 27 of which four involved nursing assessments, and five involved nursing interventions.29 30 31 OIG clinicians did not identify any patterns or trends; however, at times, TTA nurses made incomplete nursing assessments or reassessments, and in one case, did not timely carry out a provider’s order. The following are examples: • In case 1, the TTA RN evaluated this walk-in patient for chest pain. However, the RN consulted with the provider for a further plan of care rather than using the chest pain nursing protocol to provide immediate medications to treat chest pain. The provider ordered aspirin and nitroglycerin (NTG) STAT.32 However, the RN waited until 12 minutes to administer the aspirin and 26 minutes to administer the NTG. In addition, the nurse did not obtain the patient’s vital signs after administering the NTG. • In case 25, TTA nurses provided care to this patient in respiratory distress. Upon arrival to the TTA, the nurses did not take an initial set of vital signs for 35 minutes and did not monitor vital signs at least every five minutes or place the patient on a cardiac monitor. In addition, the TTA RN documented the patient had swelling in the lower left extremity, but the nurse did not assess for pulses in the patient’s feet. Nursing Documentation CMC nurses had opportunities for improvement in performing thorough documentation for emergency events, as most nursing deficiencies in the emergency services indicator related to documentation. OIG clinicians identified 11 documentation deficiencies, including unclear timelines, conflicting nurse reports, incomplete documentation of medication administration records for administered emergency medications, and incomplete documentation of assessments.33 The following are examples: • In case 9, the licensed vocational nurse (LVN) and RN documented conflicting times for initiating CPR and oxygen, as well as the type of mask applied to the patient. Similarly, in case 25, the nurses had conflicting documentation on oxygen initiation (nasal canula vs. mask) and flow rate. • In case 10, the TTA RN documented transporting the patient from the yard to the TTA in the emergency response vehicle at 1:29 p.m. However, the TTA RN also documented arriving with the patient to the TTA at 2:03 pm. It is not clear if the time of arrival to the TTA was a documentation error as the record contains no documentation for the reason for delay to the TTA. 29 Nursing deficiencies occurred in cases 1, 3, 4–6, 8-10, 25, 26, and 30. 30 Nursing assessment deficiencies occurred in cases 1, 3, 10, and 25. A significant nursing assessment deficiency occurred in case 25. 31 Nursing intervention deficiencies occurred in cases 1, 3, 6, 8 and 25. Significant nursing intervention deficiencies occurred in cases 1, 6, 8, and 25. 32 Nitroglycerin is a medication used to relieve chest pain. It works by dilating blood vessels, which decreases the amount of work for the heart. This can result in a drop in blood pressure. STAT refers to an order, action, or medication that should be implemented or given immediately. 33 Nursing documentation deficiencies occurred in cases 3–5, 9, 10, 25, 26, and 30. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 28 Emergency Medical Response Review Committee The EMRRC met monthly and discussed emergency responses and unscheduled send- outs. However, compliance testing revealed incident packages were deficient due to cases not being reviewed within required time frames or to being incomplete (MIT 15.003, 33.3%). In contrast, OIG clinicians found health leadership and the EMRRC performed all clinical reviews; however, in six emergency responses or unscheduled send-outs, the nursing and medical leadership and the EMRRC did not identify the same opportunities for improvement the OIG clinicians identified.34 Clinician On-Site Inspection During the on-site inspection, we toured the TTA and spoke to nursing staff. At the time of inspection, the original TTA was under active renovation and the alternate TTA was located in a swing space within the main health care services clinic. The swing space TTA contained three beds in separate examination rooms, providing acceptable space for emergency care. Each room had an automated external defibrillator (AED), and the room designated for trauma care had a cardiac monitor. Nurses reported each shift had two TTA RNs scheduled and an assigned provider available during business hours, with an on-call provider available after hours. The main health care services clinic, where the swing space TTA was located, was in a location central to the housing units with no observable barriers other than gates separating the housing units from the central access areas. During an interview with the two TTA RNs on shift, they indicated the TTA officer carried gate keys on their person to eliminate delays in accessing the TTA. In addition, the nurses relayed they responded to emergencies with an emergency cart or vehicle. Furthermore, the TTA RNs shared they had cell phones and radios to contact the medical provider during an active emergency, when needed. OIG clinicians inquired about challenges community ambulances had when accessing the institution, and the TTA RNs reported no barriers. They stated the community ambulance could access the institution through the vehicle sally port and could drive directly into the yards to access the housing units. The TTA RNs described the emergency medical response process and indicated the LVNs and PTs are first responders within the housing unit gates. However, the TTA RNs were considered the first responders for emergencies called outside of the housing units, such as in the receiving and release (R&R) area, the visiting area, California Prison Industry Authority (CALPIA), or other areas.35 In addition, TTA RNs reported they are not required to respond to the CTC or to the mental health care crisis bed (MHCB) alarms, as the nurses assigned to those inpatient areas respond to their own emergencies. Therefore, patients would not be transferred to a lower level of care and would instead be transferred directly to community hospitals when required. However, the TTA RNs also reported they would respond to any area, if requested, for additional assistance. In addition to emergencies, the TTA RNs described further responsibilities such as processing patients returning from off-site specialty appointments and community 34 Clinical reviews were conducted in cases 1–11, 23, 25, 26, and 30. Deficiencies occurred in cases 1, 6, 8–10, and 26. 35 The California Prison Industry Authority (CALPIA) provides incarcerated individuals with work and training opportunities. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 29 hospitalizations. The nurses also indicated patients already housed in a higher level of care, such as the CTC or MHCBs, prior to going off site, do not return through the TTA. Those patients return directly to their previous levels of care. The TTA RNs interviewed were pleasant, knowledgeable, and transparent in their responses. One of the TTA RNs was newer to state service, and another TTA RN had many years of experience within the institution. When OIG clinicians inquired about overall position satisfaction, both TTA RNs reported good morale and great working relationships among colleagues, which was apparent during interviews with many of the staff at CMC. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 30 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: July 2025 Cycle 7, California Men’s Colony | 31 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 Adequate (77.6%) Case review found CMC performed satisfactorily with health information management (HIM). Staff retrieved hospital and emergency room records quickly, and providers appropriately documented urgent and emergency events. However, we identified handling deficiencies of specialty reports, late provider endorsements of diagnostic results, and missing or incomplete patient test result notification letters. The missing or incomplete letters did not significantly affect patient care. After careful consideration, the OIG rated the case review component of this indicator adequate. Compliance testing also showed CMC performed satisfactorily in this indicator. Staff always timely scanned patients’ requests for medical care. They also performed well in scanning and reviewing hospital discharge reports. In contrast, staff needed improvement in timely scanning specialist reports and labeling and filing patient medical records in the correct patient files. 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 1,089 events and identified 144 deficiencies related to health information management. Of these 144 deficiencies, 18 were significant.36 Hospital Discharge Reports CMC staff performed well in managing hospital records. Compliance testing showed CMC staff retrieved and scanned most hospital discharge documents timely (MIT 4.003, 84.6%). The hospital discharge documents often contained key elements and providers endorsed most hospital records timely (MIT 4.005, 84.6%). OIG clinicians reviewed 34 off- 36 Deficiencies occurred in cases 1–3, 9–17, 19, 21, 22, 24–30, and 57–59. Significant deficiencies occurred in cases 13, 24, 30, 57, and 58. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 32 site emergency department and hospital encounters. We identified four deficiencies, all involving late provider endorsements.37 The following are two significant examples: • In case 30, a provider endorsed a hospitalization discharge report 10 days late. Also in this case, the same provider endorsed a hospital procedure report 17 days late. Specialty Reports CMC’s performance in handling specialty reports ranged from good to poor. Compliance testing revealed CMC staff needed improvement in retrieving specialty reports timely (MIT 4.002, 69.0%). Providers generally endorsed routine-priority specialty reports timely (MIT 14.008, 84.6%), but they only occasionally endorsed medium-priority and high- priority specialty reports within required time frames (MIT 14.005, 53.3% and MIT 14.002, 44.4%). OIG clinicians reviewed 184 specialty reports and identified 22 deficiencies, only one of which was significant as follows:38 • In case 30, a provider endorsed a hematology specialist’s report 13 days late.39 We also discuss these findings in the Specialty Services indicator. Diagnostic Reports CMC’s performance in managing diagnostic reports varied. Compliance testing showed providers endorsed most laboratory and radiology reports within required time frames (MIT 2.005, 80.0% and MIT 2.002, 70.0%). However, staff needed improvement in timely receiving and endorsing final pathology reports (MIT 2.010 60.0% and MIT 2.011, 62.5%). In addition, providers performed poorly in timely communicating test results to patients with test result notification letters. Providers never timely communicated pathology results to patients in notification letters (MIT 2.012, zero). The OIG clinicians identified 118 minor deficiencies related to health information management.40 The following are examples: • In case 24, a provider endorsed laboratory test results but did not send the patient a test result notification letter. • In case 28, a provider endorsed laboratory test results and then forwarded them to the patient’s primary provider. However, neither provider sent the patient a test result notification letter. • In case 30, a provider endorsed separate laboratory test results 11, 15, and 30 days late and did not generate patient test result notification letters. Please refer to the Diagnostic Services indicator for additional information. 37 Deficiencies occurred in cases 3, 30, and 58. 38 Deficiencies occurred in cases 1, 9, 10, 29, 30, 57, and 58. 39 A hematology specialist evaluates and treats disorders of the blood. 40 Deficiencies occurred in cases 1, 2, 10–17, 19, 21, 22, 24–30, and 57–59. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 33 Urgent and Emergent Records OIG clinicians reviewed 24 emergency care events and found staff generally documented these events acceptably. Although CMC providers also recorded their emergency care sufficiently, including on-call telephone encounters, CMC nurses needed improvement in performing thorough documentation for emergency events. The Emergency Services indicator provides additional details. Scanning Performance CMC performed poorly with scanning documents. Compliance testing revealed staff properly scanned, labeled, and filed documents in the correct patient file only half the time (MIT 4.004, 50.0%). The OIG clinicians identified four minor deficiencies related to scanning.41 Clinician On-Site Inspection The OIG clinician met with the medical records supervisor, HIM staff, and providers. The supervisor and HIM staff reported HIM staff was responsible for retrieving and scanning all off-site specialty reports. After patients returned from an off-site specialty appointment, TTA staff entered patient names into a shared computer log. HIM staff would begin tracking documents the following day. HIM staff would then retrieve dictated reports from most specialists and hospitals within a few days; however, retrieving surgical specialty reports was more difficult. Notably, HIM staff reported the time frame for retrieving specialty reports was 72 hours, instead of the 48 hours currently required per CCHCS policy.42 41 Deficiencies occurred in cases 9, 12, 29, and 58. 42 HCDOM 3.1.11.c.4.k. HCDOM is the department’s Health Care Department Operations Manual. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 34 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 20 9 10 69.0% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 11 2 0 84.6% (4.003) During the inspection, were medical records properly scanned, labeled, 12 12 0 50.0% 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 11 2 0 84.6% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 77.6% 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: July 2025 Cycle 7, California Men’s Colony | 35 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 7 3 0 70.0% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 8 2 0 80.0% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did N/A N/A N/A N/A nursing staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 6 4 0 60.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 5 3 2 62.5% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 8 2 0 pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 4 5 0 44.4% 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 8 7 0 53.3% 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 11 2 2 84.6% 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: July 2025 Cycle 7, California Men’s Colony | 36 Recommendations • Health care leadership should identify challenges to scanning, labeling, and filing medical records properly and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 37 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (64.9%) Overall, CMC performed poorly with respect to its health care environment. We found medical supply storage areas inside clinics contained expired, unorganized, unidentified, or inaccurately labeled medical supplies. Several clinics did not meet the requirements for essential core medical equipment and supplies. Emergency medical response bags (EMRBs) contained expired medical supplies as well as compromised medical supply packaging and had not been properly inventoried. Finally, staff did not adhere to universal hand hygiene precautions after patient encounters. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Outdoor Waiting Areas We inspected outdoor patient waiting areas (see Photo 1). Health care and custody staff reported existing waiting areas had sufficient seating capacity. The staff reported the outdoor waiting area was only utilized when the indoor waiting area was at capacity. In addition, staff reported patients used the gym instead of the outdoor waiting area during inclement weather. Indoor Waiting Areas Photo 1. Outdoor patient wating area (photographed on 6-4-24). We inspected indoor waiting areas. Health care and custody staff reported Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 38 the existing waiting areas contained sufficient seating capacity. Dependent on the population, patients either remained in the clinic waiting area or were held in individual modules (see Photos 2 and 3, below). During our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Photo 2. Individual waiting modules (photographed on 6-4-24). Photo 3. Indoor patient waiting area (photographed on 6-4-24). Clinic Environment Nine of 10 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, 90.0%). In one clinic, the triage stations were in proximity to each other, which hindered auditory privacy. Eight of the 10 clinics we observed contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 80.0%). The remaining two clinics had one or both of the following deficiencies: the Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 39 examination room lacked visual privacy during patient encounters, and the examination table had a torn vinyl cover. Clinic Supplies Five of the 10 clinics followed proper medical supply storage and management protocols (MIT 5.107, 50.0%). We found one or more of the following deficiencies in five clinics: expired medical supplies (see Photos 4 and 5); unorganized, unidentified, or inaccurately labeled medical supplies; and long-term storage of staff members’ food in the medical supply storage area (see Photo 6). Photo 4. Expired medical supply dated April 2024 (photographed on 6-5-24). Photo 5. Expired medical supply dated November 30, 2023 (photographed on 6-5-24). Photo 6. Long-term storage of staff’s food in the medical supply storage area (photographed on 6-4-24). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 40 Only three of the 10 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 30.0%). The remaining seven clinics contained improperly calibrated equipment or nonfunctional equipment. Staff had not properly calibrated an AED and a nebulization unit. We found several nonfunctional oto-ophthalmoscopes. In addition, staff had not completed AED or defibrillator performance test log documentation within the last 30 days or had not recorded the results of the defibrillator performance test on the monitor defibrillator performance test form (CDCR Form 7548-1). In addition, the clinic daily glucometer quality control log showed inaccurate documentation. We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only 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 one EMRB’s compartments were sealed and intact; one EMRB log had inaccurate staff documentation; staff had not inventoried the EMRBs when the seal tags were replaced; and one EMRB contained compromised or expired medical supplies. Medical Supply Management All medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, 100%). According to the CEO, the institution did not have any concerns about the medical supply process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process. Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected seven of 10 clinics (MIT 5.101, 70.0%). In three clinics, we found one or more of the following deficiencies: cleaning logs were not maintained; biohazard waste was not emptied after each clinic day; and the health care area cabinet or the cabinet under the sink was unsanitary. Staff in six of 10 clinics properly sterilized or disinfected medical equipment (MIT 5.102, 60.0%). In three clinics, staff did not mention disinfecting the examination table as part of their daily start-up protocol. In one clinic, we observed the clinician use the examination table without a disposable paper cover during a patient encounter. We found operational sinks and hand hygiene supplies in the examination rooms in eight of 10 clinics (MIT 5.103, 80.0%). In two clinics, the patient restrooms lacked antiseptic soap and disposable hand towels. We observed patient encounters in six clinics. In five clinics, staff did not immediately remove their gloves after physically touching the patients (MIT 5.104, 16.7%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of our medical inspection, CMC leadership reported the health care facility improvement program project of renovating the TTA that had started January 28, 2021, Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 41 was expected to be completed by May 2025. They reported the renovation had been delayed due the COVID-19 pandemic, transition of new staff, and limited availability of inmate ward labor.43 Despite these delays, CMC’s health care management did not believe the institution’s ability to provide good patient care was negatively impacted (MIT 5.999). 43 The inmate ward labor program is a program providing incarcerated persons with the opportunity to learn basic construction skills involving construction or repair of building and structures. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 42 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, 7 3 0 70.0% 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 6 4 0 60.0% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 8 2 0 80.0% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 1 5 4 16.7% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 10 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 5 5 0 50.0% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 3 7 0 30.0% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 9 1 0 90.0% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 8 2 0 80.0% 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 2 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): 64.9% 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: July 2025 Cycle 7, California Men’s Colony | 43 Recommendations • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement necessary remedial measures. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement necessary 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 for staff failing to properly complete monthly logs, and should implement necessary remedial measures. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 44 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 the performance of staff 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 (73.6%) CMC performed well in this indicator. Compared with Cycle 6, the OIG clinicians reviewed more events in more cases and found similar performance. In Cycle 7 we found a higher number of deficiencies compared to Cycle 6, in which we identified a pattern of providers not always endorsing hospital discharge paperwork timely. However, we also found, in this cycle, nurses performed very well in the transfer-in process and satisfactorily in the transfer-out and hospitalization process. Factoring in all the information, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed results for this indicator. CMC performed excellently in completing the assessment and disposition sections of the screening process. In contrast, the institution scored low in completing initial health screening forms and ensuring medication continuity for newly transferred patients. 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: July 2025 Cycle 7, California Men’s Colony | 45 Case Review and Compliance Testing Results We reviewed 46 events in 21 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 12 deficiencies, four of which were significant.44 Transfers In CMC had mixed performance in the transfer-in process. Compliance testing showed the receiving and release (R&R) nurses needed improvement in completing the initial health screening form thoroughly (MIT 6.001, 56.0%). However, nurses always completed the assessment and disposition sections of the form in its entirety (MIT 6.002, 100%). Compliance testing also found staff needed improvement in medication continuity occurring at the time of transfer (MIT 6.003, 64.7%) and in medication continuity for patient layovers at the institution (MIT 7.006, 60.0%). In addition, compliance testing showed providers generally saw newly arrived patients within necessary time frames (MIT 1.002, 83.3%). While compliance testing results varied, OIG clinicians found CMC performed excellently in the transfer-in process. We reviewed six events in four cases in which patients transferred into the facility from other institutions. We identified only one minor deficiency. Transfers Out CMC performed well in the transfer-out process. Compliance had no samples that met the required criteria for testing (MIT 6.101, N/A). However, OIG clinicians found patients who transferred out of the institution always had their medications and required documents. OIG clinicians reviewed a total of five transfer-out events in three cases in which patients transferred out of the facility to other institutions. We identified two deficiencies, one of which was significant and is provided below:45 • In case 35, the R&R nurse prepared the patient for transfer but did not identify the patient’s 24-hour pre-boarding vital signs as abnormal. Consequently, the RN did not recheck the patient’s critically elevated blood pressure prior to transfer. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is 44 Deficiencies occurred in cases 2, 3, 10, 23–26, 30, 35, 36, and 58. Significant deficiencies occurred in cases 24, 30, and 35. 45 Transfer out deficiencies occurred in cases 35 and 36. A significant deficiency occurred in case 35. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 46 necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. CMC had mixed performance in the process for returns from hospitalizations and emergency room encounters. Compliance testing revealed CMC showed opportunities for improvement in ensuring follow-up appointments for returning patients occurred within required time frames (MIT 1.007, 75.0%). CMC sufficiently ensured staff scanned hospital discharge documents into the patient’s electronic health record within three calendar days of discharge (MIT 4.003, 84.6%). Compliance testing also found providers generally reviewed and endorsed documents within required time frames (MIT 4.005, 84.6%). OIG clinicians found CMC performed satisfactorily in the hospitalization process. We reviewed 35 hospitalization events in 15 cases, 21 of which were hospitalization or emergency room encounter returns. We identified nine deficiencies, three of which were significant.46 Two of the three significant deficiencies related to providers not timely endorsing hospital records and are discussed in the Health Information Management indicator. The one additional significant deficiency related to hospital discharge medications is addressed in the Medication Management indicator. Remaining deficiencies related to nursing assessment, nursing documentation, and additional hospital discharge record endorsement challenges. Examples are below: • In case 23, the RN evaluated the patient upon return from the community hospital. The patient was treated for thrombophlebitis and an infection of the left foot with pain and swelling.47 The RN documented the skin was within normal limits; however, the nurse did not assess and describe the infection site or the IV site where the patient received intravenous antibiotics. In addition, the RN documented the patient was ambulatory, but did not describe the patient’s gait, assess left leg range of motion, assess neurological strength or sensation, or palpate for pulses in the feet to ensure blood flow. • In case 26, the RN evaluated the patient upon return from a community hospitalization for blood in the urine and urinary retention.48 The RN did not palpate the patient’s abdomen upon assessment. In addition, although the nurse sent a message to the provider regarding foley catheter placement, the nurse did not document the presence of the foley catheter or document the volume of urine in the bag in the progress note.49 Clinician On-Site Inspection OIG clinicians toured the R&R and interviewed the on-duty RN, who reported being a registry nurse staffed as coverage for the area. However, upon further discussion, the 46 Hospital deficiencies occurred in cases 3, 23–26, 30, and 58. Significant deficiencies occurred in cases 24 and 30. 47 Thrombophlebitis is a medical condition when a blood clot forms in a vein, often in the legs, causing inflammation and pain. The blood clot can travel to the lungs, where it can block an artery and become potentially life threatening. 48 Urinary retention occurs when bladder does not completely empty during urination. 49 A foley catheter is a thin, flexible, sterile tube that drains urine from the bladder. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 47 registry RN revealed having many years of experience working at this institution and had received training in the duties required for the R&R. The nurse was familiar with R&R processes and described how a shift is generally managed in this area. The nurse indicated one RN was assigned to each shift as well as one provider assigned for consultation. The R&R nurse reported the area was open 24 hours a day during the week, and TTA staff would process patients transferring into or out of the institution on the weekend. Within the week the OIG was on-site, the nurse estimated CMC had about 47 arrivals and 33 departures. The R&R nurse demonstrated how the R&R processed transfer-in and transfer-out patients. CMC employed two best practices during this process. First, the R&R nurse demonstrated tracking spreadsheets the institution’s R&R developed to communicate to nurses the items either pending or already completed for patients. The nurse also shared a sample transfer envelope with contents and a checklist. Second, for outgoing patients, CMC had a custom checklist attached to each transfer envelope, which R&R staff used to ensure the patients had all transfer requirements met. The checklist included items such as information on current conditions being treated, transfer medications, and information on pending appointments or specialty consultations to ensure continuity of care upon transfer and release. Compliance On-Site Inspection and Discussion During the week of the on-site inspection, CMC had no patients transferring out who met the required criteria for testing medications ordered or durable medical equipment (MIT 6.101, N/A). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 48 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 14 11 0 56.0% questions within the required time frame? (6.001) For endorsed patients received from another CDCR institution: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the patient to the TTA if TB signs and 24 0 1 100% 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 11 6 8 64.7% 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 0 0 1 N/A required documents? (6.101) Overall percentage (MIT 6): 73.6% 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: July 2025 Cycle 7, California Men’s Colony | 49 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 20 4 1 83.3% 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 8 4 1 66.7% 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? 11 2 0 84.6% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 11 2 0 84.6% 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 10 1 16.7% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 20 5 0 80.0% medications continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 6 4 0 60.0% administered or delivered without interruption? (7.006) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 5 8 0 38.5% 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: July 2025 Cycle 7, California Men’s Colony | 50 Recommendations • Nursing leadership should identify strategies to ensure nursing staff completely answer and address required initial health screening questions. Leadership should implement remedial measures as appropriate. • Healthcare leadership should identify the challenges to maintaining medication continuity for patients transferring into the institution without their medications and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 51 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (68.9%) Case review found CMC’s performance improved in Cycle 7 when compared with Cycle 6. The OIG clinicians reviewed a similar number of events and cases but found fewer deficiencies in Cycle 7. However, we also identified more significant deficiencies in this cycle, and we identified a pattern related to delays in patient receipt of clinically important keep-on-person (KOP) medications, such as antibiotics, steroids, and rescue medications.50 However, in most cases, though patients did not receive medications the same day as ordered, patients did ultimately receive their medications. In addition, CMC performed well in ensuring continuity of new and chronic care medications as well as in providing specialty and hospital recommended medications. CMC also performed well with medication administration and continuity in the specialized medical housing unit as well as for patients transferring into and out of the institution. Factoring in all the information, the OIG rated the case review component of this indicator adequate. Compliance testing showed CMC needed improvement in this indicator. CMC 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 170 events in 33 cases related to medications and found only 11 medication deficiencies, seven of which were significant.51 New Medication Prescriptions Compliance found CMC needed improvement with timely administration and availability of new prescription medications (MIT 7.002, 60.0%). In contrast, OIG clinicians found 50 Keep-on-person (KOP) refers to medications that a patient can keep and self-administer according to the directions provided. 51 Deficiencies occurred in cases 1, 2, 10, 14, 19, 22–24, and 26. Significant deficiencies occurred in cases 1, 19, 22, 24, and 26. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 52 only four deficiencies related to new prescriptions in the outpatient setting.52 The following is an example: • In case 19, the provider increased the patient’s dose of a prostate medication from 1mg to 2mg. However, the patient did not receive the increased dose for nearly eight days. Chronic Medication Continuity CMC had mixed performance in chronic medication continuity. Compliance testing showed patients sporadically received their chronic care medications within required time frames (MIT 7.001, 38.1%). In contrast, OIG clinicians found CMC had only four significant deficiencies related to delivering and administering chronic care medications.53 The following are examples: • In case 22, in the month of October 2023, the patient did not receive a refill of a medication used to prevent blood clots from forming. • In case 24, in the month of November 2023, the patient did not receive a refill of a blood pressure medication. Hospital Discharge Medications In compliance testing, CMC performed poorly in ensuring patients received their medications upon return from an off-site hospital or emergency room encounter (MIT 7.003, 16.7%). In contrast, OIG clinicians only found two deficiencies related to hospital discharge medications.54 The following is an example: • In case 24, the patient returned from a community hospitalization with new hospital recommended medication orders, new CMC provider orders, and orders for previous medications to be continued. However, staff did not timely administer the hospital recommended KOP orders for a steroid, a potassium supplement, and aspirin. In addition, staff did not issue the CMC provider’s new order for a diuretic at all.55 Furthermore, staff did not timely issue previous orders for a blood pressure medication and a rescue inhaler. Specialized Medical Housing Medications CMC performed excellently in ensuring patients received their needed medications during admission to the specialized medical housing unit. The OIG clinicians found only one minor deficiency as listed below: 52 New medication prescription deficiencies occurred in cases 1, 2, 19, and 24. Significant deficiencies occurred in cases 1, 19, and 24. 53 Significant deficiencies for chronic medication continuity occurred in cases 22 and 24. 54 Hospital discharge medication deficiencies occurred in cases 23 and 24. A significant deficiency occurred in case 24. 55 A diuretic is a medication that helps the kidneys flush fluid and salt from the body through urine. A diuretic treats medical conditions such as high blood pressure, heart failure, and fluid retention. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 53 • In case 10, a nurse did not administer a scheduled dose of an injectable narcotic pain medication and instead documented the patient had tolerated an oral dose of the narcotic pain medication earlier. However, the medication administration record did not reflect the patient had received the oral dose at the time indicated by the nurse. Transfer Medications Compliance testing showed CMC had mixed performance in transfer medications. CMC performed sufficiently in medication continuity for patients transferring from yard to yard (MIT 7.005, 80.0%). However, nurses only intermittently ensured patients who transferred into the institution received their medications timely (MIT 6.003, 64.7%). In addition, CMC needed improvement in medication administration for patients who were on layover and temporarily housed at CMC, as they only sometimes received their medications within required time frames (MIT 7.006, 60.0%). In contrast, OIG clinicians found no medication deficiencies within the transfer processes. Medication Administration Compliance found nurses performed sufficiently in administering tuberculosis (TB) medications within required time frames (MIT 9.001, 83.3%). OIG clinicians did not have any case review samples with events related to TB medications. OIG clinicians found nurses performed well in administering medications properly. However, we identified a pattern in four cases related to patients not receiving clinically significant antibiotics, steroids, or rescue medications on the same day as ordered.56 The following are examples: • In case 1, the provider ordered a one-time dose of an antibiotic to start at noon. However, staff did not administer the antibiotic until the following day. In addition, on another occasion, the provider ordered an antibiotic, a steroid, and ear drops to start in the afternoon. However, the patient did not receive any of the three medications until the following day. • In cases 2, 23, and 24, the patients did not receive orders for rescue inhalers timely. Anticoagulation Management At CMC, the pharmacy assisted with managing patients on warfarin, an anticoagulation medication that requires close monitoring. A pharmacist independently managed the more stable patients. However, with the introduction of newer, safer anticoagulation medications in recent years, fewer patients are prescribed warfarin at CMC. This decreased the amount of pharmacy staff required for monitoring warfarin treatment and allowed them more time for other duties. The OIG clinicians identified only one minor deficiency related to warfarin management.57 56 Deficiencies for delay in clinically significant medication administration occurred in cases 1, 2, 23, and 24. Significant deficiencies occurred in cases 1 and 24. 57 This minor anticoagulation medication deficiency occurred in case 14. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 54 Clinician On-Site Inspection During the on-site inspection, OIG clinicians interviewed the pharmacist-in-charge (PIC) and nurses. We toured the Facility A medication line, which had two medication administration windows staffed with medication-line LVNs. Both medication-line LVNs had been working in their roles at CMC for many years and were well versed in their processes. The nurses said patients are generally compliant with reporting for medication administration lines and KOP medication pick-up times. They described the KOP process from the time of reception in the medication room to patient pick-up. They reported the LVNs provide a KOP list to officers to post in the housing units to notify patients when their KOP medications are available for pickup. However, for important medications, such as antibiotics, steroids, and rescue medications, the nurses reported they would send a ducat for the patient, call the housing unit officer to send the patient, or page the patient to come pick up their medications as soon as the nurses received them from the pharmacy. Other than those important medications, the nurses reported patients could pick up routine KOPs within four business days from the time the medications were available. While interviewing the PIC regarding patient pick up of time-sensitive medications, the PIC reported the nurses were very diligent about ensuring patients received their medications timely and communicating with the pharmacy regarding patient needs. OIG clinicians inquired about chronic care medications that were ordered as “request refill” and how medication compliance was tracked for KOP pickup. The PIC reported few chronic care medications were ordered with this special request; however, all chronic care medications, regardless of this “request refill” designation, were routinely filled and sent to the medication room for the patient to pick up or sign for refusal. The only medications not automatically refilled were medications ordered on an “as needed” basis, which would require the patient to submit a refill request. Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in nine of 10 applicable clinic and medication line locations (MIT 7.101, 90.0%). In one location, the supervising nurse did not accurately describe the narcotic medication discrepancy reporting process. CMC appropriately stored and secured nonnarcotic medications in nine of 11 clinic and medication line locations (MIT 7.102, 81.8%). In two locations, we observed one or more of the following deficiencies: nurses did not maintain unissued medication in its original labeled packaging; treatment cart log was missing daily security check entries; medication nurses lacked a process to return medications with expired pharmacy labels to the pharmacy; the medication area lacked a clearly labeled designated area for nonrefrigerated medications to be returned to the pharmacy; and medications were not properly and securely stored as required by CCHCS policy. Staff kept medications protected from physical, chemical, and temperature contamination in six of the 11 clinic and medication line locations (MIT 7.103, 54.6%). In five locations, we found one or more of the following deficiencies: staff did not consistently record the room temperature; temperature log entries indicated on several days medications were not kept within acceptable temperature range; and several medication refrigerators were unsanitary. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 55 Staff successfully stored valid, unexpired medications in 10 of the 11 applicable medication line locations (MIT 7.104, 90.9%). In one location, nurses did not label the multiple-use medication as required by CCHCS policy. Nurses exercised proper hand hygiene and contamination control protocols in four of six applicable locations (MIT 7.105, 66.7%). In two locations, some nurses neglected to wash or sanitize their hands when required. These occurrences included before preparing and administering medications, or before each subsequent re-gloving. Staff in all medication preparation and administration areas showed appropriate administrative controls and protocols when preparing medications for patients (MIT 7.106, 100%). Staff in five of six applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 83.3%). In one clinic, we observed a medication nurse did not follow the CCHCS care guide when administering Suboxone medication. Pharmacy Protocols CMC followed general security, organization, and cleanliness management protocols in its main and remote pharmacies (MIT 7.108, 100%). In both pharmacies, CMC properly stored nonrefrigerated medication (MIT 7.109, 100%). Although both pharmacies monitored the room temperature using a digital data logger, pharmacy staff did not maintain a room temperature log using the medication storage temperature log (CDCR Form 7217), which is still required by CCHCS policy (MIT 7.110, zero). The PIC correctly accounted for narcotic medications stored in the main and remote pharmacies (MIT 7.111, 100%). We examined two medication error reports. For one report, the PIC did not initiate the medication follow-up report timely (MIT 7.112, 50.0%). 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. At CMC, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Nine of 10 applicable patients interviewed indicated they had access to their rescue medications. One patient stated the medication was taken away and placed in the patient’s property when he transferred to the restricted housing unit. We promptly notified the CEO of this concern, and health care management immediately issued a replacement rescue inhaler to the patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 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 or did the institution follow departmental policy for refusals or no‑shows? 8 13 4 38.1% (7.001) Did health care staff administer, make available, or deliver new order 15 10 0 60.0% prescription 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 10 1 16.7% 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 N/A N/A N/A N/A to the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 20 5 0 80.0% 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 6 4 0 60.0% delivered without interruption? (7.006) All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic medications 9 1 1 90.0% 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 2 0 81.8% storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 6 5 0 54.6% contamination in 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 10 1 0 90.9% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 4 2 5 66.7% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 6 0 5 100% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 5 1 5 83.3% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote pharmacies? 2 0 0 100% (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 2 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 0 2 0 0 medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 2 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 1 1 0 50.0% (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please see the indicator for OIG find that medication errors were properly identified and reported by the institution? (7.998) discussion of this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator for have immediate access to their KOP prescribed rescue inhalers and nitroglycerin discussion of this test. medications? (7.999) Overall percentage (MIT 7): 68.9% 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: July 2025 Cycle 7, California Men’s Colony | 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 11 6 8 64.7% 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 0 0 1 N/A required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 15 3 0 83.3% 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 14 2 2 87.5% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 7 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: July 2025 Cycle 7, California Men’s Colony | 58 Recommendations • Medical and nursing leadership should determine the challenges to ensuring chronic care patients, hospital discharge patients, and newly arrived patients receive their medications timely and without interruption. Leadership should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for nursing staff not documenting patient refusals and no-shows in the medication administration record (MAR), as described in CCHCS policy and procedures, and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 59 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 (93.5%) CMC performed excellently in preventive services. Staff performed outstandingly in providing annual TB screenings, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for patients from ages 45 through 75, and offering required immunizations to chronic care patients. Staff generally administered TB medications to patients as prescribed, frequently monitored patients taking TB medications, and often timely transferred patients who were at the highest risk of coccidioidomycosis out of CMC. These findings are set forth in the table on the next page. 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: July 2025 Cycle 7, California Men’s Colony | 60 Compliance Score Results Table 15. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 15 3 0 83.3% 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 14 2 2 87.5% 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 N/A N/A N/A N/A offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was patient N/A N/A N/A N/A offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care 15 1 9 93.8% patients? (9.008) Are patients at the highest risk of coccidioidomycosis (Valley Fever) 9 1 0 90.0% infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 93.5% 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: July 2025 Cycle 7, California Men’s Colony | 61 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: July 2025 Cycle 7, California Men’s Colony | 62 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 that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable CMC’s overall nursing care was satisfactory. In Cycle 7, although OIG clinicians reviewed fewer cases with fewer nursing encounters, we also found fewer overall deficiencies than in Cycle 6. Nurses generally performed good assessments, interventions, and documentation. However, we also identified patterns of nurses not scheduling patients with urgent sick call symptoms for the same day, not performing complete pain assessments, and not performing complete focused abdominal assessments when clinically indicated. Taking all factors into account, the OIG rated this indicator adequate. Case Review Results We reviewed 238 nursing encounters in 58 cases. Of the nursing encounters we reviewed, 88 occurred in the outpatient setting, which included 61 nursing sick call encounters. We identified 82 overall nursing performance deficiencies, 19 of which were significant.58 Outpatient Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) 58 Deficiencies occurred in cases 1–6, 8–11, 18, 20–26, 30, 35–37, 39, 43, 46, 48–50, 52–54, and 57–60. Significant deficiencies occurred in cases 2, 3, 5, 6, 8, 20, 21, 23, 25, 26–28, 44, 50, 52, and 60. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 63 elements. A comprehensive assessment allows nurses to gather essential information about their patients and develop appropriate interventions. Nurses generally provided satisfactory patient care. However, the OIG clinicians identified 39 outpatient nursing deficiencies, 11 of which were significant.59 We identified a pattern in which nurses performed incomplete pain assessments and abdominal assessments when focused examinations were clinically indicated.60 In addition, we identified a pattern in which nurses were not always scheduling patients with urgent symptoms to be seen the same day for evaluation.61 The following are examples: • In case 26, the sick call RN evaluated the patient for a complaint of pain when urinating. However, the RN did not subjectively assess the patient’s pain or pain scale level, and did not describe the appearance of the abdomen or palpate the abdomen. • In case 46, an RN triaged a health care request for the patient with a complaint of extreme pain from a severe toothache, his throat swelling up, and pain in the left ear. However, the RN did not schedule the patient to be seen the same day for these urgent symptoms. Outpatient Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. Nurses generally documented their assessment findings and interventions sufficiently. However, the following are examples of outpatient documentation deficiencies: • In cases 10, 48, and 54, nurses’ documentation contained multiple errors, including incorrectly documenting the pulse as absent when all other vital signs were stable, documenting assessment of the wrong limb location, and erroneously repeating a pulse reading for the patient’s oxygen saturation reading. • In case 18, the sick call RN evaluated the patient for a recurrent upper respiratory infection. The nurse indicated the patient had clear lungs, but did not document a description of the patient’s breathing pattern. • In case 26, the RNs evaluated the patient who had a foley catheter. However, the RNs did not always document observations of the urine, such as volume, color, turbidity (transparency), odor, or density. 59 Outpatient nursing deficiencies occurred in cases 2, 10, 11, 18, 20–22, 24, 26, 37, 39, 43, 46, and 48–54. Significant outpatient deficiencies occurred in cases 10, 11, 22, 24, 26, 43, 46, 51, and 54. 60 RNs did not subjectively assess the patient’s pain scale level or inquire about the characteristics of the patient’s pain complaint in cases 18, 22, 26, 43, and 49. RNs did not describe the appearance of the abdomen or palpate the abdomen for tenderness when performing a focused exam for a related complaint, in cases 10, 21, and 26. 61 RNs did not schedule the patient to be seen the same day in cases 10, 18, 21, 24, 26, 46, and 54. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 64 Case Management The OIG clinicians reviewed 15 care manager events during this review period.62 At CMC, a primary care RN (PCRN) is assigned to each clinic to act as care managers. The OIG clinicians did not identify any care manager deficiencies. See below in the section titled Clinician On-Site Inspection for more details on the PCRNs assigned tasks and responsibilities. Wound Care The OIG clinicians reviewed two outpatient cases involving wound care or dressing changes.63 We identified only one minor deficiency as follows: • In case 11, the RN conducted a follow-up wound evaluation for the patient with a recurrent skin infection. The RN documented the skin was intact with no redness, and the right lower extremity (RLE) remained swollen. However, the nurse did not obtain the patient’s vital signs or palpate the RLE to assess the depth of swelling. Emergency Services The OIG clinicians reviewed 24 urgent or emergent events. CMC nurses responded promptly to all medical alarms. We identified no patterns or trends that were cause for concern; however, nurses had opportunities for improvement in nursing assessments, interventions, and documentation. OIG clinicians identified 11 nursing deficiencies, four of which were significant and are detailed further in the Emergency Services indicator.64 Hospital Returns OIG clinicians reviewed 21 nursing events in which patients returned from a community hospital or emergency room. We identified three minor nursing deficiencies, none of which were significant and are detailed further in the Transfers indicator.65 Transfers The OIG clinicians reviewed seven nursing events in which patients transferred into or out of the institution. We identified three nursing deficiencies, one of which was significant and is detailed further in the Transfers indicator.66 Specialized Medical Housing The OIG clinicians reviewed 38 nursing events for patients housed in the CTC, which include up to two weeks of bundled nursing care in each event. We identified 13 nursing 62 Care manager events occurred in cases 2, 10–12, 14, 15 and 28. 63 Wound care occurred in cases 11 and 28. 64 Emergency services nursing deficiencies occurred in cases 1, 3–6, 10, 25, 26, and 30. Significant emergency services nursing deficiencies occurred in cases 1, 6, 8, and 25. 65 Hospital nursing deficiencies occurred in cases 23, 25, and 26. 66 Transfer nursing deficiencies occurred in cases 2, 35, and 36. A significant transfer-out nursing deficiency occurred in case 35. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 65 deficiencies, two of which were significant and are detailed further in the Specialized Medical Housing indicator.67 Specialty Services The OIG clinicians reviewed 60 nursing events in which nurses evaluated patients prior to or after a procedure or telemedicine encounter, or upon return from an off-site specialty appointment. We identified 13 nursing deficiencies related to specialty services, one of which was significant and is detailed further in the Specialty Services indicator.68 Medication Management The OIG clinicians reviewed 170 events involving medication management and administration. We identified 11 deficiencies, seven of which were significant, and are detailed further in the Medication Management indicator.69 Clinician On-Site Inspection OIG clinicians interviewed nurses and managers in the TTA, outpatient clinics, medication areas, the R&R, and specialty clinics. We also observed several well-organized and efficient huddles in the primary care clinics. We found all clinic staff knowledgeable and with a vested interest in providing good patient care. CMC had one main central clinic that was open during business days from 7:30 a.m. to 3:30 p.m. At the main clinic, patients from all four yards intermingled for scheduled appointments; however, patients housed in the restricted housing unit had a separate clinic in another building. The nursing lines were divided among the patient care teams by the patients’ last two identification numbers. This resulted in a mix of patient medical risk levels shared among assigned patient care teams. The triage nurse estimated receiving an average of 30 to 40 health care requests daily between pharmacy services, medical services, mental health services, and dental services. Staff scheduled an average of five to 10 patients to be seen daily, with up to two add-on patients or walk-in patients per day. The triage nurse reported no current backlog. OIG clinicians inquired about the process to ensure patients submitting health care requests on weekends and holidays were seen timely. The triage nurse reported these patients were seen on the next business day through a process termed “white paper triage,” as the cut off times for ducats closes prior to the weekend. 70 In this process, the TTA nurses would pick up, review, and scan the health care requests, as well as order the appointment for the next business day. They then gave the health care requests with a designated appointment time to the medical sergeant to distribute to the housing units, in place of a ducat. The triage nurse reported experiencing challenges at times with patients who did not have ducats, as they could be difficult to locate due to attendance in school, jobs, programming, or being off-site at fire camp. In these cases, although they 67 Specialized medical housing nursing deficiencies occurred in cases 3, 10, 11, and 57–60. Significant specialized medial housing deficiencies occurred in case 11. 68 Specialty services nursing deficiencies occurred in cases 11, 21, 26, 57, 58, and 60. A significant specialty services nursing deficiency occurred in case 21. 69 Medication management deficiencies occurred in cases 1, 2, 10, 14, 19, 22–24, and 26. Significant medication management deficiencies occurred in cases 1, 19, 22, 24, and 26. 70 A ducat is a pass that allows patients to move around in an institution. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 66 may have been out of date compliance if the patient was unable to come to the clinic to refuse the appointment, they would schedule the patient for the next available appointment. We also interviewed a PCRN, who described responsibilities including meeting with all newly arrived patients within 30 days to review their care needs, offering patients relevant health screenings and vaccines, educating patients, and managing registries and dashboards. The PCRN reported CMC did not house patients who were at high risk of contracting coccidioidomycosis, such as those diagnosed with HIV and cancer.71 In addition, the PCRN reported CCHCS headquarters had resumed follow-up care for patients receiving hepatitis C treatment. The PCRN also described a typical day as having an average of five to six patient appointments scheduled for care management, off-site pre-procedure education, disease-specific or general patient education, and scheduled referrals. Moreover, the PCRN was responsible for issuances and return receipts for CPAPs, sleep study equipment, Holter monitors, and continuous glucose monitors.72 The PCRN communicated staff had good morale as well as great support from leadership and stated the only experienced challenge related to space. The nurse reported, at times, some nurses may have needed to let others use their examination rooms to accommodate patient appointments. OIG clinicians also met with nursing leadership, including the chief nurse executive (CNE) and the SRN III, to review some of our case review findings and to answer clarifying questions. The CNE had many years of experience working within the prison system as a nurse in various roles. The CNE shared he monitored and evaluated the quality of nursing care through not only reviewing dashboards but also by working directly with quality management staff to analyze the dashboard data and perform random reviews of patient records. The CNE collaborated with the supervising nurses as well as the quality management staff to identify trends to discuss in “pre-meetings” and to incorporate into improvement plans. When queried, the CNE reported no significant challenges to providing quality nursing care, as the staff did all they could “to find solutions to ensure quality patient care.” The CNE felt staff morale was objectively good, which was congruent with nursing staff interview responses. The CNE reported a focus on providing training to staff when required, rather than discipline. The CNE described staff as wanting to do “an extremely good job,” and working “with their heart.” He described his staff as “rock stars” and “amazing.” He also stated, “the staff deserve credit for their hard work and dedication.” 71 Coccidioidomycosis is also known as Valley Fever or California Fever. It is a fungal infection that enters the body through inhalation of spores found in the soil in certain parts of the southwestern United States. 72 A CPAP (continuous positive airway pressure) device is a machine which delivers continuous flow of air through a face mask to treat sleep apnea. A Holter monitor is a wearable device that records a patient’s electrical activity for 24 to 48 hours. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 67 Recommendations • Nursing leadership should determine the causes that prevent CMC nurses from scheduling patients for a same-day evaluation when patients complain of urgent symptoms and should implement remedial measures as appropriate, which may include training staff. • Nursing leadership should determine the causes that prevent CMC nurses from performing thorough pain and abdominal assessments when patients present with related symptoms and should implement remedial measures as appropriate, which may include training staff. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 68 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 CMC providers delivered good care for patients. Providers generally documented thorough histories and sound assessments, referred patients to specialists, and implemented recommendations appropriately. Providers also timely reviewed hospital records, diagnostic results, and specialty reports. We identified some deficiencies but found no significant patterns. Considering all factors, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 184 medical provider encounters and identified 43 deficiencies, eight of which were significant.73 In addition, OIG clinicians examined the quality of care in 25 comprehensive case reviews and rated all 25 cases adequate. Outpatient Assessment and Decision-Making Providers generally made proper assessments and sound decisions for their patients. They formulated reasonable diagnoses, ordered pertinent tests, developed appropriate treatment plans, and referred patients for specialty care when medically indicated. However, OIG clinicians identified 19 deficiencies, one of which was significant:74 • In case 15, a provider ordered an echocardiogram for the patient, who had a heart murmur and developed new symptoms with activity.75 However, the provider should have ordered the echocardiogram to occur sooner instead of ordering it as routine-priority order. 73 Deficiencies occurred in cases 2, 11–13, 15–17, 20–22, 24–27, 29, 30, 57, and 60. Significant deficiencies occurred in cases 12, 13, 15, 24, 29, and 57. 74 Deficiencies occurred in cases 2, 11, 12, 15–17, 20–22, 24–26, 29, and 30. A significant deficiency occurred in case 15. 75 An echocardiogram is a procedure using an ultrasound to examine and image the heart. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 69 Review of Records Providers usually reviewed off-site medical records carefully, including hospital and specialty reports as well as outpatient progress notes and medication records. However, OIG clinicians identified one significant deficiency in which a provider did not review the records thoroughly as follows: • In case 12, a provider sent the patient a letter informing him, “that your Coumadin was changed to 7.5mg daily.”76 However, the patient was already prescribed that dose. Therefore, the patient’s Coumadin dose was not changed as intended. Emergency Care CMC providers appropriately treated most patients in the TTA with urgent or emergent conditions. They were available for consultation by phone and documented the required progress notes. OIG clinicians did not identify any significant TTA provider deficiencies. Chronic Care Providers appropriately managed chronic health conditions, such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. Some providers also managed the care for patients on anticoagulation or MAT medications.77 OIG clinicians identified one significant chronic care deficiency as follows: • In case 15, the provider documented the patient had uncontrolled diabetes at a chronic care appointment. The patient had tried lifestyle modifications over the past year, was taking high doses of four diabetic medications, and had fasting blood sugars that did not correlate with his HbA1c laboratory test result.78 Yet, the provider did not order finger stick blood sugar testing twice per day, add short-acting insulin to his medications, or consult with an endocrinology specialist to improve the patient’s diabetes control. Specialized Medical Housing Providers generally delivered good care in the CTC. They completed admission history and physical examinations along with rounding progress notes timely. Off-site specialty follow-up appointments occurred as ordered. OIG clinicians found providers cloned some portions of progress notes, resulting in documentation errors. We identified 16 provider deficiencies, three of which were significant.79 All three significant deficiencies involved the same provider. For more details, please refer to the Specialized Medical Housing indicator. 76 Coumadin is a blood thinning medication. 77 MAT is the Medication Assisted Treatment program for substance use disorder. 78 Hemoglobin A1c (HbA1c) is a blood test that measures the average plasma glucose over the previous 12 weeks. 79 Provider deficiencies occurred in cases 13, 30, 57, and 60. Significant deficiencies occurred in case 13 and 57. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 70 Specialty Services CMC providers generally referred patients for specialty consultations with appropriate priority designations. They also reviewed specialty reports timely and followed recommendations. However, OIG clinicians identified three instances in which providers did not refer patients timely, two of which were significant as follows: • In case 24, the patient was discharged from the hospital with a diagnosis of congestive heart failure with recommendations for an urgent outpatient cardiology appointment. The original cardiology appointment was ordered as high priority; however, the patient refused the appointment. A provider reordered the cardiology specialty appointment as medium priority instead. The patient was ultimately seen by cardiology seven weeks after his hospitalization instead of within two weeks, resulting in delay of cardiology care. • In case 29, the patient underwent a CT angiogram, which showed severe artery disease in the left lower extremity and moderate to severe artery disease in the right lower extremity.80 The patient was supposed to have a follow-up with a vascular surgery specialist after this procedure.81 However, a provider did not order the follow-up with a vascular surgeon until five weeks later and ordered the specialty referral as medium-priority. As a result, the vascular surgeon did not re-evaluate the patient until more than two months after the angiogram. Documentation Quality Providers mostly documented outpatient patient encounters well and generally completed their progress notes on the day of the encounter. They also documented interactions with nurses or messaged the care team. Although OIG clinicians did not identify any significant outpatient documentation deficiencies, we identified cloned portions of progress notes and a missing discharge summary as discussed in the Specialized Medical Housing indicator. Patient Notification Letter Providers often did not send complete test result notification letters to patients. When they did, the letters only sometimes contained all four elements required by policy. We discuss this further in the Diagnostics and Health Information Management indicators. Outpatient Provider Continuity CMC offered good provider continuity. OIG clinicians identified no deficiencies related to provider continuity of care. 80 A CT angiogram is an imaging test using computerized tomography (CT) and contrast dye to create images of the body’s blood vessels. 81 A vascular surgeon is a specialist who diagnoses, manages, and treats blood vessel problems and diseases. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 71 Clinician On-Site Inspection The OIG clinician met with medical leadership and providers. Medical leadership reported all CMC medical providers were physicians with training in family practice, internal medicine, or emergency medicine. Providers generally worked full-time schedules and shared the on-call duties. Medical leadership described providers as hardworking, cooperative, and reliable. Medical leadership and providers mentioned a collegial rapport with specialists in the community and a mutual commitment to providing high-quality health care to CMC’s incarcerated population. Providers voiced excellent morale at CMC, expressed appreciation and satisfaction for their leadership, and expressed gratitude and respect for nursing, ancillary staff, and custody staff. Leadership stated CMC had no provider staffing vacancies and no provider retention concerns. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 72 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: July 2025 Cycle 7, California Men’s Colony | 73 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. Our clinicians also interpreted relevant compliance results and incorporated them into this indicator. At the time of our inspection, CMC’s specialized medical housing consisted of a correctional treatment center (CTC). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Proficient (86.0%) As in Cycle 6, providers and nurses continued to deliver good care to their CTC patients in Cycle 7. OIG clinicians did not find any patterns or trends in deficiencies, although both provider and nursing documentation showed opportunities for improvement. Considering all factors, the OIG clinicians rated the case review component of this indicator as adequate. CMC’s performance in compliance testing also remained consistent in Cycle 7. Compliance testing showed nurses performed excellently in timely completing admission assessments and histories with physical examinations. In contrast, staff needed improvement in medication administration. Based on the overall compliance score result, the OIG rated the compliance component of this indicator proficient. Case Review and Compliance Testing Results We reviewed 134 specialized medical housing events that included 55 provider events and 38 nursing events. Due to the frequency of nursing and provider contacts in specialized medical housing, the OIG bundles up to two weeks of patient care into a single event. We identified 30 deficiencies, five of which were significant.82 Provider Performance Compliance testing showed providers always completed admission history and physicals without delay (MIT 13.002, 100%). Although OIG clinicians found providers generally delivered good care to patients housed in the CTC, we identified opportunities for 82 Deficiencies occurred in cases 3, 10, 11, 13, 30, and 57–60. Significant deficiencies occurred in cases 11, 13, and 57. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 74 improvement in provider assessments, interventions, and documentation. We identified 16 provider deficiencies, three of which were significant.83 The following are examples: • In case 13, a provider conducted patient rounds and documented the patient’s last INR laboratory result level was lower than the goal range.84 The dosage of blood thinning medication had been increased two days prior. However, the provider did not order a repeat laboratory level until six weeks later. This increased the patient’s risk for blood clots. In addition, the provider repeatedly cloned documentation of an abnormal abdominal examination, although the patient’s pain had resolved in a previous encounter. Moreover, the provider documented two different “most recent” INR levels and referenced older laboratory values when more current results were available. Lastly, the provider did not address the patient’s reported neck and back pain in the assessment and plan portions of the progress note. • In case 57, the patient was discharged from the CTC and transferred to another institution. However, the provider did not write a discharge summary. Nursing Performance Compliance testing showed CTC nurses performed timely admission assessments (MIT 13.001, 100%). OIG clinicians found nurses frequently conducted regular rounds and generally provided good care. However, we also found opportunities for improvement in nursing documentation. We reviewed 38 nursing events and found 13 nursing deficiencies, two of which were in the same case and significant, as described below.85 • In case 11, the CTC RN evaluated the patient upon return from the community hospital for direct CTC admission related to a skin infection of the left leg with sepsis and other complications. The RN indicated the patient had an indwelling foley and rectal tube; however, the nurse did not describe the volume or appearance of the contents in each collection bag and did not describe the appearance of the abdomen or palpate the abdomen.86 In addition, the RN did not notify the provider the patient had foot swelling and was complaining of severe intermittent sharp pain to the left leg, which could indicate the infection was worsening and a further plan of care was needed. A few hours later, when the RN reassessed the patient, he had continued pain and a new complaint of abdominal pain. However, the patient did not receive treatment for pain for more than three hours. • In addition, in case 11, upon RN reassessment, the patient reported, “I think I’m going to die.” The nurse indicated the patient had low blood pressure, was dizzy and confused, and continued to complain of severe pain. The nurse also documented the patient had rapid breathing, a distended abdomen with 83 Provider deficiencies occurred in cases 13, 30, 57, and 60. Significant deficiencies occurred in case 13 and 57. 84 INR, International Normalized Ratio, is a laboratory test to measure the body’s blood clotting. This test is used to monitor the effectiveness of blood thinning medications such as warfarin. 85 CTC nursing deficiencies occurred in cases 3, 10, 11, 57–60. Significant deficiencies occurred in case 11. 86 A rectal tube is a thin, flexible tube inserted into the rectum to collect fecal matter or administer enemas. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 75 rebound tenderness, and black stool in the rectal tube.87 Furthermore, the nurse documented the patient had weak and flaccid extremities, was pale and cool, was sweating, and had redness and swelling in both lower legs. However, CTC nurses did not immediately initiate emergency medical services upon identifying the emergent examination results and instead waited until 21 minutes later after notifying the provider. The provider ordered the patient be transferred to a higher level of care. Medication Administration Compliance testing revealed CMC performed poorly in ensuring patients admitted to the CTC received their medications within required time frames (MIT 13.003, 30.0%). In contrast, OIG clinicians identified only one minor deficiency, which is detailed further in the Medication Management indicator. Wound Care The OIG clinicians reviewed two CTC cases involving wound care or dressing changes.88 We identified only one minor deficiency, as follows: • In case 60, the patient was housed in specialized medical housing after a surgical repair of the right knee tendon. The patient had orders for daily dressing changes; however, the nurses did not perform a dressing change on one occasion. In addition, when the nurses did perform dressing changes, they did not always document the appearance of the surgical incision and wound care interventions performed. Clinician On-Site Inspection The OIG clinicians toured the institution’s CTC and interviewed nursing staff. The CTC contained 37 medical beds, 24 of which were occupied at the time of our inspection. Two of the medical rooms allowed for negative pressure for respiratory isolation. The CTC RN reported the CTC housed, on average, an estimated 10 to 15 patients, but during our inspection, they were experiencing a high occupancy. The RN shared CMC followed a staffing matrix based on the patient census. The matrix showed a maximum of four RNs and four LVNs assigned to the second and third shifts as well as a maximum of three RNs and three LVNs assigned to the first shift. Each shift was assigned one RN lead regardless of occupancy. However, the CTC RN reported nurses could be redirected to assist in other areas depending on the shift census. The CTC RN reported RNs conducted one patient assessment daily and LVNs administered medications. However, both RNs and LVNs conducted patient rounds based on their calculation of the patient’s fall risk score. The CTC RN also reported an assigned medical provider was available during business hours, and the CTC maintained a clinic schedule for after hours on-call coverage. The 87 A distended abdomen with rebound tenderness is when the patient’s abdomen is enlarged and, when palpated, the patient experiences pain or tenderness on releasing the pressure. Black stool is indicative of possible bleeding in the stomach or intestines. 88 Wound care occurred in cases 3 and 60. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 76 CTC provider conducted rounds weekly and as needed based on patient condition. The CTC also had a pharmacy within the area with one assigned pharmacist. The CTC RN reported the area was considered a higher level of care. According to the RN, instead of patients being processed through the R&R, the nurses completed all requirements within the CTC. This included patients returning from off-site specialty appointments and community hospital returns, as well as direct CTC admissions from other institutions and patients transferring out of CMC. The CTC nurse also reported staff handled emergencies within the area, and patients could be sent by ambulance directly to a higher level of care rather than through the TTA. The RN reported the TTA was considered a lower level of care; therefore, the TTA RNs did not respond to the CTC for emergencies unless backup was requested. Compliance On-site Inspection and Discussion At the time of on-site inspection, the medical CTC had a functional call light communication system (MIT 13.101, 100%). In addition, the mental health CTC had an approved flex waiver from the California Department of Public Health. Staff in the mental health CTC maintained a patient safety check log as specified in the institution’s local operating procedure (MIT 13.102, 100%). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 77 Compliance Score Results Table 16. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial 10 0 0 100% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 10 0 0 100% required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 7 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 1 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 1 100% operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 86.0% 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: July 2025 Cycle 7, California Men’s Colony | 78 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: July 2025 Cycle 7, California Men’s Colony | 79 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (78.2%) Case review found CMC performed well in providing specialty services. Patients generally received care from a variety of specialists, both in person and via telemedicine. Providers appropriately referred patients for specialty care when medically necessary and frequently reviewed and implemented recommendations promptly. Nurses usually aptly assessed patients after specialty appointments. After considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed CMC performed satisfactorily in this indicator. Initial appointment access to specialists ranged from satisfactory to very good, depending on the appointment priority. Follow-up specialty appointments frequently occurred timely. However, preapproved specialty referrals for newly arrived patients only occasionally occurred within recommended time frames. In addition, retrieval of specialty reports and prompt provider endorsements both needed improvements. 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 184 events related to specialty services, including 93 specialty consultations and 23 procedures. We identified 50 deficiencies in this category, seven of which were significant.89 Access to Specialty Services CMC provided good access to specialists. Compliance testing showed staff often completed initial specialty consultations for high-priority (MIT 14.001, 77.8%), medium- priority (MIT 14.004, 86.7%), and routine-priority (MIT 14.007, 86.7%) referrals within scheduled time frames. Patients frequently received their follow-up specialty high- priority appointments (MIT 14.003, 88.9%) and medium-priority appointments (MIT 14.006, 87.5%) within required time frames, and all patients received their follow-up specialty routine-priority appointments (MIT 14.009, 100%) timely. However, CMC 89 Deficiencies occurred in cases 1, 9–12, 16, 21, 26–30, and 57–60. Significant deficiencies occurred in cases 16, 21, 26, 30, and 59. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 80 needed improvement with specialty access for newly arrived patients from other institutions, as compliance testing revealed these patients only occasionally received timely specialty appointments (MIT 14.010, 38.5%). OIG clinicians identified 13 deficiencies related to specialty access, four of which were significant.90 The following is an example: • In case 59, staff scheduled the patient for a follow-up appointment with a telemedicine neurologist for management of his seizure disorder. The neurologist had evaluated the patient in the past for seizures, at which time the neurologist did not recommend a follow-up. However, the patient had recently been hospitalized for possible new seizures and did not receive the follow-up appointment with the neurologist. As a result, the neurologist did not evaluate the patient for his symptoms within the review period, and the CMC providers received no specialty guidance on the patient’s management. The patient’s CMC providers should have contacted the neurologist to ensure the patient received the necessary follow-up appointment. Provider Performance Compliance testing revealed providers conducted timely follow-up appointments after a specialty appointment only about half the time (MIT 1.008, 54.6%). In contrast, OIG clinicians found providers referred patients to specialists appropriately and followed specialty recommendations. OIG clinicians further found CMC providers delivered outstanding on-site care for patients on medication for anticoagulation or substance use. The Provider Performance indicator provides further details. Nursing Performance The specialty nurses reviewed specialty services requests and appropriately scheduled patients for specialty appointments. Nurses generally performed thorough assessments of patients returning from specialty appointments, reviewed specialists’ recommendations, and communicated them to providers. OIG clinicians reviewed 60 nursing encounters related to specialty services and identified 13 nursing deficiencies, one of which was significant and is described below:91 • In case 21, the nurse assessed the patient upon return from an outpatient procedure to remove a bladder tumor. The patient had an elevated blood pressure and complained of severe pain. The nurse notified the provider and received orders for a narcotic pain medication and to assess the patient’s respiratory status prior to discharging the patient to the housing unit. However, the nurse did not implement the provider’s orders. Health Information Management CMC staff needed improvement in managing specialty reports. Compliance testing revealed staff only sometimes scanned specialty documents timely (MIT 4.002, 69.0%). Compliance testing also showed, while providers endorsed most routine-priority reports 90 Deficiencies occurred in cases 10, 12, 16, 26, 28, 30, 58, and 59. Significant deficiencies occurred in cases 16, 30, and 59. 91 Deficiencies occurred in cases 11, 21, 26, 57, 58, and 60. A significant deficiency occurred in case 21. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 81 within required time frames (MIT 14.008, 84.6%), providers performed poorly in timely endorsing medium-priority reports (MIT 14.005, 53.3%) and high-priority reports (MIT 14.002, 44.4%). The OIG clinicians identified one significant HIM deficiency, which is discussed in the Health Information Management indicator.92 Clinician On-Site Inspection The OIG clinicians met with medical and specialty services leadership, providers, and specialty nurses. Leadership reported CMC provided on-site specialty services for neurosurgery, physiatry, gastroenterology, optometry, audiology, podiatry, and orthotics.93 The physiatrist and optometrist were CDCR employees, who entered progress notes and orders into the electronic health records system. CMC also provided telemedicine services. The telemedicine nurse would prepare an information packet for each patient and send the packet to the appropriate specialist three days in advance. This nurse also maintained a folder detailing specialists’ preferences. The telemedicine clinic scheduled as many as 10 patients per day. Providers mentioned telemedicine translation services were occasionally suboptimal, requiring additional staff and more time for certain encounters. CMC offered specialty on-site imaging services such as CT and MRI scans. Providers stated off-site specialists were generally supportive and accessible. CMC medical staff and leadership reported orthopedics was exceptionally helpful in caring for CMC’s patients. Staff and leadership also described a pilot program at CMC designed to decrease the number of off-site appointment refusals. The program involved sending the patient a letter approximately one week prior to the appointment to serve as a reminder. Reportedly, patients appreciated this information, and fewer refusals occurred. 92 This significant deficiency occurred in case 30. 93 Physiatry is a branch of medicine that treats physical conditions using nonsurgical methods. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 82 Compliance Score Results Table 17. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 7 2 0 77.8% 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 4 5 0 44.4% 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? 8 1 0 88.9% (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 13 2 0 86.7% 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 8 7 0 53.3% 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? 7 1 7 87.5% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for 13 2 0 86.7% Service? (14.007) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 11 2 2 84.6% 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? 5 0 10 100% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 5 8 0 38.5% 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 18 1 0 94.7% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 18 1 0 94.7% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 78.2% 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: July 2025 Cycle 7, California Men’s Colony | 83 Table 18. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up visits 12 10 17 54.6% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 20 9 10 69.0% within five calendar days of the encounter date? (4.002) * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 84 Recommendations • Health care leadership should determine the root cause(s) of challenges to ensuring follow-up provider appointments with patients after specialty encounters occur within required time frames and should implement necessary remedial measures. • Health care leadership should determine the root cause(s) of challenges for staff timely retrieving and scanning specialty reports, as well as providers timely endorsing specialty reports, and should implement necessary remedial measures. • Health care leadership should determine the root cause(s) of challenges to ensuring staff schedule newly transferred patients with preapproved specialty services within specified time frames the providers order and should implement necessary remedial measures. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 85 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 Inadequate (67.3%) CMC’s performance was mixed in this indicator. While CMC scored well in some applicable tests, it needed improvement in several areas. The Emergency Medical Response Review Committee (EMRRC) only sporadically completed the required checklists within required time frames. In addition, staff conducted medical emergency response drills with incomplete documentation, missing required emergency response drill forms, or without participation of custody staff. Staff did not complete two initial suicide reports timely. Physician managers did not complete all probationary and annual performance appraisals in a timely manner. Lastly, nursing managers did not ensure one newly hired nurse received the required onboarding. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Nonscored Results We reviewed CMC’s root cause analysis of reported incidents. During our testing period, CMC submitted a root cause analysis (RCA) report to the CCHCS health care incident review committee. We found that the institution failed to submit RCA revisions in compliance with CCHCS policy (MIT 15.001). We obtained CCHCS mortality case review reporting data. During our inspection, for six patients, we found no evidence in the submitted documentation the preliminary mortality reports had been completed. These reports were overdue at the time of OIG’s inspection. Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 86 The compliance date for the preliminary mortality report review for one patient was beyond the first day of our compliance inspection, therefore this sample was not applicable (MIT 15.998). Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 87 Compliance Score Results Table 19. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the This is a nonscored test. Please refer to the institution meet RCA reporting requirements? (15.001) discussion in this indicator. Did the institution’s Quality Management Committee (QMC) meet monthly? 6 0 0 100% (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did the incident 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 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 5 2 0 71.4% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 7 3 0 70.0% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 0 13 0 0 timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 15 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 2 0 1 100% (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100% valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement Agency (DEA) registration certificates, and did the pharmacy maintain valid 2 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): 67.3% 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: July 2025 Cycle 7, California Men’s Colony | 88 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: July 2025 Cycle 7, California Men’s Colony | 89 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 CMC Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 90 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: July 2025 Cycle 7, California Men’s Colony | 91 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: July 2025 Cycle 7, California Men’s Colony | 92 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 93 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: July 2025 Cycle 7, California Men’s Colony | 94 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: July 2025 Cycle 7, California Men’s Colony | 95 Appendix B: Case Review Data Table B–1. CMC Case Review Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 4 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 20 Specialty Services 4 60 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 96 Table B–2. CMC Case Review Chronic Care Diagnoses Sample Set Total Anemia 11 Anticoagulation 10 Arthritis/Degenerative Joint Disease 9 Asthma 9 Cancer 5 Cardiovascular Disease 2 Chronic Kidney Disease 4 Chronic Pain 7 Cirrhosis/End-Stage Liver Disease 7 Coccidioidomycosis 3 COPD 5 COVID-19 1 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 12 Gastroesophageal Reflux Disease 11 Hepatitis C 14 Hyperlipidemia 24 Hypertension 25 Mental Health 30 Migraine Headaches 1 Seizure Disorder 3 Sleep Apnea 5 Substance Abuse 18 Thyroid Disease 5 224 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 97 Table B–3. CMC Case Review Events by Program Diagnosis Total Diagnostic Services 233 Emergency Care 51 Hospitalization 35 Intra-System Transfers In 6 Intra-System Transfers Out 5 Outpatient Care 428 Specialized Medical Housing 134 Specialty Services 197 1,089 Table B–4. CMC Case Review Sample Summary Sample Set Total MD Reviews Detailed 25 MD Reviews Focused 4 RN Reviews Detailed 15 RN Reviews Focused 35 Total Reviews 79 Total Unique Cases 60 Overlapping Reviews (MD & RN) 19 Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 98 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 99 Appendix C: Compliance Sampling Methodology California Men’s Colony 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 13 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 39 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 0 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: July 2025 Cycle 7, California Men’s Colony | 100 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 39 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 13 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 13 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 10 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 1 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: July 2025 Cycle 7, California Men’s Colony | 101 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 13 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 2 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 2 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 10 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: July 2025 Cycle 7, California Men’s Colony | 102 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 18 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to Annual Screening inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to Vaccinations inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to Screening inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to institution inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to institution inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever 10 Cocci transfer • Reports from past 2 – 8 months 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: July 2025 Cycle 7, California Men’s Colony | 103 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 003 Specialized Health 10 CADDIS • Admit date (2 – 8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101 – 102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001 – 003 High-Priority 9 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: July 2025 Cycle 7, California Men’s Colony | 104 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 13 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 19 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 1 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: July 2025 Cycle 7, California Men’s Colony | 105 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations (continued) MIT 15.103 Death Reports 7 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 13 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 15 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 7 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: July 2025 Cycle 7, California Men’s Colony | 106 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7, California Men’s Colony | 107 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: October 2023 – March 2024 Report Issued: July 2025 Cycle 7 Medical Inspection Report for California Men’s Colony OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA July 2025 OIG