Calipatria State Prison Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, Calipatria State Prison | 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 19 Emergency Services 23 Health Information Management 27 Health Care Environment 33 Transfers 41 Medication Management 48 Preventive Services 55 Nursing Performance 58 Provider Performance 62 Specialized Medical Housing 67 Specialty Services 72 Administrative Operations 78 Appendix A: Methodology 81 Case Reviews 82 Compliance Testing 85 Indicator Ratings and the Overall Medical Quality Rating 86 Appendix B: Case Review Data 87 Appendix C: Compliance Sampling Methodology 91 California Correctional Health Care Services’ Response 99 Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | iv Illustrations Tables 1. CAL Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. CAL Master Registry Data as of July 2024 7 3. CAL Health Care Staffing Resources as of July 2024 8 4. CAL Results Compared With State HEDIS Scores 10 5. Access to Care 16 6. Other Tests Related to Access to Care 17 7. Diagnostic Services 21 8. Health Information Management 30 9. Other Tests Related to Health Information Management 31 10. Health Care Environment 39 11. Transfers 45 12. Other Tests Related to Transfers 46 13. Medication Management 52 14. Other Tests Related to Medication Management 53 15. Preventive Services 56 16. Specialized Medical Housing 70 17. Specialty Services 75 18. Other Tests Related to Specialty Services 76 19. Administrative Operations 79 A–1. Case Review Definitions 82 B–1. CAL Case Review Sample Sets 87 B–2. CAL Case Review Chronic Care Diagnoses 88 B–3. CAL Case Review Events by Program 89 B–4. CAL Case Review Sample Summary 89 Figures A–1. Inspection Indicator Review Distribution for CAL 81 A–2. Case Review Testing 84 A–3. Compliance Sampling Methodology 85 Photographs 1. Indoor Patient Waiting Area 34 2. Expired Medical Supply Dated November 2023 34 3. Expired Medical Supply Dated August 2020 35 4. Bulk Food Stored Long-Term in a Supply Cabinet 35 5. Expired Medical Supplies Dated April and May 2023 36 6. Insect in the Warehouse 36 7. Insects in the Clinic 37 8. Insects in the Clinic Restroom 37 Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers the MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth, quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7, rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 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 Calipatria State Prison, 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 December 2023 to May 2024.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between July 2023 and January 2024. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of CAL in November 2024. OIG inspectors monitored the institution’s delivery of medical care that occurred between December 2023 and May 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 CAL adequate. quality at CAL inadequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 52 cases, which contained 636 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes, which may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in November 2024 to verify their initial findings. OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 17 adequate and three inadequate. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 375 patient records and 1,068 data points, and we used the data to answer 88 policy questions. We also observed CAL’s processes during an on-site inspection in July 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 CAL. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CAL Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 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 did not find any adverse events at CAL 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 CAL. OIG clinicians rated one of these 10 indicators proficient, nine adequate, and none inadequate. OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 17 were adequate and three were inadequate. In the 636 events reviewed, we identified 187 deficiencies, 30 of which OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CAL: • Staff performed well with access to care by timely offering and completing appointments for patients. • Nurses performed good screenings and referred patients appropriately to providers when patients transferred into the institution. • Nurses performed good assessments when patients returned from off-site specialty appointments. Our clinicians found the following weaknesses at CAL: • Staff needed improvement in managing diagnostic and specialists’ reports and ensuring these reports were scanned and forwarded to providers timely. • Providers did not consistently communicate results to patients with complete test result notification letters. • The Emergency Medical Response Review Committee needed improvement in identifying emergency staff’s deficiencies and providing opportunities for improvement. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 6 • Staff needed improvement in ensuring medication continuity when patients transferred into the institution. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CAL. Of these 10 indicators, our compliance inspectors rated one proficient, three adequate, and six inadequate. We solely tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. CAL showed a high rate of policy compliance in the following areas: • The institution performed excellently in offering and providing preventive services for its patients, such as influenza vaccinations and immunizations to chronic care patients. • Staff performed well in scanning community hospital discharge reports and requests for health care services into patients’ electronic medical records. • The institution provided high-priority, medium-priority, and routine specialty services within required time frames. • Nursing staff and providers completed assessments of patients admitted to the specialized medical housing unit timely. CAL showed a low rate of policy compliance in the following areas: • The institution often did not provide follow-up provider appointments for chronic care patients and patients transferring into the institution. • Providers often did not communicate results of diagnostic services timely. 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. • Health care staff did not follow hand hygiene precautions before or after patient encounters. • Staff frequently did not maintain medication continuity for chronic care patients, patients discharged from the hospital, or patients with newly prescribed medications. In addition, CAL maintained poor medication continuity for patients who had a temporary layover at CAL. Institution-Specific Metrics Calipatria State Prison (CAL) is located in the city of Calipatria in Imperial County. The institution opened in 1992. The institution operates four main medical clinics and treats patients needing urgent or emergent care in its triage and treatment area (TTA). CAL also treats patients who require assistance with activities of daily living but do not Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 7 require a higher level of inpatient care; CAL treats these patients in the institution’s outpatient housing unit (OHU). As of March 3, 2025, the department reported on its public tracker 64 percent of CAL’s incarcerated population was fully vaccinated for COVID-19 while 72 percent of CAL’s staff was fully vaccinated for COVID-19.7 On July 2, 2024, the Health Care Services Master Registry showed CAL had a total population of 2,956. A breakdown of the medical risk level of the CAL population as determined by the department is set forth in Table 2 below.8 Table 2. CAL Master Registry Data as of July 2024 Medical Risk Level Number of Patients Percentage* High 1 19 0.6% High 2 65 2.2% Medium 469 15.9% Low 2,403 81.3% Total 2,956 100% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 7-2-24. 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, CAL had no vacant executive leadership positions, one primary care provider vacancy, no nursing supervisor vacancies, and 0.9 nursing staff vacancies. Table 3. CAL Health Care Staffing Resources as of July 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 6.0 11.5 71.4 93.9 Filled by Civil Service 5.0 5.0 11.5 70.5 92.0 Vacant 0 1.0 0 0.9 1.9 Percentage Filled by Civil Service 100% 83.3% 100% 98.7% 98.0% Filled by Telemedicine 0 1.0 0 0 1.0 Percentage Filled by Telemedicine 0 16.7% 0 0 1.1% Filled by Registry 0 0 0 3.0 3.0 Percentage Filled by Registry 0 0 0 4.2% 3.2% Total Filled Positions 5.0 6.0 11.5 73.5 96.0 Total Percentage Filled 100% 100% 100% 102.9% 102.2% Appointments in Last 12 Months 1.0 0 1.0 26.0 28.0 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 2.0 7.0 9.0 Adjusted Total: Filled Positions 5.0 6.0 9.5 66.5 87.0 Adjusted Total: Percentage Filled 100% 100% 82.6% 93.1% 92.7% * 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 7-2-24, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 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 CAL’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. Currently, only two HEDIS measures are available for review: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control, and colorectal cancer screening rates for patients ages 45 to 75. We list the applicable HEDIS measures in Table 4. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CAL’s percentage of patients with poor HbA1c control was significantly lower, indicating very good performance on this measure. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. CAL had a 49 percent influenza immunization rate for adults 18 to 64 years old. Data for the influenza immunization rate for adults 65 years of age and older were not available.9 The pneumococcal rate was also not available. Cancer Screening Statewide comparative data was available for colorectal cancer screening. When compared with statewide Medi-Cal programs— California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)— CAL had a 70 percent colorectal cancer screening rate, a rate higher than California Medi-Cal but slightly lower than both Kaiser Southern California (Medi-Cal) and Kaiser Northern California (Medi- Cal). 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 10 Table 4. CAL Results Compared With State HEDIS Scores CAL 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%) ‡,§ 13% 33% 31% 22% HbA1c Control (< 8.0%) ‡ 80% – – – Blood Pressure Control (< 140/90) ‡ 94% – – – Eye Examinations 60% – – – Influenza – Adults (18 – 64) 49% – – – Influenza – Adults (65 +) N/A – – – Pneumococcal – Adults (65 +) N/A – – – Colorectal Cancer Screening 70% 40% 71% 71% Notes and Sources * Unless otherwise stated, data were collected in July 2024 by reviewing medical records from a sample of CAL’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2023– June 30, 2024 (published April 2025); https://www.dhcs.ca.gov/dataandstats/reports/Documents/CA2023-24-Medi-Cal-Managed- Care-Physical-Health-External-Quality-Review-Technical-Report-Vol1-F1.pdf ‡ For this indicator, the entire applicable CAL 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 11 Recommendations Based on our assessment of CAL’s performance, we offer the following recommendations to the department: Access to Care • Health care leadership should determine the root cause(s) of untimely provider appointments for chronic care and newly transferred patients and implement remedial measures as appropriate. Diagnostic Services • The department should develop strategies, such as an electronic solution, to ensure providers create patient letters that contain all elements required by CCHCS policy when they endorse test results and should implement remedial measures as appropriate. • Health care leadership should identify causes related to untimely providing laboratory services and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of challenges in timely retrieving pathology reports and should implement remedial measures as appropriate. Emergency Services • Medical leadership should assess the root cause(s) of the nursing and medical clinical reviews of patient transports to higher level of care, including Emergency Medical Response Review Committee (EMRRC), not identifying all deficiencies and opportunities for improvement as well as not accurately detailing their findings. Leadership 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 remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 12 Transfers • Nursing leadership should assess nursing staff’s challenges in thoroughly completing initial health screenings, including answering all questions and documenting an explanation for each “yes” answer. Leadership should implement remedial measures as appropriate. • The institution’s healthcare leadership should assess challenges in providing patients with their medications without interruption when they arrive from another institution and should implement remedial measures as appropriate. Medication Management • The institution’s health care leadership should develop and implement strategies to ensure patients with chronic care medications, newly ordered medications, and hospital discharge medications, as well as medications for patients admitted to the OHU and layover patients, receive their medications timely, without interruption. Specialty Services • Health care leadership should identify challenge(s) in ensuring staff receive and scan, and providers endorse, specialty reports in a timely manner and should implement remedial measures as appropriate. • Health care leadership should identify the root cause(s) related to untimely providing preapproved specialty appointments for newly arrived patients as well as follow-up specialty service appointments and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 13 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Proficient Inadequate (67.9%) In this cycle, case review found CAL performed excellently with access to care, showing improvement from Cycle 6. Staff provided patients with timely nurse sick calls, specialty services, follow-up appointments after hospitalizations, and follow-up appointments after transferring into CAL. Both provider and nurse rounding occurred timely for patients in the outpatient housing unit (OHU). As a result, the OIG rated the case review component of this indicator proficient. In compliance testing, CAL scored low overall for this indicator. Staff performed very well in reviewing patient sick calls and frequently completed nurse face-to-face appointments. In addition, providers almost always completed follow-up appointments for patients returning after hospitalizations and usually completed follow-up appointments for patients returning after specialty services. However, CAL needed significant improvement in timely completing provider appointments for chronic-care patients and newly transferred patients. Based on the overall Access to Care compliance score, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 189 provider, nursing, urgent or emergent care (triage and treatment area), specialty, and hospital events that required the institution to schedule appointments. We identified three access deficiencies, two of which were significant.10 Access to Care Providers Access to clinic providers is an integral part of patient care. Compliance testing revealed, although CAL performed poorly with access to chronic care follow-up appointments (MIT 1.001, 36.0%), the institution performed fairly with nurse-to-provider follow-up appointments (MIT 1.005, 75.0%) and performed excellently with follow-up sick call 10 Deficiencies occurred in cases 8, 23, and 23. Significant deficiencies occurred in cases 8 and 23. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 14 appointments (MIT 1.006, 100%). OIG clinicians found one deficiency when nursing staff did not order a follow-up appointment with a clinic provider.11 Access to Clinic Nurses CAL provided good access to clinic nurses. Compliance testing showed registered nurses timely reviewed patients’ requests for services within the required time frame (MIT 1.003, 90.0%) and usually saw patients no more than one business day after the sick-call slips were reviewed (MIT 1.004, 85.2%). OIG clinicians reviewed 51 nursing sick-call requests and identified no deficiencies related to clinic nurse access. Access to Specialty Services CAL performed well in providing referrals to specialty services. Compliance testing showed satisfactory completion rates for high-priority (MIT 14.001, 80.0%) and medium- priority (MIT 14.004, 80.0%) specialty services, and an excellent completion rate for routine-priority (MIT 14.007, 100%) specialty services. CAL needed improvement in completing high-priority (MIT 14.003, 66.7%) and medium-priority follow-up (MIT 14.006, 70.0%) specialty services, but the institution performed well in completing routine- priority follow-up (MIT 14.009, 90.0%) specialty services. OIG clinicians found most specialty appointments occurred within requested time frames. We identified one significant deficiency as follows: • In case 23, the patient became ill at the telemedicine clinic while waiting to see the neurologist for a follow-up appointment concerning the patient’s seizure disorder. Staff transferred the patient to the triage and treatment area (TTA) for chest pain. The telemedicine nurse documented asking the provider to reschedule the missed neurologist appointment. However, the neurology appointment did not occur. Follow-Up After Specialty Services CAL generally provided timely provider appointments after specialty services. Compliance testing revealed most provider appointments after specialty services occurred within the required time frame (MIT 1.008, 75.0%). OIG clinicians identified no deficiencies related to provider appointments after specialty services. Follow-Up After Hospitalization CAL almost always ensured providers evaluated patients after hospitalizations. Compliance testing showed patients frequently received provider follow-up appointments following hospitalizations (MIT 1.007, 92.9%). OIG clinicians identified no deficiencies in this category. 11 This deficiency occurred in case 8. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 15 Follow-Up After Urgent or Emergent Care (TTA) Providers always evaluated their patients after a triage and treatment area (TTA) event. OIG clinicians reviewed eight TTA events and identified no delays with provider follow- up appointments. Follow-Up After Transferring Into CAL Findings concerning access to care for patients who had recently transferred into the institution varied between compliance and case review. Compliance testing found CAL performed poorly in providing newly arrived patients with timely access to intake appointments (MIT 1.002, 40.0 %). However, OIG clinicians reviewed five transfer-in cases and only found one significant deficiency as follows: • In case 8, the provider reviewed the patient’s medical record after the patient refused a scheduled interfacility medical appointment and ordered a provider follow-up appointment to occur within 14 days. However, the appointment did not occur. Clinician On-Site Inspection OIG clinicians attended morning huddles and observed good participation by the health care team and ancillary staff. Leadership and staff reported CAL has four main clinics: Facilities A, B, C, and D. In addition to main clinics, CAL operates a TTA, an outpatient housing unit (OHU), a restricted housing unit (RHU), a minimum-support facility (MSF), and a specialty clinic in central health, offering optometry, audiology, orthotics, general surgery, orthopedic surgery, and physical therapy services. Office technicians reported scheduling about 15 appointments for each provider per day and reported no backlogs. Compliance On-Site Inspection Only one 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, 16.7%). In five housing units, custody officers did not have a system in place for restocking the forms. Custody officers reported relying on medical staff to replenish the forms in the housing units. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 16 Compliance Score Results Table 5. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or 9 16 0 36.0% 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 10 15 0 40.0% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 27 3 0 90.0% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 23 4 3 85.2% 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 9 3 18 75.0% 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 2 0 28 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 13 1 0 92.9% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 18 6 21 75.0% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 1 5 0 16.7% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 67.9% * 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 17 Table 6. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the required N/A N/A N/A N/A time frame? (12.003) For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days (prior to N/A N/A N/A N/A 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the 8 2 0 80.0% required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 12 3 0 80.0% Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 8 4 3 66.67% 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 12 3 0 80.0% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 7 3 5 70.0% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 15 0 0 100% for Service? (14.007) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care 9 1 5 90.0% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 18 Recommendation • Health care leadership should determine the root cause(s) of untimely provider appointments for chronic care and newly transferred patients and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 19 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (66.9%) In this cycle, the OIG clinicians found CAL improved its performance in this indicator compared to Cycle 6. Staff generally completed laboratory testing within required time frames. Staff also retrieved, and providers endorsed, these results timely. However, providers only intermittently sent complete patient test notification letters. After considering all factors, the OIG rated the case review component of this indicator adequate. CAL’s performance in compliance testing was mixed in this indicator. Staff performed outstandingly in completing radiology services as well as in reviewing and endorsing laboratory and pathology results within required time frames. Staff generally reviewed and endorsed radiology results timely. In contrast, staff needed improvement in timely providing laboratory services and retrieving pathology reports. Additionally, providers only sporadically generated patient test result notification letters with all required elements. Based on the overall Diagnostic Services compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 90 diagnostic events and identified 58 deficiencies, three of which were significant.12 Of these 58 deficiencies, 57 related to health information management, one related to a provider’s review of a test, and none related to delays in diagnostic test completion. Test Completion CAL performed excellently in completing radiology services within required time frames (MIT 2.001, 100%) but needed improvement in completing laboratory tests (MIT 2.004, 70.0%). OIG clinicians did not find any deficiencies with test completion. Neither case review nor compliance testing had any STAT laboratory tests in their samples to review (MIT 2.007, NA). 12 Deficiencies occurred in cases 1, 2, 10-13, 15, 16, 19, 20, 22, 23, and 50-52. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 20 Health Information Management Staff usually retrieved laboratory and diagnostic results promptly and sent them to providers for review. Compliance testing showed providers performed well in endorsing radiology reports within specified time frames (MIT 2.002, 80.0%) and always endorsed laboratory results timely (MIT 2.005, 100%). Compliance testing revealed poor provider communication with complete radiology and laboratory patient test result notification letters within specified time frames (MIT 2.003, 40.0% and MIT 2.006, 40.0%). OIG clinicians identified a pattern of 51 deficiencies concerning patient test result notification letters, though none of those deficiencies related to endorsing the results late.13 The following is an example: • In case 50, the provider endorsed urine toxicology laboratory results. However, the provider did not create a letter in the EHRS to notify the patient of the test results.14 Although providers always endorsed pathology results timely (MIT 2.011, 100%), CAL staff sometimes did not receive the pathology report within required time frames (MIT 2.010, 60.0%) and providers rarely communicated test results with timely or complete results notification letters to patients (MIT 2.012, 12.5%). OIG clinicians did not have any pathology related samples in case review. We discussed patient test results notification letters further in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians met with the chief support executive, the lead laboratory technician, the lead radiologic technologist, and a phlebotomist. The laboratory technician described the workflow of the laboratory testing process. The lead radiologic technician detailed the workflow for scheduling available diagnostic imaging studies, including digital x-rays and on-site mobile imaging services for MRI, CT, ultrasound, and FibroScan.15 13 Deficiencies occurred in cases 1, 2, 10-13, 15, 16, 19, 20, 22, 23, 25, and 50-52. 14 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for storing the patient’s medical history and health care staff communication. 15 A CT is a computed or computerized tomography scan while an MRI is a magnetic resonance imaging scan. Both create detailed images of organs and tissues to detect diseases and abnormalities. A FibroScan is a diagnostic imaging scan used to evaluate for liver scarring and fatty changes from liver disease. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 21 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 8 2 0 80.0% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 4 6 0 40.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 7 3 0 70.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 4 6 0 40.0% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive 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 8 0 2 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 1 7 2 12.5% pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 66.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 22 Recommendations • The department should develop strategies, such as an electronic solution, to ensure providers create patient letters that contain all elements required by CCHCS policy when they endorse test results and should implement remedial measures as appropriate. • Health care leadership should identify causes related to untimely providing laboratory services and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of challenges in timely retrieving pathology reports and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 23 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services solely through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable CAL generally performed acceptably in emergency care. Providers delivered satisfactory care, and nurses performed sufficient assessments, interventions, and documentation. The emergency medical response review committee (EMRRC) performed clinical reviews in all applicable cases. However, medical and nursing leadership did not perform well with identifying staff’s deficiencies. Overall, the OIG rated this indicator adequate. Case Review Results We reviewed 29 urgent or emergent events and found 25 emergency care deficiencies. Of these 25 deficiencies, four were significant.16 Emergency Medical Response CAL staff responded promptly to emergencies throughout the institution. Staff initiated CPR, activated emergency medical services (EMS), and timely notified TTA staff of medical emergencies in nearly all cases. Provider Performance CAL providers frequently provided good care. Most providers made appropriate decisions and transferred patients to a community hospital when necessary. On-call providers were generally available for consultation with nursing staff and documented most events. OIG clinicians identified three deficiencies, none of which were significant.17 The following is an example: • In case 2, when the patient presented to the TTA, nursing staff attempted to contact the on-call provider multiple times for consultation. However, the 16 Deficiencies occurred in cases 1, 2, 4-6, 9, 14, and 18-21. Significant deficiencies occurred in cases 1, 5, and 20. 17 Deficiencies occurred in cases 1, 2, and 20. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 24 registered nurse was not able to obtain a provider consultation until more than 28 minutes later. We further discuss provider performance in emergency services in the Provider Performance indicator. Nursing Performance CAL nurses often performed appropriate nursing assessments and interventions. Nurses recognized opioid overdoses and implemented the nursing overdose protocol. Nurses also communicated critical clinical findings to providers. However, the following cases showed room for improvement: • In case 5, custody staff found the patient unconscious and initiated CPR. Staff called 9-1-1 four minutes later. The nurse arrived at the scene and did not check the patient’s pulse. Staff performed CPR and administered Narcan (a medication used to reverse opioid overdose) over the course of seven minutes. However, the nurse did not apply the automated external defibrillator (AED) on the patient. Moreover, the supervising registered nurse (SRN) performed a clinical review but did not identify these deficiencies. • In case 20, the patient had a history of pneumonia. The patient had a cough and complained of shortness of breath. The nurse documented the patient had diminished lung sounds and gave the patient a breathing treatment. However, the nurse did not reassess the patient’s lung sounds to determine the effectiveness of the treatment. Nursing Documentation Nursing documentation was sufficient. Most nurses documented timelines and sequences of events. However, we identified a pattern of deficiencies related to nurses not documenting assessment details and medication administration times on the medication administration record (MAR). The following cases are examples: • In case 4, the patient was found unconscious. The nurse documented the patient had a seizure and vomited. However, the nurse did not document the details of the seizure activity or the status of the patient’s condition before emergency medical services (EMS) departed with the patient. • In cases 5, 6, and 18, nurses did not document medication administration times on the MAR. Emergency Medical Response Review Committee OIG clinicians found CAL performed clinical reviews for all patients who transferred to a higher level of care. However, CAL did not perform well with identifying staff deficiencies and opportunities for improvement. The following is an example. • In case 20, the TTA registered nurse co-consulted with the on-call physician for a patient who had shortness of breath, chest pain upon coughing, and elevated blood pressure. The patient was transferred to the community hospital emergency room in a State car as per the on-call physician’s order. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 25 Nursing and medical leadership both performed a clinical review and concurred the patient had been transferred to the community hospital in a State car. However, neither nursing nor medical leadership acknowledged the patient with shortness of breath and chest pain should have been transported by ambulance rather than by State car, and neither identified other opportunities for improvement. Compliance testing revealed CAL performed poorly in completing emergency medical response review committee (EMRRC) checklists (MIT 15.003, zero). Clinician On-Site Inspection OIG clinicians observed the triage and treatment area (TTA) during our on-site inspection. The institution had three medical beds and sufficient space to provide emergency care. Nursing staff reported having an assigned provider during regular business hours; otherwise, providers were assigned to work on call and were available by telephone. Moreover, the TTA assigned two registered nurses on each shift. We met with nursing leadership to discuss some of our case review findings. Leadership reported training staff individually and during town hall meetings. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 26 Recommendations • Medical leadership should assess the root cause(s) of the nursing and medical clinical reviews of patient transports to a higher level of care, including Emergency Medical Response Review Committee (EMRRC), not identifying all deficiencies and opportunities for improvement as well as not accurately detailing their findings. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 27 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 (84.8%) As in Cycle 6, case review found CAL performed satisfactorily in health information management. Staff performed well in retrieving and scanning hospital discharge reports, specialty reports, and diagnostic reports. However, we found staff needed improvement in forwarding test results and specialty reports to providers, and providers needed improvement in communicating diagnostic test results to patients in notification letters containing complete information. The OIG rated the case review component of this indicator adequate. Compliance testing showed CAL performed well in this indicator. Staff performed excellently in scanning patient sick-call requests, as well as scanning and reviewing hospital discharge reports within the required time frames. However, we identified room for improvement in labeling and scanning medical records into the correct patient files. Moreover, staff needed improvement in scanning specialty reports timely. Based on the overall Health Information Management compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results We reviewed 637 events and identified 68 deficiencies related to health information management, five of which were significant.18 Hospital Discharge Reports Staff performed very well in timely retrieving and scanning hospital discharge documents into patients’ electronic health records (MIT 4.003, 92.9%). Nearly all hospital discharge reports contained key elements, and providers reviewed these reports timely (MIT 4.005, 92.9%). OIG clinicians reviewed 15 off-site emergency department and hospital encounters and did not identify any deficiencies. 18 Deficiencies occurred in cases 1, 2, 10-13, 15, 16, 19, 20, 22, 23, 25, and 50-52. Significant deficiencies occurred in cases 1, 11, and 51. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 28 Specialty Reports CAL staff needed improvement in retrieving and reviewing specialty reports. Compliance testing showed staff only sometimes scanned specialty reports into the EHRS within required time frames (MIT 4.002, 63.3%). CAL staff intermittently retrieved and reviewed high-priority (MIT 14.002, 60.0%), medium-priority (MIT 14.005, 66.7%), and routine specialty service consultation reports (MIT 14.008, 64.3%) within the required time frames. OIG clinicians reviewed 55 specialty reports and identified 10 deficiencies, two of which were significant.19 The following is an example: • In case 51, staff did not forward the on-site specialty service consultation report to the provider for endorsement. We also discuss specialty reports in the Specialty Services Indicator. Diagnostic Reports CAL performed satisfactorily in timely retrieving and endorsing diagnostic reports. Compliance testing showed providers generally endorsed radiology reports within required time frames (MIT 2.002, 80.0%) and always endorsed laboratory reports within required time frames (MIT 2.005, 100%). Staff needed improvement in receiving the final pathology report within the required time frame (MIT 2.010, 60.0%). Providers always reviewed and endorsed pathology reports within required time frames (MIT 2.011, 100%) but rarely communicated results of the pathology report with complete test results letters to patients (MIT 2.012, 12.5%). OIG clinicians identified 57 deficiencies, three of which were significant.20 Most deficiencies, 51 out of 57, related to not creating patient results notification letters or not sending complete letters. The following are examples: • In case 51, the patient received an x-ray of the left elbow as a high-priority order, and the results became available on the same day. However, staff did not forward the results to the provider to review and sign. • In case 52, the provider endorsed the laboratory test results and created a patient notification letter in the EHRS. However, the letter neither included the date of the test nor indicated whether the results were within normal limits. Neither case review nor compliance testing had any STAT laboratory tests in their samples to review (MIT 2.007, NA). Urgent and Emergent Records OIG clinicians reviewed 33 emergency care events. Providers sufficiently documented their emergency care, including off-site telephone encounters. OIG clinicians did not find any deficiencies in provider documentation. 19 Deficiencies occurred in cases 1, 10, 11, and 51. Significant deficiencies occurred in cases 21 and 24. 20 Deficiencies occurred in cases 1, 2, 10-13, 15, 16, 19, 20, 22, 23, 25, and 50-52. Significant deficiencies occurred in cases 1 and 51. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 29 We discuss nursing deficiencies further in the Emergency Services indicator. Scanning Performance CAL staff performed well with the scanning process. Compliance testing showed staff always scanned health care services request forms into the EHRS within required time frames (MIT 4.001, 100%) and performed very well in scanning community hospital discharge documents (MIT 4.003, 92.9%). Compliance testing further showed hospital discharge reports included key elements, and providers reviewed reports within the required time frame (MIT 4.005, 92.9%). For the most part, staff properly scanned, labelled, and included medical records in the correct patients’ files (MIT 4.004, 75.0%). However, CAL needed improvement in scanning high-priority specialty reports within the required time frame (MIT 4.002, 63.3%). OIG clinicians identified one minor deficiency related to mislabeling a medical document as follows:21 • In case 22, staff erroneously filed the patient’s heart monitor report as a “Sleep Study” in the EHRS. Clinician On-Site Inspection OIG clinicians discussed health information management processes with medical leadership, the medical records supervisor, office technicians, and providers. The supervisor reported using a tracking spreadsheet, “eLog,” in the TTA for all off-site specialty appointments to retrieve records and reconcile them with the daily patient movement sheet. The supervisor also explained the process for retrieving specialty consultation reports and uploading them into the EHRS. 21 Deficiencies occurred in case 22. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 30 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 19 11 15 63.3% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 13 1 0 92.9% (4.003) During the inspection, were medical records properly scanned, labeled, 18 6 0 75.0% 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 13 1 0 92.9% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 84.8% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 31 Table 9. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse the 8 2 0 80.0% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A 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 8 0 2 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 1 7 2 12.5% 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 9 6 0 60.0% frame? (14.002) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 10 5 0 66.7% frame? (14.005) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 9 5 1 64.3% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 32 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 33 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 (50.5%) Overall, CAL performed poorly with respect to its health care environment. Medical supply storage areas contained expired, inaccurately labeled, and disorganized medical supplies. Several clinics did not meet the requirements for essential core medical equipment and supplies. Staff only occasionally sanitized or washed their hands during patient encounters. Additionally, emergency medical response bags (EMRBs) contained compromised medical supply packaging or had not been properly inventoried. Based on the overall Health Care Environment compliance score result, the OIG rated this indicator inadequate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 34 Compliance Testing Results Patient Waiting Areas We inspected only indoor waiting areas because CAL had no outdoor waiting areas. Health care and custody staff reported existing waiting areas contained sufficient seating capacity (see Photo 1). During our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Nine of the 10 clinics we observed contained appropriate space, configuration, supplies, and equipment to allow Photo 1. Indoor patient waiting area clinicians to perform proper clinical examinations (MIT (photographed on 7-16-24). 5.110, 90.0%). In one clinic, the examination room table had a torn cover. Clinic Supplies Only two of the 10 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 20.0%). We found one or more of the following deficiencies in eight clinics: compromised sterile medical supply packaging; expired medical supplies (see Photos 2 and 3); long- term storage of staff’s food in the medical supply storage location (see Photo 4); unorganized, unidentified, or inaccurately labeled medical supplies; and cleaning materials stored with medical supplies. Photo 2. Expired medical supply dated November 2023 (photographed on 7-16-24). Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 35 Photo 3. Expired medical supply dated August 2020 Photo 4. Bulk food stored long-term in a supply (photographed on 7-17-24). cabinet (photographed on 7-16-24). Only two of the 10 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 20.0%). The remaining eight clinics lacked medical supplies, contained improperly calibrated equipment, or contained nonfunctional equipment. For example, a nebulization unit was missing in one clinic, staff had not properly calibrated an automated vital sign machine in another clinic, and in additional clinics, we found a nonfunctional oto-ophthalmoscope and thermometer as well as an incomplete clinic glucometer quality-control log. We also found staff had not completed automated external defibrillator (AED) or defibrillator performance test logs within the last 30 days. We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Three of the eight applicable EMRBs passed our test (MIT 5.111, 37.5%). We found one or more of the following deficiencies with five EMRBs: staff did not ensure the EMRB compartments were sealed and intact; staff had not inventoried the EMRBs when the seal tags were replaced; EMRBs contained compromised medical supply packaging; and EMRBs’ glucometer quality-control logs were incomplete. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 36 Medical Supply Management None of the medical supply storage areas located outside the medical clinics contained adequately stored medical supplies (MIT 5.106, zero). We found expired medical supplies and insects (see Photos 5 and 6). Photo 5. Expired medical supplies dated April and May 2023 (photographed on 7-17-24). Photo 6. Insect in the warehouse (photographed on 7-17-24). According to the CEO, health care leadership did not have any concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process. Infection Control and Sanitation Staff appropriately disinfected, cleaned, and sanitized four of 10 clinics (MIT 5.101, 40.0%). In six clinics, we found one or more of the following deficiencies: an unsanitary sink, an unsanitary cabinet under a sink, or insects in the clinics (see Photos 7 and 8). Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 37 Staff in eight of 10 clinics (MIT 5.102, 80.0%) properly sterilized or disinfected medical equipment. In two clinics, we observed the clinician utilize the examination table without disposable paper during patient encounters, and staff did not mention disinfecting the examination table as part of their daily start-up protocol. Photo 7. Insects in the clinic (photographed on 7-16-24). We found operating sinks and hand hygiene supplies in the examination rooms in five of 10 clinics (MIT 5.103, 50.0%). Patient restrooms in three clinics either lacked antiseptic soap or disposable hand towels. In the fourth clinic, the examination room lacked disposable hand towels. In the fifth clinic, the custody officer reported antiseptic soap and disposable hand towels were provided upon patient Photo 8. Insects in the clinic restroom request. However, no antiseptic soap (photographed on 7-16-24). and disposable hand towels were available at the time of our inspection. We observed patient encounters in eight clinics. In five clinics, staff did not wash their hands before or after examining their patients (MIT 5.104, 37.5%). Health care staff in eight of 10 clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 80.0%). In one clinic, we identified an overfilled sharps container. In another clinic, we found no sharps container in the examination room during our inspection. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 38 Physical Infrastructure At the time of our medical inspection, the institution’s administrative team reported no ongoing health care facility improvement program construction projects. The institution’s health care management and plant operations manager reported all clinical area infrastructure was in good working order (MIT 5.999). Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 39 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, 4 6 0 40.0% 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 8 2 0 80.0% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 5 5 0 50.0% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 3 5 2 37.5% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 8 2 0 80.0% 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 0 1 0 0 health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for managing and 2 8 0 20.0% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 2 8 0 20.0% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 10 0 0 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 9 1 0 90.0% 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): 50.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 40 Recommendations • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 41 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated staff performance in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals. Inspectors further confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow- up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (62.2%) Case review found CAL’s transfer process was sufficient. When patients returned from the hospital or emergency room, they received appropriate care, and follow-up appointments occurred timely. Receiving and Release (R&R) nurses appropriately performed screenings and referred patients to providers. However, when patients transferred into CAL, nurses often did not ensure medication continuity for their patients. Additionally, when patients transferred out of the institution, interfacility transfer information was often incomplete. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed a low overall score in the transfer process. The institution needed improvement in ensuring medication continuity for transfer-in patients. It also needed significant improvement in completing initial health screening forms. Based on the overall Transfers compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 34 events in 18 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 14 deficiencies, three of which were significant.22 22 Deficiencies occurred in cases 1, 8, 14, 19, 20, 21, 26-31, and 50. Significant deficiencies occurred in cases 8, 20, and 27. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 42 Transfers In Compliance testing revealed nurses only sporadically completed initial health screening forms thoroughly (MIT 6.001, 20.0%). In contrast, nurses performed excellently in addressing signs and symptoms when screening patients for tuberculosis (MIT 6.002, 100%). OIG clinicians reviewed 10 events and identified five deficiencies, two of which were significant. Our clinicians found nearly all nurses screened patients appropriately and requested provider appointments within the required time frame. Compliance testing revealed patients only intermittently received their medications timely. Further analysis showed the low score was based on one sample in which the nurse did not administer medication to the patient, another sample in which the nurse did not document the reason why the patient refused medication, and a third sample in which the nurse documented administering the patient’s medication on another institution’s medication record (MIT 6.003, 66.7%). OIG clinicians similarly found poor medication management when patients transferred into CAL without their medications. The following cases showed room for improvement: • In case 8, a patient with a history of asthma and chronic obstructive pulmonary disease (COPD) transferred into CAL from another institution.23 The nurse documented the patient did not arrive with his maintenance and rescue inhalers. Both medications were ordered to begin on the same day. However, the patient received the maintenance inhaler 11 days late and the rescue inhaler 16 days late. This placed the patient at risk for respiratory complications. • In case 27, a patient with a history of prediabetes transferred into CAL. The patient reported his diabetic medication had been packed with his property, and he would not have access to the medication for three days. The next day, the pharmacy documented the medication would be filled the same day; however, the patient received the medication 22 days late. Compliance testing revealed newly arrived patients were only occasionally seen by providers within the required time frame (MIT 1.002, 40.0%). In contrast, OIG clinicians found all patients were seen timely. When patients transferred into CAL with preapproved specialty services, compliance testing revealed appointments frequently did not occur timely (MIT 14.010, 58.8%). OIG clinicians reviewed one applicable case, and that appointment occurred on time. Transfers Out OIG clinicians reviewed six transfer out events and identified three deficiencies, none of which were significant. We found all nurses screened patients appropriately and ensured all patients had their medical equipment. Nurses provided medications to patients and 23 Chronic obstructive lung disease (COPD) is a chronic and progressive lung disease with damage to the lungs and obstruction of airflow which makes it hard to breathe. Inhalers help patients breathe better by relaxing airway muscles and reducing inflammation. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 43 transferred all patients with their medications. However, we identified a pattern of deficiencies for incomplete interfacility transfer information. • In cases 29 and 30, the nurse did not include the patient summary in the transfer packet. Compliance testing had no applicable cases in their samples (MIT 6.101, N/A). Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experience severe illness or injury and require more care, placing a strain on the institution’s resources. In addition, because these patients have complex medical issues, the successful transfer of health information is necessary for good quality care as any lapse in transfer can result in serious consequences for these patients. OIG clinicians reviewed 20 events and identified six deficiencies, one of which was significant. Nurses performed appropriate assessments, reviewed the hospitalists’ recommendations, and notified providers appropriately. The following cases showed room for improvement: • In case 1, the patient returned from the hospital with a diagnosis of “mild fluid overload versus atelectasis.”24 Nevertheless, the nurse did not assess the patient’s heart and lung sounds. • In case 14, the patient returned from the hospital with fractures to the nose and to the bones around the eye. The nurse did not inquire about the patient’s vision and did not document the appearance of the patient’s eyes. Compliance testing showed nearly all hospital discharge documents were scanned within the required time frame (MIT 4.003, 92.9%), and providers did an excellent job reviewing all documents (MIT 4.005, 92.9%). OIG clinicians similarly found all documents were scanned within the required time frame. Furthermore, providers timely reviewed all documents and addressed all hospitalists’ recommendations. Clinician On-Site Inspection During the on-site inspection, OIG clinicians observed the receiving and release (R&R) area and interviewed the nurse. The nurse was knowledgeable about the transfer process. We attended a well-organized huddle. Huddle attendees included the pharmacist-in- charge (PIC), R&R nurse, SRN, and health information management staff. Some topics of discussion in the huddle included parole medications, transfer-in and transfer-out medications, potential lapses in medication continuity, out-to-court returns, and screenings. We also met with leadership to discuss some of our case review findings. Leadership reported some of the medication deficiencies the OIG identified occurred 24 Fluid overload occurs when there is excess fluid in the body, which may lead to swelling, high blood pressure, or other medical complications. Atelectasis is a medical condition referring to a partial or complete collapse of the lungs. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 44 during the time many patients were transferring into CAL. Leadership also reported they provided training to staff. Compliance On-Site Inspection The week of the on-site inspection, no patients were transferring out of CAL with an active medication or with durable medical equipment ordered (MIT 6.101, N/A). Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 45 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 5 20 0 20.0% 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 20 0 5 100% 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 6 3 16 66.7% 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): 62.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 46 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 10 15 0 40.0% patient seen by the clinician within the required time frame? (1.002) Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider within the 13 1 0 92.9% 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? 13 1 0 92.9% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 13 1 0 92.9% 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 8 4 20.0% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 23 2 0 92.0% 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 10 7 0 58.8% 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 47 Recommendations • Nursing leadership should assess nursing staff’s challenges in thoroughly completing initial health screenings, including answering all questions and documenting an explanation for each “yes” answer. Leadership should implement remedial measures as appropriate. • The institution’s healthcare leadership should assess challenges in providing patients with their medications without interruption when they arrive from another institution and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 48 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 (58.0%) Overall, case review found CAL performed sufficiently in medication management. The institution provided good medication management for new and chronic care medications. CAL also provided good medication management when patients transferred out of the institution or returned from the hospital or emergency rooms. CAL provided sufficient medication management in the specialized medical housing unit but performed poorly when patients transferred into the institution. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing revealed CAL needed improvement in medication management. CAL scored low in providing patients with chronic care medications, newly prescribed medications, hospital discharge medications, and in providing medications for patients admitted to the outpatient housing unit or laying over at CAL. Based on the overall Medication Management compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 126 cases related to medications and found 29 medication deficiencies, three of which were significant.25 New Medication Prescriptions Compliance testing revealed new medications were often either unavailable or not administered timely (MIT 7.002, 40.0%). In contrast, OIG clinicians found staff administered all newly prescribed medications timely. Chronic Medication Continuity Compliance testing revealed patients only sporadically received their chronic medications within the required time frames (MIT 7.001, 47.4%). In contrast, OIG 25 Deficiencies occurred in cases 8, 12, 16, 27, 28, and 50. Significant deficiencies occurred in cases 8 and 27. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 49 clinicians found nearly all chronic care medications were given timely. However, the following cases showed room for improvement: • In case 8, the patient with a history of asthma and chronic obstructive pulmonary disease (COPD) submitted a medication refill request for his maintenance inhaler. However, the patient never received the medication, placing the patient at risk for respiratory complications. • In case 16, the patient was scheduled to receive an automatic refill of potassium chloride.26 However, the patient received the medication 10 days late. Hospital Discharge Medications Compliance testing revealed patients returning from off-site hospitals or emergency rooms only occasionally received their medications within the required time frame (MIT 7.003, 20.0%). In contrast, OIG clinicians found all patients received their medications timely. Specialized Medical Housing Medications Compliance testing revealed, when CAL admitted patients to the outpatient housing unit (OHU), staff only sporadically ordered, made available, and administered medications timely (MIT 13.003, 30.0%). In contrast, OIG clinicians found just one medication deficiency as follows: • In case 50, a patient with a history of end-stage liver disease did not receive two consecutive doses of his lactulose medication, a medication used to help reduce ammonia absorption.27 The nurse documented the medication was not available. Transfer Medications Compliance testing revealed patients intermittently received their medications timely. As noted above, further analysis showed the low score was based on three samples in which one nurse did not administer the patient’s medication, another nurse did not document a reason for the patient refusing medication, and a third nurse documented administering the patient’s medication on another institution’s medication record (MIT 6.003, 66.7%). OIG clinicians similarly found poor medication management when patients transferred into CAL without their medications. Please see the Transfer indicator for details. Medication Administration Compliance testing showed nurses performed excellently in administering tuberculosis (TB) medications as prescribed (MIT 9.001, 96.0%), and nurses performed satisfactorily in 26 Potassium chloride medication is used to treat and prevent low potassium levels in the body and prevent cardiac complications. 27 End-stage liver disease (ESLD), also known as liver failure, occurs when the liver is so damaged it can no longer function properly. In ESLD, the liver has lost most of its ability to function and is unable to remove ammonia, a byproduct of protein metabolism. Ammonia levels rise and impair normal brain function. This can result in symptoms that range from confusion to coma. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 50 monitoring patients taking TB medications per policy (MIT 9.002%, 79.2%). OIG clinicians also found nearly all nurses administered medications correctly, except in the following one example: • In case 12, the nurse administered the wrong dose of insulin. Clinician On-Site Inspection OIG clinicians observed the medication areas and interviewed the medication nurses, who were knowledgeable about the medication process. Medication nurses attended clinic huddles and notified providers of expiring medications and patient refusals. Nurses reported morale was good, and supervisors were supportive. Nurses also reported having a good rapport with custody staff and their peers. We also met with the current and former pharmacist-in-charge (PIC) and nursing leadership to discuss some of our findings. They reported a plan to provide additional training to the staff. Compliance Testing On-Site Inspection Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all of eight applicable clinic and medication line locations (MIT 7.101, 100%). CAL appropriately stored and secured nonnarcotic medications in four of nine applicable clinic and medication line locations (MIT 7.102, 44.4%). In five locations, we observed one or more of the following deficiencies: nurses did not maintain unissued medication in its original, labeled packaging; the medication storage area was unsanitary; the medication area did not separate returned medications previously in a patient’s possession from other medications that could potentially be restocked or reissued by the pharmacy; and daily security check entries were missing from the treatment cart log. Staff kept medications protected from physical, chemical, and temperature contamination in two of the nine applicable clinic and medication line locations (MIT 7.103, 22.2%). In seven locations, we found one or both of the following deficiencies: staff did not store internal and external medications separately, or the medication refrigerator was unsanitary. Staff successfully stored valid, unexpired medications in all nine applicable medication line locations (MIT 7.104, 100%). Nurses exercised proper hand hygiene and contamination control protocols in two of six applicable locations (MIT 7.105, 33.3%). In four locations, some medication nurses neglected to wash or sanitize their hands when required, such as before preparing and administering medications or before each subsequent regloving. Staff in three of six applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 50.0%). In three locations, medication nurses did not describe the process they followed when reconciling newly received medication and the medication administration record (MAR) with the corresponding physician’s order. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 51 Staff in one of six applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 16.7%). In five locations, we observed one or both of the following deficiencies: medication nurses did not follow the CCHCS care guide when administering Suboxone medication, or medication nurses did not describe the appropriate medication error reporting process. Pharmacy Protocols CAL followed general security, organization, and cleanliness management protocols, and properly stored nonrefrigerated medications in its pharmacy (MIT 7.108, 100% and MIT 7.109, 100%). The institution did not properly store refrigerated or frozen medications in the pharmacy. We found an unsanitary refrigerator (MIT 7.110, zero). The PIC correctly accounted for narcotic medications stored in CAL’s pharmacy (MIT 7.111, 100%). We examined 25 medication error reports and found the PIC timely or correctly processed only 15 of these reports (MIT 7.112, 60.0%). In seven reports, the PIC did not document one of the following: determination or findings regarding the error; where the error occurred within the pharmacy process; or the recommended changes to prevent the errors from occurring in the future. For the remaining three reports, the PIC did not initiate a medication error follow-up form at the time of our inspection. 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 CAL, 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. All 10 applicable patients we interviewed indicated they had access to their rescue medications (MIT 7.999). Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 52 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 9 10 6 47.4% or did the institution follow departmental policy for refusals or no‑shows? (7.001) Did health care staff administer, make available, or deliver new order prescription 10 15 0 40.0% medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 2 8 4 20.0% required time frames? (7.003) For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or delivered to N/A N/A N/A N/A the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 23 2 0 92.0% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 6 4 0 60.0% without interruption? (7.006) All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic medications 8 0 2 100% assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the assigned 4 5 1 44.4% storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of contamination in 2 7 1 22.2% 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 9 0 1 100% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and 2 4 4 33.3% medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 3 3 4 50.0% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 1 5 4 16.7% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 1 0 0 100% cleanliness management protocols in its main and remote pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 0 1 0 0 medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 15 10 0 60.0% (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the OIG This is a nonscored test. Please see the indicator find that medication errors were properly identified and reported by the institution? (7.998) for discussion of this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator have immediate access to their KOP prescribed rescue inhalers and nitroglycerin medications? (7.999) for discussion of this test. Overall percentage (MIT 7): 58.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 53 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 6 3 16 66.7% 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 24 1 0 96.0% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 19 5 1 79.2% 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 54 Recommendations • The institution’s health care leadership should develop and implement strategies to ensure patients with chronic care medications, newly ordered medications, and hospital discharge medications, as well as medications for patients admitted to the OHU and layover patients, receive their medications timely, without interruption. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 55 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 patients out 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 (91.9%) CAL performed very well in this indicator. Staff performed excellently in offering patients an influenza vaccine for the most recent influenza season, offering required immunizations to chronic care patients, and administering TB medications to patients as prescribed. Staff also performed well in offering colorectal cancer screening for patients from ages 45 through 75 and screening patients annually for TB. Staff also performed satisfactorily in monitoring patients taking TB medications. These findings are set forth in the table on the next page. Based on the overall Preventive Services compliance score result, the OIG rated this indicator proficient. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 56 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 24 1 0 96.0% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 19 5 1 79.2% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 22 3 0 88.0% (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 22 3 0 88.0% offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the patient N/A N/A N/A N/A offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was patient N/A N/A N/A N/A offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? (9.008) 15 0 10 100% Are patients at the highest risk of coccidioidomycosis (Valley Fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 91.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 57 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 58 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 CAL’s overall nursing care was sufficient. Specifically, nurses performed good nursing care in specialty services and with the transfer-in process. Nurses provided sufficient nursing care in the following areas: emergency services, hospitalization, transfer-out process, outpatient, and specialized medical housing. Considering all factors, the OIG rated this indicator adequate. Case Review Results We reviewed 180 nursing encounters in 51 cases. Of the nursing encounters we reviewed, 101 occurred in the outpatient setting, and 51 were sick-call requests. We identified 67 nursing performance deficiencies, six of which were significant.28 Outpatient Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) elements. Nurses generally provided appropriate nursing assessments and interventions. We identified 36 outpatient nursing deficiencies, five of which were significant.29 The following cases showed room for improvement: 28 Deficiencies occurred in cases 1, 2, 4-6, 9-12, 14-21, 29-32, 34, 36, 39, 40, 43-48, and 50-52. Significant deficiencies occurred in cases 5, 12, 19, 20, and 21. 29 Outpatient deficiencies occurred in cases 1, 2, 10–12, 15-21, 32, 34, 36, 39, 40, and 43-48. Significant deficiencies occurred in cases 12, 19, 20, and 21. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 59 • In case 12, the patient with a history of diabetes had very high blood sugar readings on multiple occasions. However, the nurses did not notify the provider. • In case 15, the patient’s blood pressure and heart rate were elevated. However, the nurse did not notify the provider. Nurses triaged sick calls appropriately and generally provided appropriate assessments and interventions. However, the following cases showed room for improvement: • In case 15, the patient admitted to intravenous (IV) drug use, which can cause infections, and the patient complained of hand pain and redness. The nurse documented the patient’s hand was red, swollen, and warm to the touch. However, the nurse did not assess hand strength, sensation, and range of motion. • In case 20, the patient complained of a cough, chest discomfort, and shortness of breath. The nurse documented the patient was wheezing. However, the nurse did not apply oxygen to the patient. 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 care appropriately. Emergency Services We reviewed 29 urgent or emergent events. Nurses performed sufficient assessments, interventions, and documentation, which we detail further in the Emergency Services indicator. Hospital Returns We reviewed 20 events involving returns from off-site hospitals or emergency rooms. Nurses performed sufficient assessments and notified providers of the hospitalists’ recommendations. Please refer to the Transfers indicator for additional information. Transfers We reviewed 10 events involving the transfer-in process. Nurses performed good screenings and referred patients appropriately to providers. We also reviewed six events involving the transfer-out process. Nurses screened patients appropriately but did not always include patient summaries in the transfer packets. Please refer to the Transfers indicator for further details. Specialized Medical Housing We reviewed 17 nursing encounters and found nurses performed sufficient assessments, interventions, and documentation. For more specific details, please refer to the Specialized Medical Housing indicator. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 60 Specialty Services We reviewed 11 events in which patients returned from an off-site specialty appointment and found nurses performed good assessments. Nurses generally reviewed specialists’ findings and recommendations and communicated those results to the provider. The Specialty Services indicator provides further details. Medication Management OIG clinicians reviewed 126 events involving medication management and found nearly all nurses administered patients’ medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection OIG clinicians observed outpatient clinics, the specialty services area, medication areas, the triage and treatment area (TTA), the outpatient housing unit (OHU), and the receiving and release (R&R) clinic. We also attended organized huddles. Patient care teams were familiar with their patient population, and nurses were knowledgeable about processes in their respective areas. Nurses reported an increase in fights among incarcerated people, which they attributed to the comingling of patients with different custody and security designations on the yard. According to the nurses, their workload had increased as a result of these fights. Nurses also reported they observed a decrease in patient refusals due to the peer-support program, which bridged the gap between patient and medical communications. Nursing staff generally reported morale was good and described having a good rapport with their supervisors and custody staff. We met with nursing leadership to discuss some of our case review findings. We found nursing leadership organized and prepared for our discussion. Nursing leadership was very knowledgeable about the nursing process, workflow, and operations. They invited the OIG to their nursing subcommittee meeting, which included topics of discussion such as immunizations, public health, and patient refusals. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 61 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 62 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable As in Cycle 6, CAL providers delivered good care for patients. Providers generally made appropriate evaluations, diagnosed medical conditions correctly, and managed chronic conditions effectively. They referred patients to specialists appropriately and to a higher level of care when needed. However, we identified instances in which providers did not thoroughly review medical records or perform pertinent examinations. After careful consideration of all factors, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 90 medical provider encounters and identified 35 deficiencies, 11 of which were significant. In addition, we rated the quality of care in 20 comprehensive case reviews.30 Of these 20 cases, we found 17 adequate and three inadequate. Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound medical decisions for their patients. Providers usually diagnosed medical conditions correctly, ordered appropriate tests, and referred patients to specialists when needed. However, OIG clinicians identified 10 deficiencies related to poor medical assessment and decision-making, four of which were significant.31 The following are two examples: • In case 1, the provider evaluated the patient for an abnormal chest x-ray with atypical chest pain and documented the patient was wheezing on exertion with bilateral lower leg swelling. However, the provider did not perform relevant physical examinations including examinations of the heart and lungs. 30 Deficiencies occurred in cases 1, 2, 9-12, 14, 17-21, 23, and 51. Significant deficiencies occurred in cases 1, 9- 11, 20, 21, and 23. 31 Assessment and decision-making deficiencies occurred in cases 1, 11, 17, 18, 20, and 23. Significant deficiencies occurred in cases 1 and 11. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 63 • In case 11, the provider evaluated the patient for a surgical wound “leakage.” However, the provider did not perform a pertinent physical examination of the wound. Review of Records Providers generally reviewed medical records and addressed hospitalists’ recommendations for patients returning from hospitalizations. However, OIG clinicians identified four deficiencies related to the review of hospital records, three of which were significant.32 The following are examples: • In case 20, the patient received ibuprofen (nonsteroidal, anti-inflammatory drug or “NSAID”) in addition to his regular NSAID medication, sulindac, for postoperative pain when the patient returned from a surgical procedure.33 Taking two NSAID medications simultaneously increases risks such gastrointestinal bleeding and adverse kidney effects. The provider did not thoroughly review the discharge medication list to avoid interactions between the two drugs. • In case 23, the provider evaluated the patient for follow-up after a recent emergency department encounter for urinary retention. However, the provider did not thoroughly review hospital records to address the abnormal CT of the abdomen showing an ill-defined 2.4 cm lesion in the liver. Further work up was performed significantly late, thereby delaying the evaluation of this abnormal CT finding. Emergency Care Providers usually managed patients in the TTA with urgent or emergent conditions appropriately, and providers were generally available for consultation with TTA staff. OIG clinicians identified three deficiencies related to emergency care, none of which were significant.34 We provide further details in the Emergency Services indicator. Chronic Care In most instances, providers appropriately managed patients’ chronic health conditions, such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. However, OIG clinicians identified nine deficiencies, three of which were significant.35 The following is an example: • In case 10, the provider endorsed a laboratory test result of an elevated HbA1c 12.6, indicating uncontrolled diabetes.36 However, the provider did 32 Record review deficiencies occurred in cases 14, 20, 21, and 23. Significant deficiencies occurred in cases 20, 21, and 23. 33 Sulindac is an NSAID medication used to treat pain. 34 Emergency care deficiencies occurred in cases 1, 2, and 20. 35 Chronic care deficiencies occurred in cases 1 and 10-12. 36 Hemoglobin A1c (HbA1c) is a blood test that measures the average plasma glucose over the previous 12 weeks. For most patients with diabetes, the HbA1c goal is 7 percent or less. https://www.cdc.gov/diabetes/diabetes-testing/prediabetes-a1c-test.html Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 64 not follow up with the patient within shorter intervals for closer evaluation and intervention. Specialty Services Providers appropriately referred patients for specialty consultation when medically indicated. When specialists made recommendations, providers mostly followed the recommendations appropriately and reviewed specialty reports timely. OIG clinicians identified one minor deficiency for not thoroughly reviewing the specialty report.37 We also discuss providers’ specialty performance in the Specialty Services indicator. Documentation Quality Providers frequently documented outpatient encounters on the day of the encounter. However, OIG clinicians identified two minor deficiencies of providers not completing a progress note.38 The following is an example: • In case 12, the provider ordered an increase in Lantus insulin from five units to 10 units. However, the provider did not document a progress note with a rationale or plan of care for this medication adjustment. Documentation is important because it shows the provider’s thought process during clinical decision-making. When contacted by nurses, providers generally documented the interactions. However, OIG clinicians identified one undocumented interaction:39 • In case 11, the nursing staff called the provider and sent a general message regarding the patient’s very high blood sugar reading. Despite a recent specialist recommendation to increase the insulin dose to 30 units if the sugars were high, the provider recommended the nurse administer the usual dose of insulin, Lantus 20 units, with the intent to adjust the medication order as needed. However, the provider did not document a progress note to explain the rationale for not following the specialist’s recommendation to increase the Lantus to 30 units. Provider Continuity CAL offered good provider continuity. Providers were assigned to specific clinics and took care of their assigned patients. Provider Notification Letters Providers did not always send patient test results notification letters to patients. When they did, the letters did not always contain the four elements required by policy: the date of the test; the reviewing health care provider’s name; whether the results are within normal limits; and whether a provider follow-up appointment is required and will be scheduled. After endorsing laboratory results, providers are responsible for notifying 37 The deficiency occurred in case 14. 38 Deficiencies occurred in case 12. 39 Deficiencies occurred in case 11. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 65 patients of the laboratory results and the necessary next steps. OIG clinicians identified 51 deficiencies concerning patient test result notification letters, but none of those deficiencies related to late endorsement of the results.40 We further discuss patient notification letters in Diagnostic Services and Health Information Management indicators. Clinician On-Site Inspection OIG clinicians observed morning huddles led by clinic providers, which were well attended. The OIG physician met with the chief medical executive (CME), the chief physician and surgeon (CP&S), and other clinic physicians. Providers reported they felt well-supported by medical leadership. We discussed expectations for physician documentation, medical scheduling priorities, and appropriate telemedicine patient profiles with medical leadership. Medical leadership explained CAL plans to procure telemedicine equipment because one outpatient yard clinic did not have a full set of telemedicine equipment for virtual patient encounters. Medical leadership explained one yard clinic is scheduled to close in early 2025, and its telemedicine equipment will be moved to the yard clinic that lacks a full set of equipment. 40 Results notification deficiencies occurred in cases 1, 2, 10-13, 15, 16, 19, 20, 22, 23, 25, and 50-52. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 66 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 67 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. At the time of our inspection, CAL’s specialized medical housing consisted of an outpatient housing unit (OHU). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (75.0%) Case review found CAL provided sufficient care in the OHU. Both providers and nurses performed satisfactory care. The institution’s medication management was also satisfactory. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed results in this indicator. Nursing staff performed very well in completing initial assessments. Providers performed well in completing history and physical (H&P) examinations within required time frames. However, nursing staff needed significant improvement in ensuring medication continuity for patients newly admitted to the specialized medical housing unit. Based on the overall Specialized Medical Housing compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results We reviewed 50 OHU events, including 18 provider events and 17 nursing events. Because of the frequency of nursing and provider contacts in the specialized medical housing unit, we bundle up to two weeks of patient care into a single event. We identified 13 deficiencies, one of which was significant.41 Provider Performance Compliance testing showed providers completed most admission histories and physical examinations timely (MIT 13.002, 80.0%). Providers completed rounds at clinically appropriate intervals and performed sufficient assessments. However, OIG clinicians identified one deficiency in completing the admitting history and physical examination 41 Deficiencies occurred in cases 18, 19, 50, 51, and 52. A significant deficiency occurred in case 51. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 68 timely and four deficiencies in following specialists’ recommendations for physical therapy.42 The following are examples: • In case 19, the provider performed a chart review for the patient admitted to the OHU when discharged from the hospital after a cardiac procedure. We found no record a provide performed an admitting history and physical examination within 24 hours of the patient’s OHU admission. • In case 51, the patient had a ruptured arm tendon and was admitted to the OHU for brace adjustments and physical therapy. However, the provider did not order a physical therapy follow-up evaluation. Consequently, the patient did not receive physical therapy. The provider documented on multiple occasions the patient was being seen for physical therapy, but the physical therapist never actually treated the patient. Nursing Performance Compliance testing showed nearly all OHU nurses completed admission assessments within the required time frame (MIT 13.001, 90.0%). OIG clinicians found OHU nurses completed all admission assessments, conducted rounds appropriately, and generally provided satisfactory care. However, we identified a pattern of deficiencies related to incomplete nursing assessments and documentation. The following are examples: • In case 18, the patient with a history of appendix removal complained of abdominal pain and bloating. The registered nurse did not assess bowel sounds, inquire about the patient’s last bowel movement, or document the appearance of the patient’s abdomen. • In case 51, the patient had a surgical wound. The LVN documented the registered nurse completed wound care. However, the registered nurse did not document the details of the wound care. Medication Administration Compliance testing revealed patients admitted to the OHU only sporadically received their medications timely (MIT 13.003, 30.0%). In contrast, OIG clinicians found just one medication deficiency. Please refer to the Medication Management indicator for further details. Clinician On-Site Inspection OIG clinicians observed the OHU. The OHU had 18 beds, two of which were negative pressure rooms.43 We attended a well-organized huddle and found good staff participation. The nurse reported the unit had been staffed with a designated provider, a 42 Deficiencies occurred in cases 19 and 51. 43 Negative pressure rooms, also known as isolation rooms, are rooms specifically designed to have lower air pressure inside the room than outside of the room. This prevents spread of airborne pathogens, such as measles, COVID, and tuberculosis. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 69 registered nurse on second watch, and LNVs on first and third watch. The nurse reported good morale and good rapport with nursing leadership and custody staff. We met with the nursing supervisor, who was highly knowledgeable about the OIG’s history and purpose as well as OHU operations and policies. We also met with nursing leadership to discuss some of our case review findings, and leadership reported a plan to provide training. Compliance On-Site Inspection At the time of our on-site inspection, the OHU had a functional call light communication system (MIT 13.101, 100%). Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 70 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 9 1 0 90.0% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 8 2 0 80.0% required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 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 0 100% system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local 0 0 1 N/A operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 75.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 71 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 72 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 (75.3%) Case review found CAL generally provided satisfactory specialty services for patients. Providers made appropriate referrals and followed up after specialty services. Triage-and- treatment-area (TTA) nurses assessed patients after returning from specialty appointments. However, we found opportunities for improvement in providers reviewing specialists’ reports, staff retrieving and scanning the reports, and staff forwarding the reports for providers’ endorsements. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed results in this indicator. Depending on the priority of the specialty service, access ranged from needing improvement to excellent. Preapproved specialty services for newly arrived patients sometimes occurred within required time frames. CAL’s performance in retrieving specialty reports and in timely provider endorsements needed improvement. Based on the overall Specialty Services compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 80 events related to Specialty Services, including 63 specialty consultations and procedures, six on-site specialty services, and 11 nursing encounters. We identified 15 deficiencies in this category, three of which were significant.44 Access to Specialty Services Compliance testing showed patients always received timely routine-priority specialty appointments (MIT 14.007, 100%), while patients generally received timely high-priority (MIT 14.001, 80.0%) and medium-priority specialty appointments (MIT 14.004, 80.0%). However, newly transferred patients sometimes did not receive their preapproved specialty services appointments within the required time frame (and MIT 14.010, 58.8%). 44 Deficiencies occurred in cases 1, 10, 11, 14, 18, 22, 23, and 51. Significant deficiencies occurred in cases 11 and 23. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 73 OIG clinicians identified one significant deficiency related to specialty appointments, which is further discussed in the Access to Care indicator.45 Provider Performance In general, providers appropriately referred patients to specialists, followed specialists’ recommendations, and endorsed specialty reports timely. Compliance testing showed follow-up appointments with providers after specialty consultations often occurred within required time frames (MIT 1.008, 75.0%). OIG clinicians identified one deficiency with a provider not following a specialist’s recommendation as follows: • In case 14, the provider endorsed the eye specialist’s report to continue with artificial tears for the patient with a pinguecula.46 However, the provider did not order the artificial tears or document a rationale for not following the recommendation. Nursing Performance The specialty nurses reviewed specialty services requests and appropriately scheduled patients for specialty appointments. Nurses properly assessed patients after returning from specialty appointments, reviewed specialists’ recommendations, and communicated those recommendations to providers. OIG clinicians reviewed 11 nursing encounters related to specialty services and identified two deficiencies, none of which were significant.47 The following is an example: • In case 11, the specialist evaluated the patient with active sarcoidosis.48 The specialty nurse reviewed recommendations to start a steroid medication and an antibiotic medication. However, the nurse did not notify the provider on the same day, thereby delaying the recommended treatment. Health Information Management Compliance testing showed CAL needed improvement in their receipt and review of high-priority (MIT 14.002, 60.0%), medium-priority (MIT 14.005, 66.7%), and routine- priority specialty reports (MIT 14.008, 64.3%) within required time frames. CAL staff sometimes scanned specialty reports into the EHRS within the required time frame (MIT 4.002, 63.3%). OIG clinicians identified six deficiencies related to delays in retrieving and scanning reports, two of which were significant. One deficiency related to mislabeling a report, and four deficiencies related to staff not forwarding reports to providers for review.49 The following is an example: • In case 11, staff scanned a specialty consultation report into the EHRS 10 calendar days after the date of the patient’s specialist encounter, which was five days late. 45 This deficiency occurred in case 23. 46 A pinguecula is a benign, abnormal tissue growth on the surface of the eye. 47 These deficiencies occurred in cases 4, 12, 20, 50, and 51. A significant deficiency occurred in case 12. 48 Sarcoidosis is an inflammatory condition affecting the lungs, skin, lymph nodes, and other parts of the body. 49 These deficiencies occurred in cases 1, 10, 11, 18, and 51. Two significant deficiencies occurred in case 11. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 74 We discuss specialty deficiencies related to HIM further in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians discussed specialty referral management with medical and nursing leadership, providers, specialty nurses, the utilization management nurse, and nursing staff. Nursing leadership and staff reported nurses reviewed requests for specialty services, contacted specialists for available appointments, and scheduled the appointments. Schedulers at CCHCS headquarters arrange telemedicine specialist appointments. Nursing leadership provided the local operating procedure (CAL LOP 3.1.11, Outpatient Specialty Services), showing the workflow. Leadership reported, after a scheduled specialist appointment, the designated nurse (i.e., the on-site specialty nurse or telemedicine specialty nurse) notifies the primary care provider or on-call provider via a phone call and sends a message to the EHRS pool of any immediate medication or follow- up requirement. The designated nurse then forwards specialty reports to HIM staff to scan into the EHRS. CAL leadership reported identifying delays in forwarding the reports to the provider and implemented strategies to forward the specialist’s recommendations directly to providers for endorsement. CAL offered on-site specialty services, including optometry, general surgery, orthopedic surgery, physical therapy, orthotics, and a hearing aid specialist. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 75 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 12 3 0 80.0% Service? (14.001) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 9 6 0 60.0% frame? (14.002) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 8 4 3 66.7% (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 12 3 0 80.0% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 10 5 0 66.7% frame? (14.005) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 7 3 5 70.0% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for 15 0 0 100% Service? (14.007) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 9 5 1 64.3% frame? (14.008) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 9 1 5 90.0% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 10 7 0 58.8% 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 5 1 0 83.3% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 5 1 0 83.3% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 75.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 76 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 18 6 21 75.0% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 19 11 15 63.3% within five calendar days of the encounter date? (4.002) * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 77 Recommendations • Health care leadership should identify challenge(s) in ensuring staff receive and scan, and providers endorse, specialty reports in a timely manner and should implement remedial measures as appropriate. • Health care leadership should identify the root cause(s) related to untimely providing preapproved specialty appointments for newly arrived patients as well as follow-up specialty service appointments and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 78 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 (73.0%) CAL’s performance was mixed in this indicator. While CAL scored well in some applicable tests, it needed improvement in several areas. CAL did not provide any evidence the Emergency Medical Response Review Committee (EMRRC) completed the required checklists or reviewed the cases within required time frames. In addition, staff conducted medical emergency response drills with incomplete documentation for the most recent quarter. Lastly, physician managers did not complete probationary and annual performance appraisals in a timely manner. These findings are set forth in the table on the next page. Based on the overall Administrative Operations compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Nonscored Results The OIG did not identify any applicable adverse sentinel events requiring root cause analysis at CAL during our inspection period (MIT 15.001). We obtained CCHCS Mortality Case Review reporting data. In our inspection, for seven patients, we found no evidence in the submitted documentation the preliminary mortality reports had been completed. These reports were overdue at the time of our inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 79 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 0 12 0 0 packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local operating N/A N/A N/A N/A procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 6 1 0 85.7% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 9 1 0 90.0% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 0 6 0 0 timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 9 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 2 0 1 100% (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100% valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement Agency (DEA) registration certificates, and did the pharmacy maintain valid 1 0 0 100% Automated Drug Delivery System (ADDS) licenses? (15.109) Did nurse managers ensure their newly hired nurses received the required 1 0 0 100% onboarding and clinical competency training? (15.110) Did the CCHCS Death Review Committee process death review reports This is a nonscored test. Please refer to the timely? Effective 05/2022: Did the Headquarters Mortality Case Review discussion in this indicator. process mortality review reports timely? (15.998) What was the institution’s health care staffing at the time of the OIG medical This is a nonscored test. Please refer to Table 3 inspection? (15.999) for CCHCS-provided staffing information. Overall percentage (MIT 15): 73.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 80 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 81 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review California Correctional Health Care Services’ (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 California Department of Corrections and Rehabilitation, 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 CAL Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 82 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 83 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 84 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 85 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 86 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 87 Appendix B: Case Review Data Table B–1. CAL Case Review Sample Sets Sample Set Total CTC/OHU 3 Death Review/Sentinel Events 2 Diabetes 4 Emergency Services – CPR 5 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 18 Specialty Services 4 52 Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 88 Table B–2. CAL Case Review Chronic Care Diagnoses Sample Set Total Anemia 1 Arthritis/Degenerative Joint Disease 6 Asthma 4 Cancer 1 Cardiovascular Disease 2 Chronic Kidney Disease 2 Chronic Pain 14 Cirrhosis/End-Stage Liver Disease 6 COPD 1 Diabetes 7 Gastroesophageal Reflux Disease 6 Hepatitis C 17 HIV 1 Hyperlipidemia 7 Hypertension 12 Mental Health 7 Seizure Disorder 1 Sleep Apnea 1 Substance Abuse 29 125 Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 89 Table B–3. CAL Case Review Events by Program Diagnosis Total Diagnostic Services 90 Emergency Care 56 Hospitalization 20 Intrasystem Transfers In 10 Intrasystem Transfers Out 6 Outpatient Care 322 Specialized Medical Housing 50 Specialty Services 82 636 Table B–4. CAL Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 3 RN Reviews Detailed 11 RN Reviews Focused 32 Total Reviews 66 Total Unique Cases 52 Overlapping Reviews (MD & RN) 14 Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 90 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 91 Appendix C: Compliance Sampling Methodology Calipatria State Prison 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 14 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 92 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 14 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 14 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 93 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 14 OIG Q: 4.005 • See Health Information Management Community Hospital (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 10 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med Areas by test on-site review line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical Preparation and by test on-site review areas that prepare and administer Administration Areas medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 1 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 94 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 25 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to Annual Screening inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to Vaccinations inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to Screening inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to institution inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to institution inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2 – 8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 95 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 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care / addiction medication, narcotic treatment program, and transgender services • Randomize MITs 14.004 – 006 Medium-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 96 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 17 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 6 InterQual • Review date (3 – 9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events events report (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB N/A at this LGB meeting • Quarterly meeting minutes institution minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 97 Quality Sample Category No. of Data Source Filters Indicator Samples 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 6 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 9 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: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 98 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Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7, Calipatria State Prison | 99 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: December 2023 – May 2024 Report Issued: September 2025 Cycle 7 Medical Inspection Report for Calipatria State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA September 2025 OIG