Centinela State Prison Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, Centinela 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 5 Institution-Specific Metrics 6 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 19 Emergency Services 24 Health Information Management 27 Health Care Environment 33 Transfers 39 Medication Management 45 Preventive Services 52 Nursing Performance 55 Provider Performance 59 Specialized Medical Housing 63 Specialty Services 68 Administrative Operations 74 Appendix A: Methodology 78 Case Reviews 78 Compliance Testing 82 Indicator Ratings and the Overall Medical Quality Rating 83 Appendix B: Case Review Data 84 Appendix C: Compliance Sampling Methodology 87 California Correctional Health Care Services’ Response 94 Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | iv Illustrations Tables 1. CEN Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. CEN Master Registry Data as of February 2024 7 3. CEN Health Care Staffing Resources as of February 2024 8 4. CEN Results Compared With State HEDIS Scores 10 5. Access to Care 16 6. Other Tests Related to Access to Care 17 7. Diagnostic Services 22 8. Health Information Management 30 9. Other Tests Related to Health Information Management 31 10. Health Care Environment 37 11. Transfers 42 12. Other Tests Related to Transfers 43 13. Medication Management 49 14. Other Tests Related to Medication Management 50 15. Preventive Services 53 16. Specialized Medical Housing 66 17. Specialty Services 71 18. Other Tests Related to Specialty Services 72 19. Administrative Operations 75 A–1. Case Review Definitions 79 B–1. CEN Case Review Sample Sets 84 B–2. CEN Case Review Chronic Care Diagnoses 85 B–3. CEN Case Review Events by Program 86 B–4. CEN Case Review Sample Summary 86 Figures A–1. Inspection Indicator Review Distribution for CEN 78 A–2. Case Review Testing 81 A–3. Compliance Sampling Methodology 82 Photographs 1. Patient Waiting Area 33 2. Expired Medical Supply Dated August 9, 2023 34 3. Expired Medical Aupply Dated September 1, 2022 34 4. Expired medical supplies Dated November 30, 2018 35 5. Medical Supplies Stored Directly on the Floor 35 Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 that the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 Centinela 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 July 2023 to December 2023.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between December 2022 and June 2023, and emergency cardiopulmonary resuscitation reviews between June 2023 and August 2023. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of Centinela State Prison (CEN) in June 2024. OIG inspectors monitored the institution’s delivery of medical care that occurred between July 2023 and December 2023. 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 CEN Adequate. quality at CEN Inadequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 51 cases, which contained 967 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in June 2024 to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 19 adequate and one 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 362 patient records and 1,065 data points, and used the data to answer 94 policy questions. In addition, we observed CEN’s processes during an on- site inspection in March 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 Multiple OIG physicians and nurses 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. As noted above, we listed the individual indicators and ratings applicable for this institution in the CEN Summary Table. 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to CEN. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CEN Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 CEN 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 CEN. Of these 10 indicators, OIG clinicians rated two proficient and eight adequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 19 were adequate and one was inadequate. In the 967 events reviewed, we identified 221 deficiencies, 25 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CEN: • Staff provided excellent access to nursing, provider, and specialty appointments. • CEN’s transfer process was proficient. Nurses performed good assessments and appropriately referred patients to the providers. In addition, staff scanned hospital paperwork within the required time frames, and providers reviewed the documents timely. Furthermore, patients received their medications timely, and all patient follow-up appointments occurred within the required time frame. CEN employed a best practice of using a quick reference guide to screen new arrivals prior to patients transferring into the institution. Our clinicians found the following weaknesses at CEN: • Providers did not consistently communicate results to patients with complete test result notification letters. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CEN. Of these 10 indicators, our compliance inspectors rated four adequate and six inadequate. We tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 6 CEN showed a high rate of policy compliance in the following areas: • The institution completed high-priority, medium-priority, and routine-priority specialty services within the required time frames. • Staff performed excellently in offering immunizations and providing preventive services for their patients, such as influenza vaccination, annual testing for tuberculosis (TB), and colorectal cancer screenings. • Nurses reviewed health care services request forms and conducted face-to-face encounters within the required time frames. • Staff performed well in scanning, labeling, and entering community hospital discharge reports, specialty services reports, and health care service requests into patients’ electronic medical records within the required time frames. CEN showed a low rate of policy compliance in the following areas: • CEN’s medical clinics and warehouse had multiple expired supplies. • Nursing staff did not regularly inspect emergency medical response bags (EMRBs) and treatment carts. • Providers often did not timely communicate results of diagnostic tests with complete letters. Most patient letters communicating these test results were missing the date of the diagnostic service, the date of the results, or whether the results were within normal limits. • Staff frequently did not maintain medication continuity for chronic care patients, patients discharged from the hospital, and patients admitted to the specialized medical housing unit. We also found poor medication continuity for patients who transferred into the institution. • Health care staff did not consistently follow universal hand hygiene precautions during patient encounters. Institution-Specific Metrics Centinela State Prison (CEN), located in the city of Imperial, in Imperial County, opened in 1993 as a complex of four separate facilities: A, B, C, and D. CEN primarily provides housing for general population, Level I and Level III sensitive needs, and Level IV maximum security incarcerated persons. The institution runs multiple medical clinics, where staff members manage nonurgent requests for medical services. CEN also treats patients requiring urgent or emergent care in its triage and treatment area (TTA) and admits patients needing a higher level of care to its correctional treatment center (CTC). CEN is designated as a basic care institution, located in a rural area, away from tertiary care centers and specialty care providers whose services would be required frequently by higher-risk patients. Basic care institutions can provide limited specialty medical services and consultation for a generally healthy patient population. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 7 As of October 17, 2024, the department reports on its public tracker that 71 percent of CEN’s incarcerated population is fully vaccinated for COVID-19 while 76 percent of CEN’s staff is fully vaccinated for COVID-19.7 In February 2024, the Health Care Services Master Registry showed that CEN had a total population of 2,949. A breakdown of the medical risk level of the CEN population as determined by the department is set forth in Table 2 below.8 Table 2. CEN Master Registry Data as of February 2024 Medical Risk Level Number of Patients Percentage* High 1 25 0.8% High 2 51 1.7% Medium 548 18.6% Low 2,325 78.8% Total 2,949 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 2-20-24. 7 For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, CEN had one vacant executive leadership position, two primary care provider vacancies, 1.2 nursing supervisor vacancies, and 2.7 nursing staff vacancies. Table 3. CEN Health Care Staffing Resources as of February 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 6.0 5.0 11.7 76.9 99.6 Filled by Civil Service 5.0 3.0 10.5 73.6 92.1 Vacant 1.0 2.0 1.2 2.7 6.9 Percentage Filled by Civil Service 83.3% 60.0% 89.7% 95.7% 92.5% Filled by Telemedicine 0 2.0 0 0 2.0 Percentage Filled by Telemedicine 0 40.0% 0 0 2.0% Filled by Registry 0 0 0 11.0 11.0 Percentage Filled by Registry 0 0 0 14.3% 11.0% Total Filled Positions 5.0 5.0 10.5 84.6 105.1 Total Percentage Filled 83.3% 100.0% 89.7% 110.0% 105.5% Appointments in Last 12 Months 2.0 1.0 1.0 9.0 13.0 Redirected Staff 0 0 0 1.0 1.0 Staff on Extended Leave ‡ 0 0 1.0 2.8 3.8 Adjusted Total: Filled Positions 5.0 5.0 9.5 80.8 100.3 Adjusted Total: Percentage Filled 83.3% 100.0% 81.2% 105.1% 100.7% * 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 on February 20, 2024, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered CEN’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)— CEN’s percentage of patients with poor HbA1c control was significantly lower at 5 percent, 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. CEN had a 54 percent influenza immunization rate for adults 18 to 64 years old. Data were not available for either the influenza immunization rate for adults 65 years of age and older or the pneumococcal vaccination rate.9 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)— CEN’s colorectal cancer screening rate of 85 percent was significantly higher, indicating very good performance on this measure. 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV15, and PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than where the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 10 Table 4. CEN Results Compared With State HEDIS Scores CEN California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 97% – – – Poor HbA1c Control (> 9.0%) ‡,§ 5% 36% 31% 22% HbA1c Control (< 8.0%) ‡ 85% – – – Blood Pressure Control (< 140/90) ‡ 87% – – – Eye Examinations 73% – – – Influenza – Adults (18 – 64) 54% – – – Influenza – Adults (65 +) N/A – – – Pneumococcal – Adults (65 +) N/A – – – Colorectal Cancer Screening 85% 37% 68% 70% Notes and Sources * Unless otherwise stated, data were collected in March 2024 by reviewing medical records from a sample of CEN’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2022 – June 30, 2023 (published March 2024); https://www.dhcs.ca.gov/dataandstats/reports/Documents/Medi-Cal-Managed- Care-Technical-Report-Volume-1.pdf. ‡ For this indicator, the entire applicable CEN 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 11 Recommendations As a result of our assessment of CEN’s performance, we offer the following recommendations to the department: Diagnostic Services • The department should develop and implement strategies, such as an electronic solution, to ensure providers create patient letters when they endorse test results and ensure patient letters contain all elements required by CCHCS policy. • CEN leadership should ascertain causative factors related to the untimely collection of STAT laboratory specimens and should implement remedial measures as appropriate. Health Care Environment • Medical and nursing leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Nursing leadership should determine the root causes for staff either not ensuring the EMRBs are regularly inventoried and sealed, or not properly completing monthly logs, and should implement all necessary remedial measures. • Executive leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. Transfers • Nursing leadership should identify the root cause(s) for Receiving and Release (R&R) nurses not completing the initial health care screening, including answering all questions and documenting an explanation for each “yes” answer; not documenting a complete set of vital signs as part of the patient’s initial health care screening assessment; and not completing the initial health care screening form prior to the patient being placed in housing. Nursing leadership should implement remedial measures as appropriate. Medication Management • The institution should develop and implement measures to ensure staff timely make available and administer medications to patients, and staff document administering medications in the electronic health record system (EHRS), as described in CCHCS policy and procedures. • Nursing leadership should develop and implement measures to ensure nursing staff properly document patient refusals in the medication administration record, as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 12 • Medical and nursing leadership should determine the challenges to ensuring layover patients as well as patients with chronic care, newly ordered, or hospital discharge medications receive those medications timely, without interruption. Leadership should implement remedial measures as appropriate. Specialized Medical Housing • Nursing leadership should implement measures to ensure nursing staff completes initial assessments within the time frame required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 Adequate (77.1%) Compared with Cycle 6, CEN improved and delivered excellent access to care. The OIG clinicians found excellent access to providers, nurses, and specialty services. Generally, follow-up appointments after specialty services, hospitalizations, and transfers occurred timely. Both provider and nursing rounding occurred timely for patients in the correctional treatment center (CTC). As a result, the OIG rated the case review component of this indicator proficient. Compliance testing showed CEN performed satisfactorily in access to care. Staff performed excellently in reviewing patient sick call requests, completing face-to-face encounters, and ensuring provider follow-up appointments for patients returning from hospitalizations and transferring into the institution. However, compliance testing resulted in low scores for timely completing provider follow-up appointments for patients with chronic care conditions, provider appointments from nurse referrals, and sick call follow-up appointments. CEN also needed improvement in maintaining adequate supplies of health care request forms. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 242 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events requiring the institution to generate appointments. We identified three deficiencies related to Access to Care, none of which were significant.10 Access to Care Providers Access to clinic providers is an integral part of patient care in health care delivery. Compliance testing showed chronic care face-to-face follow-up appointments (MIT 1.001, 52.0%) and nurse-to-provider follow-up appointments (MIT 1.005, 57.1%) only timely occurred intermittently, whereas sick call follow-up appointments timely occurred even more sporadically (MIT 1.006, 40.0%). OIG clinicians found two deficiencies when nursing staff failed to order follow-up appointments with clinic providers. 10 Deficiencies occurred in cases 10 and 14. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 14 • In case 14, the RN assessed the patient for stomach pain and documented to follow- up with the provider in 14 days in the progress note. However, the nurse did not order a follow-up appointment with the provider. • In case 14, the RN assessed the patient for foot pain and ringing in his left ear, and documented to follow-up with the provider in the progress note. However, the nurse did not order a follow-up appointment with the provider. Access to Specialized Medical Housing Providers CEN provided excellent access to specialized medical housing providers. Compliance testing showed CTC providers always completed patient history and physical examinations timely (MIT 13.002, 100%). OIG clinicians similarly did not identify any deficiencies related to CTC provider access. Access to Clinic Nurses CEN provided excellent access to clinic nurses. Compliance testing showed the RNs always reviewed patient requests for services within the required time frame (MIT 1.003, 100%) and almost always assessed patients within one business day after reviewing sick call submissions (MIT 1.004, 96.7%). OIG clinicians reviewed 70 nursing sick call requests and identified no deficiencies related to clinic nurse access. Access to Specialty Services CEN performed well in referrals to specialty services. Compliance testing showed a satisfactory completion rate of high-priority specialty services (MIT 14.001, 80.0%) and excellent completion rates of medium-priority (MIT 14.004, 93.3%) and routine-priority specialty services (MIT 14.007, 100%). CEN also performed well to excellently for timely follow ups for high-priority (MIT 14.003, 91.7%), medium-priority (MIT 14.006, 90.0%), and routine-priority (MIT 14.009, 100%) specialty services. OIG clinicians similarly found most specialty appointments took place within requested time frames. We identified one deficiency, which was not significant: • In case 10, the endocrinology specialist evaluated the patient for follow-up care for type 1 diabetes. However, CEN staff scheduled the three-month follow-up appointment 20 days late. Follow-Up After Specialty Services CEN generally provided timely provider appointments after specialty services. Compliance testing showed provider appointments after specialty services typically occurred within the required time frame (MIT 1.008, 81.5%). OIG clinicians identified no deficiencies related to provider appointments after specialty services. Follow-Up After Hospitalization CEN always ensured providers evaluated patients after hospitalizations. Compliance testing showed excellent provision of provider follow-up appointments following hospitalizations (MIT 1.007, 100%). OIG clinicians also identified no deficiencies related to provider follow- up appointments after hospitalizations. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 15 Follow-Up After Urgent or Emergent Care (TTA) The providers evaluated their patients following a triage and treatment area (TTA) event as medically indicated. OIG clinicians reviewed 15 TTA events and identified no delays in provider follow-up. Follow-Up After Transferring Into CEN Access to care for patients who recently transferred into the institution was similar between compliance and case review. Compliance testing showed excellent access to intake appointments for newly arrived patients (MIT 1.002, 100%). OIG clinicians reviewed three transfer-in cases and also did not find any deficiencies. Clinician On-site Inspection CEN has five main clinics, facilities A, B, C, D, and E. In addition to these clinics, staff operate TTA, CTC, restricted housing unit (RHU), and specialty clinics in the central health building. The office technicians schedule about 12 provider outpatient clinic appointments per day and reported no backlogs. The medical leadership reported having three on-site providers, five telemedicine providers from headquarters, and one chief physician and surgeon (CP&S) via telemedicine. One of the telemedicine providers worked on the weekends to assist with any backlogs. The OIG clinicians attended morning huddles, which were well attended by the health care team and ancillary staff. Compliance On-Site Inspection Four of six housing units randomly tested at the time of inspection had access to Health Care Services Request Forms (CDCR Form 7362) (MIT 1.101, 66.7%). In two housing units, custody officers did not have a system in place for restocking the forms. The custody officers reported reliance on medical staff to replenish the forms in the housing units. In addition, one of the housing units lacked access to a functional lockbox for the patients to submit the forms. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 13 12 0 52.0% within the ordered time frame, whichever is shorter? (1.001) For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 25 0 0 100% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 30 0 0 100% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 29 1 0 96.7% 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 8 6 16 57.1% 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 3 25 40.0% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 13 0 0 100% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 22 5 18 81.5% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 4 2 0 66.7% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 77.1% * 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 10 0 0 100% required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 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 11 1 3 91.7% provider? (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician Request 14 1 0 93.3% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 9 1 5 90.0% (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 11 0 4 100% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 18 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 (65.0%) As in Cycle 6, case review found CEN delivered good performance in diagnostic services. Staff generally completed laboratory testing within required time frames. Staff also retrieved these test results, and providers endorsed the results timely. However, case review found providers needed improvement in generating or sending complete patient notification test results letters containing all required elements. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. CEN’s compliance testing showed mixed results in this indicator. CEN performed excellently in completing radiology services and endorsing laboratory test results. The institution showed satisfactory performance in completing laboratory results and very good performance in endorsing pathology results. However, CEN scored low for timely completing STAT laboratory tests, endorsing radiology results, retrieving pathology results, and generating patient test results letters with all required key elements. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 209 diagnostic related events and identified 88 deficiencies, one of which was significant.11 Test Completions CEN performed excellently in completing radiology services within required time frames (MIT 2.001, 100%) and satisfactorily in completing laboratory tests (MIT 2.004, 80.0%), but very poor in completing STAT laboratory tests (MIT 2.007, zero) within the required time frame. OIG clinicians found six deficiencies, one of which was significant.12 The following is an example: 11 Deficiencies occurred in cases 2, 3, 10-24, 50, and 51. A significant deficiency occurred in case 3. 12 Deficiencies occurred in cases 3, 12, 15 and 24. A significant deficiency occurred in case 3. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 20 • In case 3, the provider ordered a “time study” laboratory test. However, staff performed the test two days late.13 OIG clinicians reviewed 13 STAT laboratory tests and four STAT on-site x-ray imaging studies. We found three minor deficiencies related to late test completion and one minor deficiency related to late provider notification.14 The following is an example: • In case 3, the provider ordered a STAT laboratory test. However, the results were not available until over seven hours later. OIG clinicians identified a higher number of STAT laboratory tests at CEN, as compared to other institutions. The majority of these laboratory tests related to elevated potassium levels. We discuss this further in the Clinician On-Site Inspection section below. Health Information Management CEN staff retrieved laboratory and diagnostic results promptly and sent them to providers for review. Compliance testing showed providers needed improvement in endorsing radiology reports within specified time frames (MIT 2.002, 70.0%), but always endorsed laboratory results timely (MIT 2.005, 100%). For STAT laboratory results, nurses always notified providers of results (MIT 2.008, 100%), and providers always endorsed the results timely (MIT 2.009, 100%). However, providers performed poorly in timely communicating results with complete patient notification letters for radiology test results (MIT 2.003, 50.0%), laboratory test results (MIT 2.006, 20.0%), and pathology study results (MIT 2.012, zero). OIG clinicians also found providers always endorsed test results timely. However, we similarly identified 80 deficiencies related to patient test results notification letters.15 The following is an example: • In case 50, the provider endorsed the laboratory urine toxicology results. However, the provider did not create a patient notification test results letter. We discuss this further in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians met with the acting chief supportive executive, lead laboratory technician, lead radiologic technician, and phlebotomists. We discussed the increased number of STAT laboratory tests with elevated blood potassium values. The laboratory technician explained strategies to minimize falsely elevated potassium values in a laboratory test following Clinical Laboratory Standards Institute (CLSI). The staff were trained to use proper venipuncture techniques in collecting blood samples. The technician also described the workflow of the STAT laboratory test process. The staff reported, during the review period, the number of staffing was reduced from four down to three. The lead radiologic technician 13 A “timed study” order is an order with a specified due date to be collected by that specific date. 14 Clinicians reviewed STAT tests in cases 3, 4, 18, 21, 23, 24, and 50. Deficiencies occurred in cases 3 and 24. 15 Deficiencies occurred in cases 3, 10-24, 50, and 51. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 21 discussed the digital x-ray process and on-site mobile services for MRI, CT, and ultrasound imaging.16 16 A CT is a computed, or computerized, tomography scan while an MRI is a magnetic resonance imaging scan. Both create detailed images of the organs and tissues to detect diseases and abnormalities. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 22 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 7 3 0 70.0% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 5 5 0 50.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 8 2 0 80.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 2 8 0 20.0% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive 0 2 0 0 the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing 2 0 0 100% staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory 2 0 0 100% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 7 3 0 70.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 9 1 0 90.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 10 0 0 pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 65.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 23 Recommendations • The department should develop and implement strategies, such as an electronic solution, to ensure providers create patient letters when they endorse test results and ensure patient letters contain all elements required by CCHCS policy. • CEN leadership should ascertain causative factors related to the untimely collection of STAT laboratory specimens and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 24 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 CEN generally provided sufficient emergency care. The providers delivered good care, and the nurses performed sufficient assessments, interventions, and documentation. The emergency medical response review committee performed clinical reviews and identified most of their staff members’ deficiencies. Overall, we rated this indicator adequate. Case Review Results We reviewed 33 urgent or emergent events and found 20 emergency care deficiencies. Of these 20 deficiencies, four were significant.17 Emergency Medical Response CEN staff responded promptly to emergencies throughout the institution. They initiated CPR, activated emergency medical services (EMS), and notified TTA staff timely. Provider Performance Providers generally provided good care. Most providers made appropriate decisions and transferred patients to a community hospital when necessary. On-call providers were available for consultation with the nursing staff. Providers also documented most encounters except for two cases. The following is an example: • In case 13, the nurses assessed the patient, who was confused and had a very low abnormal blood sugar level. The patient received two supplements (GlucoGel) to improve the severe low blood sugar level. The nurse consulted the provider on call. However, the provider did not document the interaction with the nursing staff. Furthermore, the provider did not document a care plan to manage the low blood sugar level. 17 Deficiencies occurred in cases 1, 3, 6-10, 13, 15, 17-20, and 22. Significant deficiencies occurred in cases 13 and 17. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 25 This will be further discussed in the Provider Performance indicator. Nursing Performance CEN nurses generally performed appropriate nursing assessments and interventions. Nurses recognized opioid overdoses and implemented the nursing overdose protocol. They also communicated critical clinical findings to the providers. However, the following cases showed room for improvement: • In case 7, the patient was found unresponsive. Custody staff initiated cardiopulmonary resuscitation (CPR), and the nurse administered four doses of Narcan (opiate antagonist). However, the nurse did not apply the automated external defibrillator (AED) on the patient. • In case 17, the patient complained of abdominal pain, nausea, vomiting, and chills. The patient’s oxygen saturation level decreased and respirations increased. However, the nurse did not reassess the patient’s vital signs to determine whether the patient’s condition was worsening. Nursing Documentation CEN nursing documentation was sufficient. However, we identified a pattern of deficiencies for nurses not documenting the medications administration times on the medication administration record (MAR). Emergency Medical Response Review Committee OIG clinicians found CEN performed clinical reviews for all patients who transferred to a higher level of care or expired. The nursing and medical leadership self-identified most of their staff members’ deficiencies; however, they did not always identify when staff did not reassess patients’ conditions when warranted. In addition, they did not identify when their staff members did not document the medication administration times on the MAR. Compliance testing showed none of the sample EMRRC checklists were completed timely and thoroughly (MIT 15.003, zero). This is discussed further in the Administrative Operations indicator. Clinician On-Site Inspection OIG clinicians toured the TTA during our on-site inspection. The institution had three medical beds and sufficient space to provide emergency care. The nursing staff reported having an assigned provider during regular business hours; otherwise, providers were assigned on call and were available by telephone. In addition, TTA staffing included two RNs on each shift. The nurses also reported having a good rapport and collaborative working relationship with custody staff, and stated they felt supported by their supervisor. The supervisor reported debriefing with staff members after emergency events and performing monthly mock codes. Additionally, the nurse instructor assisted with quarterly mock drills. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 26 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 (75.6%) Case review found CEN performed satisfactorily in health information management. Staff performed well in retrieving and scanning hospital discharge reports, specialty reports, and diagnostic reports. However, case review found opportunities for improvement in communicating diagnostic test results to patients with notification letters containing all required elements. In reviewing all this information, the OIG rated the case review component of this indicator adequate. Compliance testing showed CEN performed sufficiently in this indicator. Staff performed excellently in scanning patient health care services request forms. In addition, staff frequently retrieved, scanned, and endorsed hospital records within required time frames. However, in testing, staff performed poorly in scanning, labeling, and including medical records into the correct patient files. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 967 events and identified 95 deficiencies related to health information management, two of which were significant.18 Hospital Discharge Reports Staff performed excellently in timely retrieving and scanning hospital discharge documents into patients’ electronic health records (MIT 4.003, 92.3%). Nearly all the hospital discharge reports contained physician discharge summaries, and providers reviewed these reports timely (MIT 4.005, 92.3%). OIG clinicians reviewed 21 off-site emergency department and hospital encounters and did not identify any deficiencies. Specialty Reports For the most part, CEN performed well in retrieving and reviewing specialty reports. Compliance testing showed almost all specialty reports were scanned into the EHRS within 18 Deficiencies occurred in cases 2, 3, 4, 10-24, 50, and 51. The significant deficiencies occurred in cases 21 and 24. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 28 required time frames (MIT 4.002, 93.3%). Staff also performed very well in timely retrieving and reviewing high-priority specialty service consultant reports (MIT 14.002, 93.3%) and satisfactorily in timely retrieving and reviewing medium-priority specialty service consultant reports (MIT 14.005, 80.0%). However, CEN staff needed improvement in timely retrieving and reviewing routine-priority specialty service consultant reports (MIT 14.008, 73.3%). OIG clinicians reviewed 76 specialty reports and identified six deficiencies, two of which were significant:19 • In case 12, the provider reviewed and signed the specialty report six days late. • In case 24, the physical therapist evaluated the patient and submitted the report, which was scanned into EHRS. However, staff did not forward the report to the provider for review and endorsement during the review period. We also discuss specialty reports in the Specialty Services Indicator. Diagnostic Reports CEN performed variably in retrieving and endorsing diagnostic reports timely. Compliance testing showed providers always endorsed laboratory reports within required time frames (MIT 2.005, 100%); however, providers only intermittently endorsed radiology reports within required time frames (MIT 2.002, 70.0%). Staff similarly needed improvement in timely receiving final pathology studies (MIT 2.010, 70.0%). Providers often reviewed and endorsed pathology reports within required time frames (MIT 2.011, 90.0%) but never communicated results of the pathology study to patients with complete test result letters (MIT 2.012, zero). OIG clinicians identified 81 diagnostic report deficiencies, none of which were significant.20 Most deficiencies (80 out of 81) related to not creating, or creating incomplete, patient test result notification letters. The following is an example: • In case 10, the provider endorsed laboratory test results and created a patient notification letter in the EHRS. However, the letter did not include the date of the test or whether the results were within normal limits. Diagnostic STAT Reports Compliance testing showed CEN performed poorly in collecting the STAT laboratory test and retrieving the results within the required time frame (MIT 2.007, zero). However, the providers always acknowledged the STAT test results and nursing staff always notified the providers within the required time frames (MIT 2.008, 100%). OIG clinicians identified two deficiencies related to delays in retrieving the STAT test results, neither of which was significant.21 The following is an example: • In case 3, staff collected a patient’s STAT blood test in the morning. However, the nursing staff received the results one hour and 12 minutes beyond the required time frame. 19 Deficiencies occurred in cases 4, 10, 13, 21, and 24. Significant deficiencies occurred in cases 21 and 24. 20 Deficiencies occurred in cases 3, 10 – 24, 50, and 51. 21 Deficiencies occurred in case 3. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 29 The Diagnostic Services indicator provides more details on CEN’s diagnostic performance, including STAT tests. Urgent and Emergent Records OIG clinicians reviewed 33 emergency care events. Providers recorded their emergency care sufficiently, including off-site telephone encounters. However, OIG clinicians found one significant deficiency in provider documentation: • In case 3, the on-call provider recommended the patient be evaluated in the TTA for a critical laboratory value of high potassium level and be subsequently transferred to the community hospital. However, the provider did not document a progress note in the EHRS. Scanning Performance Generally, CEN staff performed satisfactorily with the scanning process. Compliance testing showed staff always scanned health care service request forms into the EHRS within required time frames (MIT 4.001, 100%). However, CEN performed poorly in properly scanning and labeling medical records into the correct patient files (MIT 4.004, zero). OIG clinicians identified two deficiencies related to delayed and missing medical documents, neither of which was significant.22 The following is an example: • In case 2, the patient refused COVID-19 quarantine rounds. The nursing staff documented the refusal form was scanned into the EHRS; however, OIG clinicians found no evidence of the refusal form in the EHRS during the review period. Clinician On-Site Inspection OIG clinicians discussed health information management processes with the health record technician supervisor and office technicians (OT). The supervisor reported tracking the providers’ reviews of reports to ensure the providers endorsed the reports timely. The supervisor also reported being short staffed at CEN and indicated difficulties in hiring. 22 Deficiencies occurred in case 2. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 28 2 15 93.3% 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? 12 1 0 92.3% (4.003) During the inspection, were medical records properly scanned, labeled, 0 24 0 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 12 1 0 92.3% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 75.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 7 3 0 70.0% 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 2 0 0 100% staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 7 3 0 70.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 9 1 0 90.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 10 0 0 pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 14 1 0 93.3% 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 12 3 0 80.0% frame? (14.005) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 11 4 0 73.3% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 32 Recommendations • The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela 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 (43.2%) Overall, CEN performed poorly with respect to its health care environment. Medical supplies storage areas contained expired, unidentified, or inaccurately labeled medical supplies. We also found disorganized medical supplies. In addition, emergency medical response bags (EMRBs) were either missing staff log verification or lacked evidence of staff performing required inventories. The EMRBs further contained compromised medical supply packaging. Lastly, staff did not regularly sanitize or wash their hands during patient encounters. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Patient Waiting Areas We inspected only indoor waiting areas, as CEN had no outdoor waiting areas. Health care and custody staff reported the 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. Photo 1. Patient waiting area (photographed on 3-6-24). Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 34 Clinic Environment All clinic environments were sufficiently conducive for medical care. They provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the 10 clinics we inspected, six contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 60.0%). In four clinics, we found one or more of the following deficiencies: torn or worn examination room chairs or gurney, a clinician chair in disrepair, and unsecured confidential medical records. Clinic Supplies Staff in three of the 10 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 30.0%). We found one or more of the following deficiencies in the remaining seven clinics: expired medical supplies (see Photo 2 and Photo 3); unorganized, unidentified, or inaccurately labeled medical supplies; and cleaning materials stored with medical supplies. Photo 2. Expired medical supply dated August 9, 2023 (photographed on 3-6-24). Photo 3. Expired medical supply dated September 1, 2022 (photographed on 3-6-24). Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 35 Staff in two of the 10 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 20.0%). In the remaining eight clinics, we found the following deficiencies: nebulization units had not been properly calibrated; Snellen reading charts were not placed on the clinic walls; and staff did not properly log the results of the automated external defibrillator (AED) performance test or glucometer quality control test within the last 30 days. We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only two of the eight applicable EMRBs passed our test (MIT 5.111, 25.0%). We found one or more of the following deficiencies with six EMRBs: staff failed to ensure EMRB compartments were sealed and intact; staff had not inventoried the EMRB when the seal tags were replaced; the EMRB contained compromised medical supplies; and staff did not always log EMRB glucometer daily quality control performance results within the last 30 days. In addition, the treatment cart in the TTA did not meet the minimum inventory level at the time of our inspection. Medical Supply Management None of the medical supply storage areas located outside the medical clinics adequately stored medical supplies (MIT 5.106, zero). We found expired medical supplies (see Photo 4) and medical supplies stored directly on the floor (see Photo 5). Photo 4. Expired medical supplies dated November 30, 2018 (photographed on 3-6-24). Photo 5. Medical supplies stored directly on the floor (photographed on 3-6-24). Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 36 According to the CEO, the institution did not have any concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process. Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected only three of 10 clinics (MIT 5.101, 30.0%). In seven clinics, we found one or both of the following deficiencies: cleaning logs were not maintained and the clinic sink, floor, wall, nebulization unit, or medical supply cabinet were unsanitary. Staff in four of 10 clinics properly sterilized or disinfected medical equipment (MIT 5.102, 40.0%). In six clinics, we found one or more of the following deficiencies: staff did not mention disinfecting the examination table as part of their daily start-up protocol; a clinician utilized the examination table without a disposable paper during patient encounter; and equipment was stored unsterilized and unpackaged. Staff reported they did not have a system in place to sterilize reusable invasive medical equipment. We found operating sinks and hand hygiene supplies in the examination rooms in seven of 10 clinics (MIT 5.103, 70.0%). The patient restrooms in three clinics lacked either antiseptic soap or disposable hand towels. We observed patient encounters in seven applicable clinics. In all seven clinics, clinicians did not wash their hands before or after examining their patients, or during subsequent re- gloving (MIT 5.104, zero). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of our medical inspection, 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 infrastructures were in good working order (MIT 5.999). Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 37 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, 3 7 0 30.0% 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 4 6 0 40.0% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 7 3 0 70.0% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 0 7 3 0 hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 10 0 0 100% borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs of the medical 0 1 0 0 health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for managing and 3 7 0 30.0% 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 6 4 0 60.0% 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 2 6 2 25.0% 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): 43.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 38 Recommendations • Medical and nursing leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Nursing leadership should determine the root causes for staff either not ensuring the EMRBs are regularly inventoried and sealed, or not properly completing monthly logs, and should implement all necessary remedial measures. • Executive leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 39 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated the performance of staff in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Proficient Inadequate (74.5%) Our clinicians found CEN’s transfer process was proficient. Receiving and Release (R&R) nurses performed good assessments and appropriately referred patients to the providers. In addition, staff scanned hospital paperwork within the required time frames, and providers reviewed the documents timely. Furthermore, patients received their medications timely, and all patient follow-up appointments occurred within the required time frame. Overall, the OIG rated the case review component of this indicator proficient. Compliance testing showed CEN had a mixed performance in this indicator. The institution performed very well in completing the assessment and disposition sections of the screening process. Staff ensured transfer packets for departing patients included all required documents and medications. In contrast, the institution scored low in completing initial health screening forms. The institution also needed improvement in medication continuity for newly transferred patients. Based on the overall compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 40 Case Review and Compliance Testing Results We reviewed 47 events in 20 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified three deficiencies, none of which were significant.23 Transfers In Compliance testing revealed nurses did not complete initial health screening forms thoroughly (MIT 6.001, 40.0%). In contrast, the nurses performed well in addressing signs and symptoms when screening for tuberculosis (MIT 6.002, 91.3%). OIG clinicians reviewed six events and did not identify any deficiencies. The nurses screened all patients appropriately and requested provider appointments within the required time frame. Compliance testing showed patients only intermittently received their medications timely (MIT 6.003, 66.7%). However, our clinicians found all patients received their medications timely. In compliance testing, newly arrived patients were always seen by the providers within the required time frame (MIT 1.002, 100%). Our clinicians also found all patients were seen timely. When patients transferred into CEN with preapproved specialty services, compliance testing revealed appointments only occasionally occurred timely (MIT 14.010, 45.5%). Our clinicians did not review any applicable cases. Transfers Out Compliance testing showed transfer packets included all medications and required documents (MIT 6.101, 100%). Our clinicians reviewed seven events and identified one deficiency, which was not significant. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients have typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. Our clinicians reviewed 34 events. We identified two deficiencies, neither of which was significant. The nurses performed good assessments, reviewed hospital recommendations, and notified the providers. In compliance testing, staff scanned nearly all hospital discharge documents within the required time frame (MIT 4.003, 92.3%), and providers reviewed the documents timely (MIT 23 Deficiencies occurred in cases 18, 20, and 31. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 41 4.005, 92.3%). Our clinicians found all documents were scanned within the required time frames, and providers reviewed all documents timely. Compliance testing revealed poor medication continuity for patients returning from an off- site hospitalization (MIT 7.003, 36.4%). In contrast, our clinicians found all these patients received their medications timely. Compliance testing showed CEN performed excellently in ensuring patients had timely follow-up appointments after hospitalizations (MIT 1.007, 100%). Our clinicians also found all follow-up appointments occurred timely. Clinician On-Site Inspection During the on-site inspection, the OIG clinicians toured the R&R area and interviewed the nurse. The nurse was knowledgeable about the transfer process. The nurse reported the R&R staffed one nurse on each shift. The R&R staff informed us they received approximately 25 new arrivals and prepared approximately 18 departures weekly. Our clinicians identified a best practice in which staff reported screening all new arrivals before they arrived at the institution by using a quick reference guide they had created. Information in the guide included, but was not limited to, pending specialty referrals, chronic care appointments, and immunizations. Staff gathered additional information once the patient arrived. This information was then disseminated to the care team and the specialty nurse. The R&R nurse indicated morale was good, the supervisor was supportive, and custody staff worked collaboratively with the nurses. Compliance On-Site Inspection R&R nursing staff ensured all patients transferring out of the institution had the required medications, transfer documents, and assigned durable medical equipment (DME) (MIT 6.101, 100%). Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 42 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 10 15 0 40.0% 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 21 2 2 91.3% 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 4 2 19 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 2 0 0 100% required documents? (6.101) Overall percentage (MIT 6): 74.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 43 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 25 0 0 100% 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 0 0 100% required time frame? (1.007) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 12 1 0 92.3% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 12 1 0 92.3% 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 4 7 2 36.4% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 22 3 0 88.0% medications continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 6 2 0 75.00% administered or delivered without interruption? (7.006) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 5 6 0 45.5% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 44 Recommendations • Nursing leadership should identify the root cause(s) for Receiving and Release (R&R) nurses not completing the initial health care screening, including answering all questions and documenting an explanation for each “yes” answer; not documenting a complete set of vital signs as part of the patient’s initial health care screening assessment; and not completing the initial health care screening form prior to the patient being placed in housing. Nursing leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 45 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. When rating this indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. 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 (55.3%) Overall, case review found CEN performed sufficiently in medication management. Staff provided good medication management when patients transferred into the institution and when patients returned from the hospital or emergency rooms. They provided sufficient medication management in the specialized medical housing and when patients transferred out of the institution. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed CEN needed to improve in this indicator. The institution showed good performance in employing general security and in storing medications in its medication line locations and main pharmacy. In contrast, CEN had low scores in medication continuity for patients with chronic care medications, newly prescribed medications, and hospital discharge medications. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 121 events in 28 cases related to medications and found 18 medication deficiencies, five of which were significant.24 New Medication Prescriptions Compliance testing showed new medications were intermittently not available or were not administered timely (MIT 7.002, 68.0%). Our clinicians identified eight deficiencies, one of which was significant as detailed below: • In case 10, the patient had a fungal infection. The provider ordered an anti- fungal cream. However, the patient did not receive the medication. 24 Deficiencies occurred in cases 3, 10, 13-15, 19, 20, 22, 50, and 51. Significant deficiencies occurred in cases 3, 10, 13, and 50. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 46 Chronic Medication Continuity Compliance testing revealed patients sporadically received their chronic care medications within required time frames (MIT 7.001, 33.3%). Our clinicians identified six deficiencies, three of which were significant. The following are examples: • In case 3, the patient had a history of high potassium levels. For two days, the patient did not receive his medication that lowers the potassium level. This increased the patient’s risk for cardiac complications.25 • In case 13, the patient with a history of high blood pressure did not receive his blood pressure medication for one month. This placed the patient at risk for cardiac complications. Hospital Discharge Medications Compliance testing revealed patients returning from off-site hospitals or emergency rooms only occasionally received their medications within the required time frames (MIT 7.003, 36.4%). In contrast, our clinicians found all patients who returned from an off-site hospital or emergency room received their medications timely. Specialized Medical Housing Medications Compliance testing showed, when patients were admitted to the correctional treatment center (CTC), staff sporadically administered medications timely (MIT 13.003, 33.3%). Our clinicians found five deficiencies, one of which was significant. The following case is an example: • In case 50, the patient was receiving a medication for chronic pain three times a day. The provider decreased the frequency of the medication to twice a day but did not discontinue the original order. Subsequently, the patient received an additional dose of the medication. Transfer Medications Compliance testing revealed patients intermittently received their medications within the required time frame when they transferred into the institution (MIT 6.003, 66.7%). In contrast, when patients transferred out of the institution, all their transfer packets included required medications (MIT 6.101, 100%). Our clinicians found all patients who transferred in and out of the institution received their medication timely and transferred out with a five- day supply of medications. Medication Administration Compliance testing showed all nurses administered TB medications as prescribed (MIT 9.001, 100%); however, they sporadically monitored patients taking TB medications per policy (MIT 9.002, 33.3%). Our clinicians found most nurses administered medications properly. 25 Elevated potassium levels may cause abnormal heart rhythms. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 47 Clinician On-Site Inspection Our clinicians toured the medication areas. We interviewed the medication nurses and found they were knowledgeable about the medication processes. They attended clinic huddles and notified the providers of expiring medications and patient refusals. The nurses reported nursing morale was generally good. They also reported having a good rapport with their supervisor and custody staff. We also met with the pharmacist and nursing leadership to discuss some of our findings. In response, nursing leadership reported additional training will be provided. Compliance Testing Results 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%). CEN appropriately stored and secured nonnarcotic medications in six of 10 clinic and medication line locations (MIT 7.102, 60.0%). In each of the four remaining locations, we observed one of the following deficiencies: treatment cart log was missing daily security check entries; nurses did not maintain unused medication in its original labeled packaging; or the medication area lacked a clearly labeled designated area for refrigerated medications that were to be returned to the pharmacy. Staff kept medications protected from physical, chemical, and temperature contamination in one of the 10 clinic and medication line locations (MIT 7.103, 10.0%). In nine locations, we observed one or more of the following deficiencies: staff did not store internal and external medications separately; the medication refrigerator was unsanitary; medication was not stored to prevent exposure to moisture; and staff did not consistently record room temperatures. Staff successfully stored valid, unexpired medications in nine of the 10 applicable clinic and medication line locations (MIT 7.104, 90.0%). In one location, medication was stored beyond the expiration date. Nurses exercised proper hand hygiene and contamination control protocols in two of six locations (MIT 7.105, 33.3%). The medication nurses in the four remaining locations neglected to wash or sanitize their hands when required. Specifically, in two locations, the medication nurses did not wash or sanitize their hands before each subsequent re-gloving, and in the other two locations, medication nurses did not wash or sanitize their hands before preparing and administering medications or before each subsequent re-gloving. Staff in five of six medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 83.3%). In one location, the medication nurse did not correctly describe the process the nurse followed when reconciling newly received medication and the medication administration record (MAR) against the corresponding physician’s order. Staff in one of six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 16.7%). In five locations, we Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 48 observed one or more of the following deficiencies: medication nurses did not reliably observe patients while they swallowed direct observation therapy medications; or medication nurses did not follow CCHCS care guide when administering Suboxone medication. In addition, medication nurses did not follow downtime procedures as required by CCHCS policy. Nurses were observed manually writing paper MARs by copying patient information and medication orders from the automated drug delivery system (ADDS), instead of printing the downtime MAR.26 Pharmacy Protocols CEN followed general security, organization, and cleanliness management protocols for refrigerated or frozen medications in its pharmacy (MIT 7.108 and 7.110, 100%). The institution did not properly store nonrefrigerated medications in the pharmacy. Our inspectors found medication stored outside of its original labeled packaging (MIT 7.109, zero). The pharmacist-in-charge (PIC) did not thoroughly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the nurse present at the time of the medication-area inspection did not correctly complete a medication-area inspection checklist (CDCR Form 7477) (MIT 7.111, zero). We examined 24 pharmacy related medication error reports. The PIC timely or correctly processed only 11 of these 24 reports (MIT 7.112, 45.8%). The PIC at CEN did not complete nine medication error follow-up reports within the required period. For three reports, the report date was inaccurate. For the remaining report, the PIC did not document the recommended changes to correct the medication error. 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 CEN, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in the restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Seven of eight applicable patients interviewed indicated they had access to their rescue medications. One patient had possession of their rescue inhaler, but the canister was broken. We promptly notified the CEO of this concern, and health care management immediately reissued a replacement rescue inhaler to the patient (MIT 7.999). 26 The OIG’s understanding of the department’s downtime procedure expectations is for staff to perform the medication administration using the printed Medication Pass Downtime MARs from the electronic health record system. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 49 Compliance Score Results Table 13. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames 6 12 7 33.3% or did the institution follow departmental policy for refusals or no‑shows? (7.001) Did health care staff administer, make available, or deliver new order prescription 17 8 0 68.0% medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 4 7 2 36.4% required time frames? (7.003) For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or delivered to N/A N/A N/A N/A the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 22 3 0 88.0% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 6 2 0 75.0% 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 6 4 0 60.0% 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 1 9 0 10.0% the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in the 9 1 0 90.0% 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 5 1 4 83.3% 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 0 1 0 0 medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 0 1 0 0 medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 11 13 0 45.8% (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): 55.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 50 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 4 2 19 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 2 0 0 100% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 12 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 4 8 0 33.3% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 6 1 33.3% within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 51 Recommendations • The institution should develop and implement measures to ensure staff timely make available and administer medications to patients, and staff document administering medications in the electronic health record system (EHRS), as described in CCHCS policy and procedures. • Nursing leadership should develop and implement measures to ensure nursing staff properly document patient refusals in the medication administration record, as described in CCHCS policy and procedures. • Medical and nursing leadership should determine the challenges to ensuring layover patients as well as patients with chronic care, newly ordered, or hospital discharge medications receive those medications timely, without interruption. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 52 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (82.4%) CEN performed satisfactorily in preventive services. Staff performed excellently in administering TB medications, screening patients annually for TB, and offering patients an influenza vaccine for the most recent influenza season. They also frequently offered colorectal cancer screenings for patients from ages 45 through 75. However, staff needed improvement in offering required immunizations to chronic care patients. Moreover, they performed poorly in monitoring patients taking prescribed TB medications. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 53 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 12 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 4 8 0 33.3% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 25 0 0 100% (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the patient 23 2 0 92.0% 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) 9 4 12 69.2% 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): 82.4% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 54 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 55 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 CEN’s overall nursing care was sufficient. Specifically, the nurses provided good nursing care in the following areas: transfer-in, hospitalization, and transfer-out. Nurses provided sufficient nursing care in the following areas: emergency services, outpatient, specialty services, and specialized medical housing. Considering all factors the OIG rated this indicator adequate. Case Review Results We reviewed 250 nursing encounters in 50 cases. Of the nursing encounters we reviewed, 127 occurred in the outpatient setting and 70 were sick call requests. We identified 77 nursing performance deficiencies, nine of which were significant. 27 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. CEN nurses generally performed appropriate assessments and interventions. We identified 36 outpatient nursing deficiencies, five of which were significant.28 The following case showed room for improvement: 27 Deficiencies occurred in cases 1-4, 6-9, 12-20, 24, 31, 35, 42, 43, 46, 48, 50, and 51. Significant deficiencies occurred in cases 2, 4, 12, 13, 15, 17, 18, and 42. 28 Outpatient deficiencies occurred in cases 1, 2, 13-16, 18-20, 24, 35, 42, 43, 46, and 48. Significant deficiencies occurred in cases 2, 13, 15, 18, and 42. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 56 • In case 13, the nurses obtained finger stick blood glucose (FSBG) checks for a patient who was diabetic. Intermittently, the patient’s FSBG was low and sometimes high, but the nurses did not always notify the provider. CEN nurses triaged most sick call requests appropriately and generally provided appropriate nursing assessments and interventions. However, nurses did not always recognize urgent symptoms that warranted same day assessments. The following cases are examples: • In case 18, the patient submitted a health care request form with complaints of difficulty breathing since having surgery. However, the nurse did not assess the patient the same day. • In case 42, the patient documented on the sick call request, “Can I get my nose put back in place? It is broken and hard to breathe from.” However, the nurse did not assess the patient the same day. Outpatient Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. CEN nurses generally documented care appropriately. However, the following cases showed room for improvement: • In case 13, the patient presented to the clinic to have sutures removed from his shoulder and wound care. The nurse did not document the condition of the wound. • In case 20, the patient complained of pain in the feet and toes. The nurse did not document the steadiness of the patient’s gait. • In case 43, the patient complained of wounds on his knuckles. The nurse documented applying first aid to the wounds. However, this nurse did not document the details of the first aid provided. Emergency Services We reviewed 33 urgent or emergent events. The nurses performed sufficient assessments and documentation, and good interventions, which we further detail in the Emergency Services indicator. Hospital Returns We reviewed 21 events that involved returns from off-site hospitals or emergency rooms. The nurses performed good assessments, interventions, and documentation. Please refer to the Transfers indicator for further details. Transfers We reviewed three cases involving the transfer-in process. The nurses performed good screenings, interventions, and documentation. We also reviewed four cases involving the transfer-out processes. The nurses performed good screenings and documentation, and sufficient interventions. Please refer to the Transfers indicator for further details. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 57 Specialized Medical Housing We reviewed 40 nursing encounters. The nurses performed sufficient assessments, interventions, and documentation. For more specific details, please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed 21 events in which patients returned from an off-site specialty appointment. The nurses performed good assessments. They generally reviewed the specialists’ findings and recommendations and communicated those results to the provider. However, the nurses did not always provide the specialist with pertinent information. The Specialty Services indicator provides further details. Medication Management OIG clinicians reviewed 121 events involving medication management and found most nurses administered patients’ medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection Our clinicians toured the outpatient clinics, specialty services, medication areas, TTA, CTC, and R&R. We attended organized huddles. The patient care teams were familiar with their patient population, and the nurses were knowledgeable about the processes in their respective areas. The nurses informed us, when patients submit sick call requests on a Friday, they were seen the same day. This provided the nurses more time to evaluate patients with special needs. Nursing staff generally reported nursing morale was good. They also described having a good rapport with their supervisors and custody staff. However, some nurses did not feel supported by executive leadership. We met with nursing leadership to discuss some of our case review findings. They were organized and prepared for our discussion. The nursing supervisor reported they assessed the quality of nursing care by utilizing an audit tool for face-to-face nursing encounters. The nursing supervisor reviewed 10 patient encounters from each nurse. The reviews included whether the nurses appropriately identified the patients’ complaints as symptomatic versus asymptomatic. The audit also included steps such as reviewing the nurses’ assessments and the use of appropriate nursing protocols. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 58 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 59 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 Similar to Cycle 6, CEN providers delivered acceptable care for patients. Providers generally made appropriate evaluations, diagnosed medical conditions correctly, and managed chronic conditions effectively. They referred patients to specialists as medically indicated and for a higher level of care when needed. However, we found providers needed improvement in managing diabetic patients with low sugar readings. After careful consideration of all factors, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 132 medical provider encounters and identified 18 deficiencies, seven of which were significant.29 In addition, we reviewed the quality of care in 20 comprehensive case reviews. Of these 20 cases, we found 19 cases adequate and one inadequate. Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound medical decisions for their patients. Most of the time, providers diagnosed medical conditions correctly, ordered appropriate tests, and referred their patients to specialists when needed. However, OIG clinicians identified two deficiencies related to poor medical assessment and decision- making, neither of which were significant.30 The following is an example: • In case 2, the patient had an electrocardiogram (EKG) performed, which showed an abnormally slow heart rate.31 The provider reviewed and signed the EKG result; however, the provider did not notify the patient 29 Deficiencies occurred in cases 2, 3, 13, 17, and 25. Significant deficiencies occurred in case 13. 30 Deficiencies occurred in cases 2 and 25. 31 An EKG is an electrocardiogram. This non-invasive test measures and records the electrical impulses from the heart and is used to help diagnose heart problems. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 60 of the results and did not address why the patient had the slow heart rate. Review of Records Providers performed well in reviewing medical records and addressing hospitalists’ recommendations for patients returning from hospitalizations. OIG clinicians did not find any deficiencies related to review of records. Emergency Care Providers generally managed patients in the TTA with urgent or emergent conditions appropriately. In addition, providers were available for consultation with TTA staff. We identified one significant provider performance deficiency related to emergency care. • In case 13, the TTA RN consulted the provider for the patient with acute chest pain. The provider recommended the patient be transferred for higher level of care to a community hospital emergency department for emergent work-up for chest pain. However, the patient refused to go to the hospital. Despite that the patient refused the higher level of care, the provider did not follow the chest pain protocol. The provider should have ordered nitroglycerin or aspirin and had the EKG repeated. Chronic Care In most instances, providers appropriately managed patients’ chronic health conditions, such as hypertension, asthma, hepatitis C infection, and cardiovascular disease. However, we identified seven deficiencies related to the management of diabetes, five of which were significant.32 The following are examples: • In case 13, the provider evaluated the diabetic patient at a chronic care appointment. However, the provider did not review blood sugar reading logs or the medication administration record (MAR) summary, which showed multiple episodes of abnormally low blood sugar levels. The provider failed to address significant hypoglycemic episodes for the patient, who was taking multiple doses of insulin daily. • Also in case 13, the provider endorsed nursing staff progress notes indicating the patient’s abnormally low blood sugar levels. However, the provider did not address these significant low sugar levels and did not closely monitor or manage the patient appropriately. Specialty Services Providers referred patients for specialty consultation when needed. When specialists made recommendations, providers usually followed the recommendations and reviewed specialty reports timely. We identified one deficiency for a provider not thoroughly reviewing the specialty report: 32 Deficiencies occurred in case 13. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 61 • In case 3, the provider reviewed and endorsed the nephrologist’s report.33 However, the provider did not thoroughly review the nephrologist’s report and, thus, did not recognize the report omitted the most recent STAT laboratory results, which included a very high potassium level. We also discuss providers’ specialty performance in the Specialty Services indicator. Outpatient Documentation Quality Documentation is important because it shows the provider’s thought process during clinical decision-making. When contacted by nurses, providers always documented the interactions. OIG clinicians did not identify any deficiencies related to these interactions. Providers also generally documented outpatient encounters on the same day as the encounter. However, we identified three minor deficiencies related to not completing the progress note. The following is an example: • In case 25, the provider ordered a referral for the gastroenterology specialist and ordered extensive laboratory tests. However, the provider did not document the medical reasons for the referral and extensive testing. Patient Notification Letters Providers performed poorly in relaying diagnostic test results to their patients with letters. Providers often did not send complete patient test results notification letters. We discuss these deficiencies further in the Diagnostic Services indicator. Provider Continuity CEN offered good provider continuity. Providers were assigned to specific clinics to care for patients. Clinician On-Site Inspection The OIG clinician met with the medical leadership and clinic providers. The institution’s CP&S reported CEN had three providers on-site and one telemedicine provider at that time, as well as two and a half vacant permanent positions. Regional telemedicine providers offered additional patient care. These telemedicine providers offered extra clinics, including weekend clinics for patients. The CP&S reported the providers evaluated 10 to 14 patients during their daily schedules. The chief medical executive (CME) and CP&S also provided backup coverage for TTA and CTC patients. One provider expressed the main challenge was feeling overburdened and understaffed with on-call coverage because each of the three on- site providers was required to cover up to 10 on-call days each month as well as covering for one another when a provider is on sick time or vacation. However, the providers expressed they are well supported by the medical leadership. 33 A nephrologist is a medical provider who specializes in diagnosing, treating, and managing kidney condition and diseases. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 62 Recommendations • The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 63 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. Our clinicians also interpreted relevant compliance results and incorporated them into this indicator. At the time of our inspection, CEN’s specialized medical housing consisted of a correctional treatment center (CTC). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (58.7%) Case review found CEN provided satisfactory care in the CTC. The providers delivered good care, and CEN’s nursing care and medication management was sufficient. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed CEN needed to improve in this indicator. Providers performed well in completing history and physical examinations within required time frames. However, nursing staff needed to improve in timely completing initial assessments and in ensuring medication continuity for patients newly admitted to the specialized medical housing unit. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 109 CTC events that included 34 provider events and 40 nursing events. Due to the frequency of nursing and provider contacts in the specialized medical housing, we bundle up to two weeks of patient care into a single event. We identified 28 deficiencies, three of which were significant.34 Provider Performance Compliance testing showed providers completed all admission history and physical examinations timely (MIT 13.002, 100%). Our clinicians similarly found providers delivered excellent care. Providers completed rounds at clinically appropriate intervals, performed good assessments, made sound decisions, and addressed the specialists’ recommendations. We did not identify any deficiencies. 34 Deficiencies occurred in cases 3, 4, 50, and 51. Significant deficiencies occurred in cases 4 and 50. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 64 Nursing Performance Compliance testing showed CTC nurses sometimes completed admission assessments within the required time frame (MIT 13.001, 60.0%). Our clinicians found CTC nurses conducted rounds appropriately and generally provided sufficient care. However, we identified a pattern of inappropriate interventions and incomplete documentation. The following are examples: • In case 4, the patient, with a history of cardiovascular disease, complained of nausea and dizziness. The patient’s skin was clammy, and the EKG (electrocardiogram) showed an irregular heart rhythm. The provider ordered nursing staff to send the patient to the hospital. However, the nurse did not call 9-1-1 until 25 minutes later. In addition, the nurse documented completing continuous cardiac monitoring and vital signs every five minutes, but did not document the findings from these tasks. • In case 50, the patient had a peripherally inserted central catheter (PICC).35 The nurses frequently did not measure the external length of the catheter. When the nurses did measure the catheter, their documentation of the length was inconsistent. • In case 51, the certified nursing assistant (CNA) frequently did not report the patient’s abnormal vital signs to the nurses. Medication Administration Compliance testing revealed patients admitted to the CTC sporadically received their medications timely (MIT 13.003, 33.3%). Our clinicians found five medication deficiencies, one of which was significant. Please refer to the Medication Management indicator for further details. Clinician On-Site Inspection Our clinicians toured the CTC, which had 13 medical beds, five of which were negative pressure rooms. However, two rooms were not available due to high temperatures in the summer months. The nurses reported they expected a new air conditioning unit. Once installed, staff would monitor the room temperatures, and the rooms would be available if the temperatures were within acceptable ranges. We attended a well-organized huddle and found staff participation was good. The nurses reported the unit was staffed with a designated provider, RNs, LVNs, and CNAs. The nurse reported morale was good and the unit worked together as a team. The nurses also reported having a good relationship with their supervisor and nursing leadership. 35 A peripherally inserted central catheter provides intravenous access to administer fluids and medication. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 65 We met with nursing leadership to discuss some of our case review findings. The nursing supervisor reported plans to provide additional training. The nursing supervisor also stated they were developing an audit tool to assess the PICC and Foley catheter care.36 Compliance On-site Inspection and Discussion At the time of on-site inspection, the CTC had a non-functional call light communication system (MIT 13.101, zero). However, staff maintained a patient safety check log as specified in the institution’s local operating procedure in an event the call light system is inoperable (MIT 13.102, 100%). 36 A Foley catheter is a device that drains urine from the urinary bladder into a collection bag outside of the body. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 66 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 6 4 0 60.0% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 10 0 0 100% required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 6 1 33.3% within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call 0 1 0 0 system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local 1 0 0 100% operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 58.7% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 67 Recommendations • Nursing leadership should implement measures to ensure nursing staff completes initial assessments within the time frame required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 68 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 (84.9%) Case review found CEN generally provided satisfactory specialty services for patients. Providers made appropriate referrals and followed up after specialty services. TTA nurses appropriately assessed patients who returned from specialty appointments. However, case reviewers identified opportunities for improvement in provider endorsement of specialists’ reports and staff retrieval and scanning of specialty reports within required time frames. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed CEN had mixed results in specialty services. Staff performed satisfactorily to excellently in providing specialty services. They performed similarly in retrieval and endorsement of specialty reports. However, staff needed significant improvement in providing preapproved specialty services for patients newly transferred into CEN. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 125 events related to specialty services, which included 92 specialty consultations and procedures and 21 nursing encounters. We identified 12 deficiencies in this category, three of which were significant.37 Access to Specialty Services Compliance testing showed patients received specialty services typically with high-priority referrals (MIT 14.001, 80.0%), very often with medium-priority referrals (MIT 14.004, 93.3%), and always with routine-priority referrals (MIT 14.007, 100%) within the required time frame. However, newly arrived patients to CEN sporadically received continuity of pre- approved specialty services (MIT 14.010, 45.5%). OIG clinicians identified one deficiency related to a specialty appointment, which was not significant. We discuss this further in the Access to Care indicator. 37 Deficiencies occurred in cases 4, 10, 12, 13, 20, 21, 24, 50, and 51. Significant deficiencies occurred in cases 12, 21, and 24. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 69 Provider Performance In general, providers referred patients appropriately, 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, 81.5%). OIG clinicians identified two minor deficiencies.38 The following is an example: • In case 10, the provider reviewed the specialty report one day late. Nursing Performance The specialty nurses generally reviewed specialty services requests and scheduled patients for specialty appointments appropriately. The nurses properly assessed patients who returned from specialty appointments, reviewed specialists’ recommendations, and communicated them to the providers. OIG clinicians reviewed 21 nursing encounters related to specialty services and identified five deficiencies, one of which was significant.39 The following is an example: • In case 12, the endocrinologist evaluated the diabetic patient and repeatedly requested the patient’s glucose readings from the continuous glucose monitoring (CGM) device. However, the nursing staff failed to download the glucose readings timely and forward the results. Health Information Management Compliance testing showed providers mostly received and reviewed the high-priority specialty reports (MIT 14.002, 93.3%) and the medium-priority specialty reports (MIT 14.005, 80.0%) within required time frames. However, CEN needed to improve with the receipt and review of routine-priority specialty reports (MIT 14.008, 73.3%). CEN staff performed excellently with scanning specialty reports into the EHRS within the required time frame (MIT 4.002, 93.3%). OIG clinicians identified three minor deficiencies related to delays in retrieving and scanning the report and one significant deficiency related to not forwarding the report to the provider for review.40 We discuss this further in Health Information Management indicator. Clinician On-Site Inspection We discussed specialty referral management with medical and nursing leadership, providers, off-site and on-site specialty nurses, a utilization management (UM) nurse, and an office technician (OT). Nursing staff reported reviewing specialty requests, contacting specialists for available appointments, and scheduling the appointments. The OT reported CEN offers on-site specialty services, including hearing aid specialty, orthotics, general surgery, ophthalmology, optometry, on-site and virtual physical therapy, and mobile imaging services 38 Deficiencies occurred in cases 3 and 10. 39 Deficiencies occurred in cases 4, 12, 20, 50, and 51. A significant deficiency occurred in case 12. 40 Deficiency occurred in cases 4, 13, 21, and 24. A significant deficiency occurred in case 24. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 70 (MRI, CT, and ultrasound). The OT also reported CEN offers many on-site telemedicine specialty services. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 71 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 14 1 0 93.3% 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? 11 1 3 91.7% (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 14 1 0 93.3% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 12 3 0 80.0% 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? 9 1 5 90.0% (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 11 4 0 73.3% frame? (14.008) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 11 0 4 100% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 5 6 0 45.5% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Did the institution deny the primary care provider’s request for specialty 7 0 0 100% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 5 2 0 71.4% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 84.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 72 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 22 5 18 81.5% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 28 2 15 93.3% 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 73 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 74 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 (71.2%) CEN’s performance was mixed in this indicator. While CEN scored excellently in some applicable tests, it needed improvement in several areas. The Emergency Medical Response Review Committee (EMRRC) did not complete the required checklists and review the cases within required time frames. The institution’s local governing body did not meet regularly as required by the policy during our review period. In addition, the institution did not conduct live medical emergency response drills. Lastly, physician managers did not complete annual performance or probationary appraisals in a timely manner. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Nonscored Results At CEN, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Mortality Case Review reporting data. In our inspection, for seven patients, we found no evidence in the submitted documentation that the preliminary mortality reports were completed. These reports were overdue at the time of OIG’s inspection. For the remaining patient, the compliance date was beyond our review period; therefore, this sample was not applicable (MIT 15.998). Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 75 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 1 3 0 25.0% 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 8 0 0 100% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 0 4 0 0 timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 13 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): 71.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 76 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 77 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 78 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for CEN Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 79 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 80 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 81 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 82 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 83 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 84 Appendix B: Case Review Data Table B–1. CEN Case Review Sample Sets Sample Set Total CTC/OHU 2 Death Review/Sentinel Events 2 Diabetes 3 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 5 51 Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 85 Table B–2. CEN Case Review Chronic Care Diagnoses Sample Set Total Anemia 3 Anticoagulation 1 Arthritis/Degenerative Joint Disease 5 Asthma 10 Cardiovascular Disease 2 Chronic Kidney Disease 2 Chronic Pain 10 Coccidioidomycosis 3 COPD 2 Diabetes 7 Gastroesophageal Reflux Disease 5 Hepatitis C 19 Hyperlipidemia 12 Hypertension 14 Mental Health 2 Migraine Headaches 3 Seizure Disorder 1 Sleep Apnea 3 Substance abuse 25 Thyroid Disease 1 130 Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 86 Table B–3. CEN Case Review Events by Program Diagnosis Total Diagnostic Services 210 Emergency Care 58 Hospitalization 34 Intrasystem Transfers In 6 Intrasystem Transfers Out 7 Outpatient Care 410 Specialized Medical Housing 109 Specialty Services 133 967 Table B–4. CEN Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 3 RN Reviews Detailed 10 RN Reviews Focused 28 Total Reviews 61 Total Unique Cases 51 Overlapping Reviews (MD & RN) 10 Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 87 Appendix C: Compliance Sampling Methodology Centinela 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 13 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 2 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 88 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 13 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for • Any misfiled or mislabeled document any tested identified during incarcerated OIG compliance review person (24 or more = No) MIT 4.005 Returns From 13 CADDIS off-site • Date (2 – 8 months) Community Hospital admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101 – 105 Clinical Areas 10 OIG inspector • Identify and inspect all on-site clinical MITs 5.107 – 111 on-site review areas Transfers MITs 6.001 – 003 Intrasystem Transfers 25 SOMS • Arrival date (3 – 9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 2 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 89 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 • See Access to Care Medication • At least one condition per patient — any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 13 OIG Q: 4.005 • See Health Information Management Community Hospital (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 8 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med Areas by test on-site review line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical Preparation and by test on-site review areas that prepare and administer Administration Areas medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 24 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 8 On-site active • KOP rescue inhalers & nitroglycerin KOP Medications medication listing medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 90 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 12 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 12 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 91 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 92 Quality No. of Indicator Sample Sample Category s Data Source Filters Specialty Services (continued) MITs 14.007 – Routine-Priority 15 Specialty Services • Approval date (3 – 9 months) 009 Initial and Follow- Appointments • Remove consult to audiology, Up chemotherapy, dietary, Hep C, HIV, RFS 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 11 Specialty Services • Arrived from (other Arrivals Arrivals departmental institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – Denials 7 InterQual • Review date (3 – 9 months) 012 • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events events report (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB 4 LGB meeting • Quarterly meeting minutes minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/close (6 months) d grievance files Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 93 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations (continued) MIT 15.103 Death Reports 8 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 4 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 13 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 8 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: July 2023 – December 2023 Report Issued: May 2025 Cycle 7, Centinela State Prison | 94 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: July 2023 – December 2023 Report Issued: May 2025 Cycle 7 Medical Inspection Report for Centinela State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA May 2025 OIG