OIG
California Medical Facility Medical Inspection Results Cycle 1
CALIFORNIA MEDICAL FACILITY
MEDICAL INSPECTION RESULTS
BUREAU OF AUDITS AND INVESTIGATIONS
OFFICE OF THE
INSPECTOR GENERAL
DAVID R. SHAW
INSPECTOR GENERAL
STATE OF CALIFORNIA
JANUARY 2009
Contents
Executive Summary.................................................................................1
Introduction..............................................................................................3
Background...................................................................................3
About the Institution.....................................................................4
Objectives, Scope, and Methodology..........................................4
Medical Inspection Results.....................................................................7
California Prison Health Care Receivership
Corporation’s Response.............................................................29
Office of the Inspector General’s Comments
On the Receiver’s Response......................................................33
Executive Summary
An April 2001 class action lawsuit filed by inmates represented by the Prison Law Office alleged
that the state provided constitutionally inadequate medical care at California state prisons in
violation of inmates’ constitutional rights. And, in October 2005, the U.S. Northern District
Court of California declared that California’s delivery system for prison medical care was
“broken beyond repair” and still not meeting constitutional standards. As a result, the federal
court imposed a receivership to raise the delivery of medical care to constitutional standards. To
evaluate and monitor the progress of medical care delivery to inmates, the receiver requested,
and the Office of the Inspector General (OIG) agreed, to establish an objective, clinically
appropriate, and metric-oriented medical program to annually inspect the delivery of medical
care at each state prison.
In October 2008, we inspected the California Medical Facility (CMF). Our
Overall
medical inspection encompassed 19 components of medical delivery and
Score
comprised 145 questions. The questions are weighted based on their importance
72.4% to the delivery of medical care to inmates. CMF received 72.4 percent of the
total weighted points possible.
The following summary table lists the 19 components we inspected in order of importance
(highest to lowest), with the institution’s score and the definitions of each inspection component.
The detailed medical inspection results, with the questions for each component, begin on page 7
of this report. While we are committed to helping each institution achieve a higher level of
medical care, it is not our intent to determine the percentage score needed by an institution to
meet constitutional standards—that is a legal matter for the federal court to determine.
Executive Summary Table
Component Weighted Definition
Score
Chronic Care 83.6% Examines how well the prison provided care and medication to inmates with
specific chronic care conditions, which are those that affect (or have the
potential to affect) an inmate’s functioning and long-term prognosis for
more than six months. Our inspection tests the following chronic care
conditions: asthma, Coumadin therapy, diabetes, HIV (Human
Immunodeficiency Virus), and hypertension.
Clinical Services 87.1% Evaluates the inmate’s access to primary health care services and focuses on
inmates who recently received services from any of the prison’s facility or
administrative segregation unit clinics. This component evaluates sick call
processes (doctor or nurse line), medication management, and nursing.
Health Screening 86.8% Focuses on the prison’s process for screening new inmates upon arrival to
the institution for health care conditions that require treatment and
monitoring, as well as ensuring inmates’ continuity of care.
Specialty Services 42.6% Focuses on the prison’s process for approving, denying, and scheduling
services that are outside the specialties of the prison’s medical staff.
Common examples of these services include physical therapy, oncology
services, podiatry consultations, and neurology services.
Urgent Services 79.1% Addresses the care provided by the institution to inmates before and after
they were sent to a community hospital.
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Office of the Inspector General State of California
Component Weighted Definition
Score
Emergency Services 72.1% Examines how well the prison responded to medical emergencies.
Specifically, we focused on “man down” or “woman down” situations.
Further, questions determine the adequacy of medical and staff response to a
“man down” or “woman down” emergency drill.
Prenatal Care/Childbirth/Post- N/A Focuses on the prenatal and post-delivery medical care provided to pregnant
delivery inmates. Not applicable at men’s institutions.
Diagnostic Services 72.2% Addresses the timeliness of radiology (x-ray) and laboratory services and
whether the prison followed up on clinically significant results.
Access to Health Care Information 58.8% Addresses the prison’s effectiveness in filing, storing, and retrieving medical
records and medical-related information.
Outpatient Housing Unit 85.5% Determines whether the prison followed department policies and procedures
when placing inmates in the outpatient housing unit. This component also
evaluates whether the placement provided the inmate with adequate care and
whether the physician’s plan addressed the placement diagnosis.
Internal Reviews 68.8% Focuses on the frequency of meetings held by the prison’s Quality
Management Committee (QMC) and Emergency Response Review
Committee (ERRC) and whether key staff attended the meetings, the
number of medical appeals filed, and the prison’s death review process.
Inmate Transfers 50.0% Focuses on inmates pending transfer to determine whether the sending
institution documented medication and medical conditions to assist the
receiving institution in providing continuity of care.
Clinic Operations 82.8% Addresses the general operational aspects of the prison’s facility clinics.
Generally, the questions in this component relate to the overall cleanliness
of the clinics, privacy afforded to inmates during nonemergency visits, use
of priority ducats (slip of paper the inmate carries for scheduled medical
appointments), and availability of health care request forms.
Preventive Services 43.7% Focuses on inmate cancer screening and influenza immunizations.
Pharmacy Services 75.9% Addresses whether the prison’s pharmacy complies with various operational
policies, such as conducting periodic inventory counts and maintaining the
currency of medications in its night lockers, keeping signature cards on file
for doctors, and having valid permits. In addition, this component also
addresses whether the pharmacy has an effective process for screening
medication orders for potential adverse reactions/interactions.
Other Services 100.0% Examines additional areas that are not captured in the other components.
The areas evaluated in this component include the prison’s provision of
therapeutic diets, its handling of inmates who display poor hygiene, and the
availability of the current version of the department’s Health Services
Policies and Procedures.
Inmate Hunger Strikes 31.6% Examines medical staff’s monitoring of inmates participating in hunger
strikes.
Chemical Agent Contraindications 86.8% Addresses the prison’s process of handling inmates who may be predisposed
to an adverse outcome from calculated uses of force (cell extractions)
involving Oleoresin Capsicum (OC), which is commonly referred to as
“pepper spray.” For example, this might occur if the inmate has asthma.
Staffing Levels and Training 95.0% Examines the prison’s medical staffing levels and training provided.
Nursing Policy 35.7% Determines whether the prison maintains written policies and procedures for
the safe and effective provision of quality nursing care. The questions in this
component also determine whether nursing staff review their duty
statements and whether supervisors periodically review the work of nurses
to ensure they properly follow established nursing protocols.
Overall Score 72.4%
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Office of the Inspector General State of California
Introduction
Under the authority of California Penal Code section 6126, which assigns the Office of the
Inspector General (OIG) responsibility for oversight of the California Department of Corrections
and Rehabilitation, and at the request of the federal receiver, the OIG developed a
comprehensive inspection program to evaluate the delivery of medical care at each of the
California Department of Corrections and Rehabilitation’s 33 adult prisons.
In October 2008, we inspected the California Medical Facility (CMF). Our medical inspection
encompassed 19 components of medical delivery and comprised 145 questions. To help readers
understand the medical risk associated with certain components of medical delivery—which
pose a greater risk to an inmate-patient—we developed a weighting system and assigned points
to each question. Consequently, we assigned more total points to more critical components, such
as chronic care, clinical services, and health screening. We assigned fewer total points to less
critical components, such as inmate hunger strikes, staffing levels and training, and chemical
agent contraindications. (For a detailed description of the weighting system, see Objectives,
Scope, and Methodology on the next page.)
Background
In April 2001, inmates represented by the Prison Law Office filed a class action lawsuit, now
known as Plata v. Schwarzenegger. The lawsuit alleged that the state provided constitutionally
inadequate medical care at California state prisons in violation of inmates’ constitutional rights.
In June 2002, the parties entered into a Stipulation for Injunctive Relief, and the state agreed to
implement over several years comprehensive new medical care policies and procedures at all
institutions.
Nevertheless, the U.S. Northern District Court of California declared in October 2005 that
California’s delivery system for prison medical care was “broken beyond repair” and still not
meeting constitutional standards. Thus, the federal court imposed a receivership to raise the
delivery of medical care to constitutional standards. In essence, the court ordered the receiver to
manage the state’s delivery of medical care and restructure day-to-day operations to develop and
sustain a system that provides constitutionally adequate medical care to inmates. The court stated
that it would remove the receiver and return control to the state once the system is stable and
provides for constitutionally adequate medical care.
To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested
that the OIG establish an objective, clinically appropriate, and metric-oriented medical
inspection program. Toward that end, the Inspector General agreed to inspect annually each state
prison until the state’s delivery of medical care to inmates meets constitutional standards. We are
committed to helping each institution achieve a higher level of medical care, but it is up to the
federal court to determine the percentage score necessary for an institution to meet constitutional
standards.
Bureau of Audits and Investigations Page 3
Office of the Inspector General State of California
About the Institution
CMF was established in 1955 by the Legislature to provide a centrally located medical
psychiatric institution for the health care needs of the male felon population in California's
prisons. CMF houses a general acute care hospital, correctional treatment center (CTC), licensed
elderly care unit, in-patient and out-patient psychiatric facilities, a hospice unit for terminally ill
inmates, housing and treatment for inmates identified with AIDS/HIV, general population, and
other special inmate housing. Along with clinics that handle urgent and non-urgent requests for
medical services, CMF has a state-licensed standby emergency room. Additionally, the
Department of Mental Health operates a licensed, acute care psychiatric hospital within CMF.
As of October 15, 2008, the California Department of Corrections and Rehabilitation reported
that CMF housed 3,086 male inmates.
Joseph Bick, M.D., who serves as the institution’s chief deputy for clinical services, is
responsible for CMF’s entire health care program.
Objectives, Scope, and Methodology
In designing the medical inspection program, we reviewed the California Department of
Corrections and Rehabilitation’s policies and procedures, relevant court orders, guidelines
developed by the department’s Quality Medical Assurance Team, and guidance developed by the
American Correctional Association. We also reviewed professional literature on correctional
medical care, consulted with clinical experts, and met with stakeholders from the court, the
receiver’s office, the department, and the Prison Law Office to discuss the nature and scope of
the inspection program. Based on input from these stakeholders, we developed a medical
inspection program that evaluates medical care delivery. Within each of 20 components, we
created “yes” or “no” questions designed to gauge performance.
To make the inspection results meaningful to both a medical expert and a lay reader, we worked
with clinical experts to create a weighting system that factors the relative importance of each
component compared to other components. Further, the program considers the relative
importance of each question within a component to the other questions in that component. This
weighting ensures that more critical components—such as those that pose the greatest medical
risk to the inmate-patient—are given more weight compared to those considered less serious. For
example, we assign a high number of possible points to the chronic care component because we
consider this the most serious of all the components. Conversely, we assign very few points to
the nursing policy component because we consider this the least serious inspection component.
Each inspection question is weighted and scored. The score is derived from the percentage of
“yes” answers for each question from all items sampled. We then multiply the percentage of
“yes” answers within a given question by the question’s weight to arrive at a score. The
following example shows how this scoring system works.
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Office of the Inspector General State of California
Example Question: Institution X
Answers Weighting Points N/A Unk
Yes No Yes + No Yes % Possible Received
Is the clinical history adequate? 40 10 50 80% 20 16 0 0
If the institution receives 40 “yes” answers and 10 “no” answers, the percentage of “yes”
answers to this question equals 80 percent. We calculate the number of points the institution
would receive by multiplying the “yes” percent of 80 by the number of possible points for this
question, which is 20, to arrive at 16 points.
To arrive at the total score, we add the points received for each question and then for each
program component. Finally, we calculate the institution’s overall score by dividing the sum of
the points received by the sum of the points possible. We do not include in the institution’s
overall score the weight for questions that are not applicable or, in some cases, where a lack of
documentation would result in numerous “no” answers for one deviation from policy (unknown).
For instance, an institution may not be able to provide documentation that its emergency
response review committee met for a particular month. Therefore, when we evaluate whether
meeting minutes document monthly meetings for a particular month, the institution would
receive a “no” answer for that question. However, when we evaluate whether the meeting
minutes document the warden’s attendance at the meeting, the answer would be “unknown” so
that the institution’s score is not penalized twice for the same reason, not documenting the
meeting.
To evaluate the institution’s delivery of medical care, we obtained various electronic data files
maintained by the institution for inmate medical scheduling and tracking, pharmacy, and census
data. We used these electronic data files only to identify random samples of inmates receiving or
requiring specific medical services. We then reviewed the medical file for each inmate in our
sample. We did not rely on the medical care information contained in these data files.
In total, we reviewed 179 inmate medical files, which are referred to as unit health records. In
addition, we reviewed staffing level reports, medical appeals summaries, nursing protocols,
summaries of medical drills and emergencies, minutes from Quality Management Committee
and Emergency Response Review Committee hearings, and assorted manual logs or tracking
worksheets related to medical care delivery. We also conducted a live medical emergency drill
and evaluated the adequacy of the responding staff’s actions. Finally, we interviewed medical
and custody staff members about the delivery of medical care to inmates, and we observed day-
to-day medical delivery at the institution.
We do not test the care provided in the licensed hospitals or correctional treatment centers
because they are subject to inspections and oversight by other regulatory agencies.
Consistent with our agreement with the receiver, our report only addresses the conditions found
related to the medical care criteria. We do not discuss the causes of noncompliance, nor do we
make specific recommendations in this report. However, if we learn of an inmate-patient who
needs immediate care, we notify the chief medical officer and request a status report. Moreover,
if we learn of significant departures from community standards, we may report such departures
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Office of the Inspector General State of California
to the institution’s chief medical officer or quality management committee. Because these
matters involve confidential medical information protected by state and federal privacy laws,
specific details related to these cases are not included in our report.
During our inspection at CMF, the OIG inspectors identified circumstances that resulted in a
referral to the Department of Corrections and Rehabilitation’s Office of Internal Affairs. We
have removed any sample items from this inspection report that could be unreliable as a result of
these circumstances. The details of this event are confidential and are therefore not provided in
this report.
For ease of reference, following is a table of abbreviations used in the remainder of this report.
Abbreviations used in this report
AED Automatic External Defibrillator
BLS Basic Life Support
CDCR California Department of Corrections and Rehabilitation
CMO Chief Medical Officer
CPR Cardio-Pulmonary Resuscitation
CTC Correctional Treatment Center
CTQ Confined to Quarters
ER Emergency Room
ERRC Emergency Response Review Committee
FOBT Fecal Occult Blood Test
FTF Face-to-Face
GACH General Acute Care Hospital
HCM Health Care Manager
HIV Human Immunodeficiency Virus
INH Isoniazid (antituberculous medication)
LVN Licensed Vocational Nurse
MD Medical Doctor
MOD Medical Officer of the Day
OB Obstetrician
OC Oleoresin Capsicum (pepper spray)
OHU Outpatient Housing Unit
OIG Office of the Inspector General
PCP Primary Care Provider
QMC Quality Management Committee
RN Registered Nurse
SOAPE Subjective, Objective, Assessment, Plan, Education
SRN Supervising Registered Nurse
TB Tuberculosis
TTA Triage and Treatment Area
UHR Unit Health Record
UM Utilization Management
Bureau of Audits and Investigations Page 6
Office of the Inspector General State of California
OFFICE OF THE INSPECTOR GENERAL CALIFORNIA MEDICAL FACILITY
Overall Score:
MEDICAL INSPECTION RESULTS
72.4%
10/20/2008 - 10/23/2008
Answers Weighting Points Questions Not Answered
Component Page Yes No Yes + No Yes % Points Possible Points Received Score % Not Applicable Unknown
Chronic Care 8 163 38 201 81.1% 133 111.1 83.6% 6 0
Clinical Services 9 221 29 250 88.4% 95 82.7 87.1% 32 0
Health Screening 11 67 12 79 84.8% 52 45.1 86.8% 87 14
Specialty Services 12 45 58 103 43.7% 71 30.2 42.6% 14 1
Urgent Services 13 98 10 108 90.7% 51 40.4 79.1% 51 1
Emergency Services 14 29 10 39 74.4% 56 40.4 72.1% 10 2
Diagnostic Services 16 47 15 62 75.8% 52 37.5 72.2% 3 0
Access to Health Care Information 17 5 2 7 71.4% 51 30.0 58.8% 0 0
Outpatient Housing Unit 18 66 15 81 81.5% 48 41.1 85.5% 2 1
Internal Reviews 19 24 9 33 72.7% 40 27.5 68.8% 0 1
Inmate Transfers 20 7 6 13 53.8% 38 19.0 50.0% 1 1
Clinic Operations 21 24 4 28 85.7% 33 27.3 82.8% 0 0
Preventive Services 22 19 16 35 54.3% 30 13.1 43.7% 0 0
Pharmacy Services 23 28 3 31 90.3% 29 22.0 75.9% 0 0
Other Services 24 10 0 10 100.0% 11 11.0 100.0% 2 0
Inmate Hunger Strikes 25 1 2 3 33.3% 19 6.0 31.6% 0 0
Chemical Agent Contraindications 26 7 1 8 87.5% 17 14.8 86.8% 0 0
Staffing Levels and Training 27 7 1 8 87.5% 16 15.2 95.0% 1 0
Nursing Policy 28 5 10 15 33.3% 14 5.0 35.7% 0 0
Totals 873 241 1114 78.4% 856 619.4 72.4% 209 21
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Chronic Care Yes No Yes + No Yes % Possible Received Score % N/A Unk
03.076 Was the inmate's most recent chronic care visit within the time frame 20 3 23 87.0% 10 8.7 87.0% 0 0
required by the degree of control of the inmate's condition based on
his or her prior visit?
03.077 Were key elements on Forms 7419 (Chronic Care Follow-Up Visit) 21 2 23 91.3% 10 9.1 91.3% 0 0
and 7392 (Primary Care Flow Sheet) filled out completely for the
inmate's two most recent visits?
03.082 Did the institution document that it provided the inmate with health 17 6 23 73.9% 12 8.9 73.9% 0 0
care education?
03.175 Did the inmate receive his or her prescribed chronic care medications 17 5 22 77.3% 18 13.9 77.3% 1 0
during the most recent three-month period or did the institution
follow departmental policy if the inmate refused to pick up or show
up for his or her medications?
03.235 Is the clinical history adequate? 17 6 23 73.9% 18 13.3 73.9% 0 0
03.236 Is the focused clinical examination adequate? 22 1 23 95.7% 19 18.2 95.7% 0 0
03.237 Is the assessment adequate? 19 2 21 90.5% 19 17.2 90.5% 2 0
03.238 Is the plan adequate and consistent with the degree of control based 19 1 20 95.0% 19 18.1 95.0% 3 0
on the chronic care program intervention and follow up requirements?
03.262 Is the inmate's Problem List complete and filed accurately in the 11 12 23 47.8% 8 3.8 47.8% 0 0
inmate's unit health record (UHR)?
Component Subtotals: 163 38 201 81.1% 133 111.1 83.6% 6 0
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Clinical Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.024 RN FTF Documentation: Did the inmate's request for health care get 24 1 25 96.0% 4 3.8 96.0% 0 0
reviewed the same day it was received?
01.027 If the RN determined a referral to a primary care physician (PCP) 14 3 17 82.4% 8 6.6 82.4% 8 0
was necessary, was the inmate seen within the timelines specified by
the RN during the FTF triage?
01.247 Sick Call Follow-up: If the provider ordered a follow-up sick call 7 2 9 77.8% 7 5.4 77.8% 16 0
appointment, did it take place within the time frame specified?
01.124 Sick Call Medication: Did the institution administer or deliver 20 5 25 80.0% 6 4.8 80.0% 0 0
prescription medications (new orders) to the inmate within specified
time frames?
01.025 RN FTF Documentation: Did the RN complete the face-to-face 21 4 25 84.0% 6 5.0 84.0% 0 0
(FTF) triage within one (1) business day after the Form 7362 was
reviewed?
01.246 Did documentation indicate that the RN reviewed all of the inmate's 23 2 25 92.0% 5 4.6 92.0% 0 0
complaints listed on Form 7362 (Health Care Services Request
Form)?
01.157 RN FTF Documentation: Did the RN's subjective note address the 24 1 25 96.0% 7 6.7 96.0% 0 0
nature and history of the inmates primary complaint?
01.159 RN FTF Documentation: Did the RN's objective note include vital 13 4 17 76.5% 6 4.6 76.5% 0 0
signs and a focused physical examination, and did it adequately
address the problems noted in the subjective note?
01.244 RN FTF Documentation: Did the RN's objective note include 16 1 17 94.1% 3 2.8 94.1% 0 0
allergies, weight, current medication, and where appropriate,
medication compliance?
01.158 RN FTF Documentation: Did the RN's assessment provide 15 2 17 88.2% 6 5.3 88.2% 0 0
conclusions based on subjective and objective data, were the
conclusions formulated as patient problems, and did it contain
applicable nursing diagnoses?
Bureau of Audits and Investigations Page 9
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Clinical Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.162 RN FTF Documentation: Did the RN's plan include an adequate 16 1 17 94.1% 7 6.6 94.1% 0 0
strategy to address the problems identified during the FTF triage?
01.163 RN FTF Documentation: Did the RN's education/instruction 16 1 17 94.1% 5 4.7 94.1% 0 0
adequately address the problems identified during the FTF triage?
15.234 Are clinic response bags audited daily and do they contain essential 2 0 2 100.0% 5 5.0 100.0% 0 0
items?
21.278 Was there adequate prior management of pre-existing medical 10 2 12 83.3% 20 16.7 83.3% 8 0
conditions that contributed to the need for the TTA visit?
Component Subtotals: 221 29 250 88.4% 95 82.7 87.1% 32 0
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Health Screening Yes No Yes + No Yes % Possible Received Score % N/A Unk
02.016 Did the institution complete the initial health screening on the same 19 0 19 100.0% 9 9.0 100.0% 0 1
day the inmate arrived at the institution?
02.020 Did the LVN/RN adequately document the tuberculin test or a review 14 6 20 70.0% 6 4.2 70.0% 0 0
of signs and symptoms if the inmate had a previous positive
tuberculin test?
02.015 Was a review of symptoms completed if the inmate's tuberculin test 0 0 0 0.0% 0 0.0 0.0% 20 0
was positive, and were the results reviewed by the infection control
nurse?
02.128 If the inmate had an existing medication order upon arrival at the 7 1 8 87.5% 8 7.0 87.5% 11 1
institution, did the inmate receive the medications by the next
calendar day, or did a physician explain why the medications were
not to be continued?
02.007 Non-reception center: Does the health care transfer information form 13 1 14 92.9% 7 6.5 92.9% 0 6
indicate that it was reviewed and signed by licensed health care staff
within one calendar day of the inmate's arrival at the institution?
02.014 Non-reception center: If the inmate was scheduled for a specialty 0 0 0 0.0% 0 0.0 0.0% 16 4
appointment at the sending institution, did the receiving institution
schedule the appointment within 30 days of the original appointment
date?
02.111 Non-reception center: Did the inmate receive medical 3 0 3 100.0% 6 6.0 100.0% 16 1
accommodations upon arrival, if applicable?
02.017 If yes was answered to any of the questions on the initial health 5 4 9 55.6% 8 4.4 55.6% 11 0
screening form(s), did the RN provide an assessment and disposition
on the date of arrival?
02.018 If, during the assessment, the RN referred the inmate to a clinician, 6 0 6 100.0% 8 8.0 100.0% 13 1
was the inmate seen within the time frame?
Component Subtotals: 67 12 79 84.8% 52 45.1 86.8% 87 14
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Specialty Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
07.037 Did the institution approve or deny the PCP's request for specialty 10 12 22 45.5% 8 3.6 45.5% 0 0
services within the specified time frames?
07.038 Did the PCP see the inmate between the date the PCP ordered the 5 11 16 31.3% 8 2.5 31.3% 0 1
service and the date the inmate received it, in accordance with
specified time frames?
07.035 Did the inmate receive the specialty service within specified time 6 11 17 35.3% 9 3.2 35.3% 0 0
frames?
07.090 Physical therapy services: Did the physical therapist assess the 2 1 3 66.7% 8 5.3 66.7% 14 0
inmate and document the treatment plan and treatment provided to
the inmate?
07.043 Did the PCP review the consultant's report and see the inmate for a 5 12 17 29.4% 9 2.6 29.4% 0 0
follow-up appointment after the specialty services consultation within
specified time frames?
07.260 Was the institution's denial of the PCP's request for specialty services 3 2 5 60.0% 9 5.4 60.0% 0 0
consistent with the "medical necessity" requirement?
07.259 Was there adequate documentation of the reason for the denial of 4 1 5 80.0% 5 4.0 80.0% 0 0
specialty services?
07.270 Did the specialty provider provide timely findings and 10 7 17 58.8% 6 3.5 58.8% 0 0
recommendations or did an RN document that he or she called the
specialty provider to ascertain the findings and recommendations?
07.261 Is the institution scheduling high-priority (urgent) specialty services 0 1 1 0.0% 9 0.0 0.0% 0 0
within 14 days?
Component Subtotals: 45 58 103 43.7% 71 30.2 42.6% 14 1
Bureau of Audits and Investigations Page 12
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Urgent Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
21.248 Upon the inmate's discharge from the community hospital, did the 18 2 20 90.0% 7 6.3 90.0% 0 0
triage and treatment area (TTA) registered nurse document that he or
she reviewed the inmate's discharge plan and completed a face-to-
face assessment of the inmate?
21.250 Upon the inmate's discharge from the community hospital, did the 8 2 10 80.0% 7 5.6 80.0% 10 0
inmate's Primary Care Provider (PCP) provide orders for appropriate
housing for the inmate?
21.251 Upon the inmate's discharge from the community hospital, did the 0 2 2 0.0% 7 0.0 0.0% 18 0
Registered Nurse intervene if the inmate was housed in an area that
was inappropriate for nursing care based on the primary care
provider's (PCP) housing orders?
21.249 Upon the inmate's discharge from the community hospital, did the 17 3 20 85.0% 7 6.0 85.0% 0 0
inmate receive a follow-up appointment with his or her primary care
provider (PCP) within five calendar days of discharge?
21.281 Upon the inmate's discharge from a community hospital, did the 17 0 17 100.0% 6 6.0 100.0% 3 0
institution administer or deliver all prescribed medications to the
inmate within specified time frames?
21.275 Was the TTA documentation adequate for evaluating the clinical care 19 1 20 95.0% 10 9.5 95.0% 0 0
provided?
21.276 While the patient was in the TTA, was the clinical care rendered by 19 0 19 100.0% 7 7.0 100.0% 0 1
the attending provider adequate and timely?
21.279 For patients managed by telephone consultation alone, was the 0 0 0 0.0% 0 0.0 0.0% 20 0
provider's decision not to come to the TTA appropriate?
Component Subtotals: 98 10 108 90.7% 51 40.4 79.1% 51 1
Bureau of Audits and Investigations Page 13
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Emergency Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
08.183 Was the medical emergency responder notified of the medical 5 0 5 100.0% 5 5.0 100.0% 0 0
emergency without delay?
08.241 Did the first responder provide adequate basic life support (BLS) 2 3 5 40.0% 6 2.4 40.0% 0 0
prior to medical staff arriving?
08.184 Did the medical emergency responder arrive at the location of the 5 0 5 100.0% 4 4.0 100.0% 0 0
medical emergency within five (5) minutes of initial notification?
08.185 Did the medical emergency responder use proper equipment to 5 0 5 100.0% 7 7.0 100.0% 0 0
address the emergency and was adequate medical care provided
within the scope of his or her license?
08.242 Did licensed health care staff call 911 without unnecessary delay 1 0 1 100.0% 6 6.0 100.0% 4 0
after a life-threatening condition was identified by a licensed health
care provider or peace officer?
08.187 Did the institution provide adequate preparation for the ambulance's 1 0 1 100.0% 4 4.0 100.0% 4 0
arrival, access to the inmate, and departure?
08.186 Were both the first responder (if peace officer or licensed health care 5 0 5 100.0% 4 4.0 100.0% 0 0
staff) and the medical emergency responder basic life support (BLS)
certified at the time of the incident?
08.222 Were the findings of the institution's Emergency Response Review 0 3 3 0.0% 7 0.0 0.0% 0 2
Committee (ERRC) supported by the documentation and completed
within 30 days?
15.256 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 1 0.0 0.0% 0 0
properly perform an assessment on the patient for responsiveness?
15.257 Emergency Medical Response Drill: Did the responding officer 1 0 1 100.0% 2 2.0 100.0% 0 0
properly perform CPR?
15.258 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 2 0.0 0.0% 0 0
begin CPR without unecessary delay?
15.282 Emergency Medical Response Drill: Did medical staff arrive on 1 0 1 100.0% 2 2.0 100.0% 0 0
scene in five minutes or less?
Bureau of Audits and Investigations Page 14
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Emergency Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
15.283 Emergency Medical Response Drill: Did the emergency medical 1 0 1 100.0% 1 1.0 100.0% 0 0
responders arrive with proper equipment (ER bag, bag-valve-mask,
AED)?
15.284 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 1 0.0 0.0% 0 0
provide accurate information to responding medical staff?
15.285 Emergency Medical Response Drill: Did emergency medical 1 0 1 100.0% 1 1.0 100.0% 0 0
responders continue basic life support?
15.286 Emergency Medical Response Drill: Did medical staff continue with 0 0 0 0.0% 0 0.0 0.0% 1 0
CPR without transporting the patient until the arrival of ambulance
personnel? If the patient was transported, was this decision justified?
15.287 Emergency Medical Response Drill: Was 911 called without 0 0 0 0.0% 0 0.0 0.0% 1 0
unnecessary delay?
15.240 Emergency Medical Response Drill: Did the responding officer 1 0 1 100.0% 2 2.0 100.0% 0 0
activate the emergency response system by providing the pertinent
information to the relevant parties, immediately and without delay?
15.255 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 1 0.0 0.0% 0 0
carry and use the proper equipment (protective shield or micro-mask,
gloves) required by the department?
Component Subtotals: 29 10 39 74.4% 56 40.4 72.1% 10 2
Bureau of Audits and Investigations Page 15
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Diagnostic Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
06.049 Radiology order: Was the radiology service provided within the time 4 1 5 80.0% 7 5.6 80.0% 0 0
frame specified in the physician's order?
06.245 Radiology order: Was the diagnostic report received by the 4 1 5 80.0% 8 6.4 80.0% 0 0
institution within 14 days?
06.200 Radiology order: Did the primary care provider (PCP) review the 1 4 5 20.0% 7 1.4 20.0% 0 0
diagnostic report and initiate written notice to the inmate within two
(2) business days of the date the institution received the diagnostic
reports?
06.188 All laboratory orders: Was the specimen collected within the 9 1 10 90.0% 6 5.4 90.0% 0 0
applicable time frames of the physician's order?
06.191 All diagnostic services: Did the PCP document the clinically 13 2 15 86.7% 7 6.1 86.7% 0 0
significant diagnostic test results on Form 7230 (Interdisciplinary
Progress Notes)?
06.263 All diagnostic services: Did the PCP adequately manage clinically 11 1 12 91.7% 10 9.2 91.7% 3 0
significant test results?
06.202 All laboratory orders: Did the PCP review the diagnostic reports and 5 5 10 50.0% 7 3.5 50.0% 0 0
initiate written notice to the inmate within two (2) business days of
the date the institution received the diagnostic reports?
Component Subtotals: 47 15 62 75.8% 52 37.5 72.2% 3 0
Bureau of Audits and Investigations Page 16
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Access to Health Care Information Yes No Yes + No Yes % Possible Received Score % N/A Unk
19.150 Is the medical records office current with its loose filing? 0 1 1 0.0% 9 0.0 0.0% 0 0
The institution's main medical records area had approximately 6 1/2 inches of
loose filing.
19.169 Did medical records staff make unit health records (UHR) available 2 0 2 100.0% 15 15.0 100.0% 0 0
to clinic staff for the inmates ducated for medical appointments the
next day?
19.243 Was the institution able to account for the OIG's requested UHR 0 1 1 0.0% 12 0.0 0.0% 0 0
files?
19.266 Does the institution properly file inmates' medical information? 1 0 1 100.0% 5 5.0 100.0% 0 0
19.271 While reviewing unit health records (UHR) as part of the OIG's 1 0 1 100.0% 5 5.0 100.0% 0 0
inspection, were the OIGs RN and MD inspectors able to locate all
relevant documentation of health care provided to inmates?
19.272 Does the institution promptly file blood pressure logs in unit health 1 0 1 100.0% 5 5.0 100.0% 0 0
records (UHR)?
Component Subtotals: 5 2 7 71.4% 51 30.0 58.8% 0 0
Bureau of Audits and Investigations Page 17
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Outpatient Housing Unit Yes No Yes + No Yes % Possible Received Score % N/A Unk
04.052 Did the RN complete an initial assessment of the inmate on the day 10 0 10 100.0% 5 5.0 100.0% 0 0
of placement?
04.051 Did the primary care provider (PCP) evaluate the inmate within one 8 2 10 80.0% 5 4.0 80.0% 0 0
calendar day after placement?
04.053 While the inmate was placed in the OHU, did the PCP complete the 7 2 9 77.8% 4 3.1 77.8% 1 0
Subjective, Objective, Assessment, Plan and Education (SOAPE) at a
minimum of every 14 days?
04.054 Did the utilization management (UM) nurse assess the inmate within 1 8 9 11.1% 4 0.4 11.1% 1 0
one week of the inmate's placement and every 30 days thereafter?
04.112 Was the PCP's initial evaluation adequate for the problem(s) 9 1 10 90.0% 5 4.5 90.0% 0 0
requiring OHU placement?
04.230 Was the PCP's initial assessment (or diagnoses) appropriate for the 9 1 10 90.0% 5 4.5 90.0% 0 0
findings in the initial evaluation?
04.056 Did the PCP's plan adequately address the initial assessment? 9 1 10 90.0% 5 4.5 90.0% 0 0
04.208 Was the level of care available in the OHU appropriate to the 9 0 9 100.0% 9 9.0 100.0% 0 1
patient's clinical presentation?
15.103 In the outpatient housing unit (OHU), are patient call buttons 2 0 2 100.0% 3 3.0 100.0% 0 0
operational or does medical staff make rounds every 30 minutes?
15.225 Does the OHU use disinfectant daily in common patient areas? 2 0 2 100.0% 3 3.0 100.0% 0 0
Component Subtotals: 66 15 81 81.5% 48 41.1 85.5% 2 1
Bureau of Audits and Investigations Page 18
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Internal Reviews Yes No Yes + No Yes % Possible Received Score % N/A Unk
17.221 Did the institution complete a medical emergency response drill for 0 1 1 0.0% 5 0.0 0.0% 0 0
each watch and include participation from each medical facility
during the most recent full quarter?
17.174 Did the institution promptly process inmate medical appeals during 1 0 1 100.0% 5 5.0 100.0% 0 0
the most recent 12 months?
17.136 For each death sampled, did the institution complete the death review 5 0 5 100.0% 5 5.0 100.0% 0 0
process?
17.132 Do the Emergency Response Review Committee (ERRC) meeting 5 1 6 83.3% 5 4.2 83.3% 0 0
minutes document monthly meetings for the last six (6) months?
17.138 Do the Emergency Response Review Committee (ERRC) meeting 0 5 5 0.0% 5 0.0 0.0% 0 1
minutes document the warden's (or his or her designee's) attendance?
17.118 Do the Quality Management Committee (QMC) meeting minutes 5 1 6 83.3% 5 4.2 83.3% 0 0
document monthly meetings for the last six (6) months?
17.119 Did the Quality Management Committee (QMC) report its findings to 5 1 6 83.3% 5 4.2 83.3% 0 0
the HCM/CMO each of the last six (6) meetings?
17.135 Did the last three Quality Management Committee (QMC) meeting 3 0 3 100.0% 5 5.0 100.0% 0 0
minutes reflect findings and strategies for improvement?
Component Subtotals: 24 9 33 72.7% 40 27.5 68.8% 0 1
Bureau of Audits and Investigations Page 19
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Inmate Transfers Yes No Yes + No Yes % Possible Received Score % N/A Unk
05.108 Did Receiving and Release have the inmate's UHR and transfer 3 0 3 100.0% 7 7.0 100.0% 0 0
envelope?
05.109 If the inmate was scheduled for any upcoming specialty services, 0 2 2 0.0% 8 0.0 0.0% 1 0
were the services noted on Form 7371 (Health Care Transfer
Information)?
05.110 Do all appropriate forms in the transfer envelope identify all 1 1 2 50.0% 8 4.0 50.0% 0 1
medications ordered by the physician, and are the medications in the
transfer envelope?
05.171 Did an RN complete all applicable sections of Form 7371 (Health 0 3 3 0.0% 7 0.0 0.0% 0 0
Care Transfer Information) based on the inmate's UHR?
05.172 Did the Health Records Department maintain a copy of the inmate's 3 0 3 100.0% 8 8.0 100.0% 0 0
Form 7371 (Health Care Transfer Information) and Form 7231A
(Outpatient Medication Administration Record) when the inmate
transferred?
Component Subtotals: 7 6 13 53.8% 38 19.0 50.0% 1 1
Bureau of Audits and Investigations Page 20
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Clinic Operations Yes No Yes + No Yes % Possible Received Score % N/A Unk
14.023 Does the institution make the Form 7362 (Health Care Services 6 0 6 100.0% 4 4.0 100.0% 0 0
Request Form) available to inmates?
14.165 Are the clinic floors, waiting room chairs, and equipment cleaned 2 1 3 66.7% 2 1.3 66.7% 0 0
with a disinfectant daily?
14.164 Are areas available to ensure privacy during RN face-to-face 0 2 2 0.0% 3 0.0 0.0% 0 0
assessments and doctors' examinations for non-emergencies?
14.166 Was the medication stored in a sealed container if food was present 1 0 1 100.0% 2 2.0 100.0% 0 0
in the clinic refrigerator?
14.131 Do medication nurses understand that medication is to be 2 0 2 100.0% 4 4.0 100.0% 0 0
administered by the same licensed staff member who prepares it and
on the same day?
14.106 Does clinical staff wash their hands (either with soap or hand 4 0 4 100.0% 4 4.0 100.0% 0 0
sanitizer) or change gloves between patients?
14.033 Does the institution have an adequate process to ensure inmates who 4 0 4 100.0% 4 4.0 100.0% 0 0
are moved to a new cell still receive their medical ducats?
14.032 Does medical staff understand the institution's priority ducat process? 2 0 2 100.0% 2 2.0 100.0% 0 0
14.160 Does the institution have a process to identify, review, and address 1 1 2 50.0% 4 2.0 50.0% 0 0
urgent appointments if a doctor's line is canceled?
14.029 Does medical staff in the facility clinic know which inmates are on 2 0 2 100.0% 4 4.0 100.0% 0 0
modified program or confined to quarters (CTQ) and does staff have
an adequate process to ensure those inmates receive their medication?
Component Subtotals: 24 4 28 85.7% 33 27.3 82.8% 0 0
Bureau of Audits and Investigations Page 21
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Preventive Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
10.228 Inmates prescribed INH: Did the institution properly administer the 4 1 5 80.0% 6 4.8 80.0% 0 0
medication to the inmate?
10.232 Inmates prescribed INH: Did the institution monitor the inmate 0 5 5 0.0% 6 0.0 0.0% 0 0
monthly for the most recent three months he or she was on the
medication?
10.229 Inmates with TB code 34: Was the inmate evaluated for signs and 0 5 5 0.0% 7 0.0 0.0% 0 0
symptoms of TB within the previous 12 months?
10.086 All inmates age 66 or older: Did the inmate receive an influenza 8 2 10 80.0% 6 4.8 80.0% 0 0
vaccination within the previous 12 months or was the inmate's refusal
documented?
10.085 Male inmates age 51 or older: Did the inmate receive a fecal occult 7 3 10 70.0% 5 3.5 70.0% 0 0
blood test (FOBT) within the previous 12 months or was the inmate's
refusal documented?
Component Subtotals: 19 16 35 54.3% 30 13.1 43.7% 0 0
Bureau of Audits and Investigations Page 22
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Pharmacy Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
13.139 Does the institution conspicuously post a valid permit in its 1 0 1 100.0% 2 2.0 100.0% 0 0
pharmacies?
13.141 Does the institution properly maintain its emergency crash cart 9 0 9 100.0% 2 2.0 100.0% 0 0
medications?
13.252 Does the institution properly maintain medications in its drug night 2 2 4 50.0% 2 1.0 50.0% 0 0
locker(s)?
13.253 Does the institution conduct monthly inspections of its emergency 13 0 13 100.0% 1 1.0 100.0% 0 0
cart and drug night locker(s)?
13.142 Is the Pharmacist in Charge's license current? 1 0 1 100.0% 5 5.0 100.0% 0 0
13.144 Does the pharmacist in charge maintain a valid signature card that 0 1 1 0.0% 6 0.0 0.0% 0 0
contains the required information for all primary care providers
(PCP)?
13.145 Does the pharmacist in charge have an effective process for screening 1 0 1 100.0% 7 7.0 100.0% 0 0
new medication orders for potential adverse reactions?
13.148 Does the pharmacist in charge monitor the quantity of medications on 1 0 1 100.0% 4 4.0 100.0% 0 0
hand, and does the pharmacy conduct an annual inventory to ensure
that the quantity of medications in the system matches the quantity of
medications on hand?
Component Subtotals: 28 3 31 90.3% 29 22.0 75.9% 0 0
Bureau of Audits and Investigations Page 23
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Other Services Yes No Yes + No Yes % Possible Received Score % N/A Unk
15.059 Did the institution properly provide therapeutic diets to inmates? 5 0 5 100.0% 4 4.0 100.0% 0 0
15.058 If the institution does not offer therapeutic diets, does staff follow the 0 0 0 0.0% 0 0.0 0.0% 1 0
department's procedures for transferring inmates who are determined
to require a therapeutic diet?
15.134 Did the institution properly respond to all active cases of TB 0 0 0 0.0% 0 0.0 0.0% 1 0
discovered in the last six months?
15.265 Is the most current version of the CDCR Health Services Policies and 1 0 1 100.0% 3 3.0 100.0% 0 0
Procedures available in the institution's law library?
20.092 Hygiene Intervention: Did custody staff understand the department's 4 0 4 100.0% 4 4.0 100.0% 0 0
policies and procedures for identifying and evaluating inmates
displaying inappropriate hygiene management?
Component Subtotals: 10 0 10 100.0% 11 11.0 100.0% 2 0
Bureau of Audits and Investigations Page 24
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Inmate Hunger Strikes Yes No Yes + No Yes % Possible Received Score % N/A Unk
11.097 Did the RN conduct a face-to-face triage of the inmate within two (2) 1 0 1 100.0% 6 6.0 100.0% 0 0
business days of receipt of the Form 128-B and document the
inmate's reasons for the hunger strike, most recent recorded weight,
current weight, vital signs, and physical condition?
11.099 After the first 48 hours, did an RN or PCP complete daily 0 1 1 0.0% 6 0.0 0.0% 0 0
assessments documenting the inmate's weight, physical condition,
emotional condition, vital signs, and hydration status?
11.100 After the first 72 hours, did a physician perform a physical 0 1 1 0.0% 7 0.0 0.0% 0 0
examination and order a metabolic panel and a urinalysis of the
inmate?
Component Subtotals: 1 2 3 33.3% 19 6.0 31.6% 0 0
Bureau of Audits and Investigations Page 25
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Chemical Agent Contraindications Yes No Yes + No Yes % Possible Received Score % N/A Unk
12.062 Did the institution document that it consulted with an RN or primary 3 1 4 75.0% 9 6.8 75.0% 0 0
care provider (PCP) before a calculated use of OC?
12.064 Did the institution record how it decontaminated the inmate and did it 4 0 4 100.0% 8 8.0 100.0% 0 0
follow the decontamination policy?
Component Subtotals: 7 1 8 87.5% 17 14.8 86.8% 0 0
Bureau of Audits and Investigations Page 26
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Staffing Levels and Training Yes No Yes + No Yes % Possible Received Score % N/A Unk
18.002 Information purposes only: Calculate the institution's average 0 0 0 0.0% 0 0.0 0.0% 1 0
vacancy percentages, the number of health care staff starting within
six (6) months of the OIG visit, and the number of health care staff
hired from the registry.
The institution provided vacancy statistics within four licensed medical staffing
groups: (1) management; (2) primary care providers; (3) RN supervision; and (4)
rank and file nursing.
Total number of filled positions: 229
Total number of vacancies: 5
Total number of positions: 234
Vacancy percentage: 2.14%
Number of staff hired within last six months: 27
Total number of registry staff: 25
18.004 Did the institution have a registered nurse (RN) available on site 24 1 0 1 100.0% 4 4.0 100.0% 0 0
hours a day, seven days a week, for emergency care?
18.005 Did the institution have a physician on site, a physician on call, or an 1 0 1 100.0% 4 4.0 100.0% 0 0
MOD available 24 hours a day, seven days a week, for the last 30
days?
18.006 Does the institution's orientation program for all newly hired nursing 1 0 1 100.0% 4 4.0 100.0% 0 0
staff include a module for sick call protocols that require face-to-face
triage?
18.001 Are licensed health care staff current with their certifications and did 4 1 5 80.0% 4 3.2 80.0% 0 0
they attend required training?
Component Subtotals: 7 1 8 87.5% 16 15.2 95.0% 1 0
Bureau of Audits and Investigations Page 27
Office of the Inspector General State of California
Answers Weighting Points
Reference
Number Nursing Policy Yes No Yes + No Yes % Possible Received Score % N/A Unk
16.231 Does the institution ensure that nursing staff review their duty 0 5 5 0.0% 5 0.0 0.0% 0 0
statements?
16.154 Does the institution have written nursing policies and procedures that 5 0 5 100.0% 5 5.0 100.0% 0 0
adhere to the department's guidelines?
16.254 Does the institution's supervising registered nurse (SRN) conduct 0 5 5 0.0% 4 0.0 0.0% 0 0
periodic reviews of nursing staff?
Component Subtotals: 5 10 15 33.3% 14 5.0 35.7% 0 0
Bureau of Audits and Investigations Page 28
Office of the Inspector General State of California
California Prison Health Care
Receivership Corporation’s
Response
Bureau of Audits and Investigations Page 29
Office of the Inspector General State of California
CALIFORNIA
PRlSON HEALTH CARE
CEMRSHIP CORP. 1. Clark Kelso
Receiver
January 13, 2009
David R. Shaw, Inspector General
Office of the Inspector General
PO Box 348780
Sacramento, CA 95834-8780
Dear Mr. Shaw,
The purpose of this letter is to inform you that the Office of the Receiver has received and reviewed the draft
report and subsequent revisions ofthe Office ofthe Inspector General's (OIG) Medical Inspection Results
(MIR) for the October 2008 inspection of the California Medical Facility (CMF), Vacaville. At this time we
would like to address the following conditions raised as a result of the MIR.
Chronic Care Reference Number 03.235, 03.236, 03.237, 03.238: Hypertension
The chart review revealed this was a chronic care visit for seizures, diabetes, and hypertension. The physical
examination and remainder of progress note are extensively documented. The blood pressure is documented to
be within normal range (127/81). The doctor wrote that the patient's hypertension was stable. The patient does
not have a history of coronary artery disease and was, therefore, not asked about this. The medication profile
was attached to the note and filed appropriately in the medical record.
Outpatient Housing Unit (OHU) - Reference Number 04.054
CMF's review has determined that this evaluation did take place for all patients by staff other than the
Utilization Management (UM) nurse.
Recognizing the importance of the efficient utilization of the OHU beds, CMF developed an alternate method to
accomplish this goal. The Chief Physician/Surgeon (PIS) who oversees the OHU, Correctional Treatment
Center (CTC), and General Acute Care Hospital (GACH) is responsible for providing medical authorization for
all movement in and out of these medical settings. This clinician has the clinical expertise to ensure that these
beds are optimally utilized.
Interdisciplinary meetings are chaired by the Chief PIS every Wednesday morning. These meetings are attended
by the OHU Primary Care Physician (PCP), mental health clinicians, nursing, dietary staff, the UM nurse, if
available, and custody. This meeting addresses all aspects ofthe ongoing care needs of all patients in medical
housing. Each patient is evaluated upon admission and then no less than every thirty days. CMF believes the
intent ofthis policy is met utilizing alternative staff.
501 J Street P.O. Box 4038 Sacramento, CA 95812-4038
Tel 916.323.1923 - Fax 916.323.1257
David R. Shaw, Inspector General
January 13,2009
Page 2
Diagnostic Services - Reference Nurrtber 06.200 & 06.202 - Radiology and Lab Orders
CMF implemented the written feedback procedure several years ago. CMF serves as a referral facility for many
of the California Department of Correction and Rehabilitation's (CDCR) most medically and mentally infirm
patients. The CMF patient population has a higher prevalence of severely mentally ill, otherwise cognitively
impaired, and blind inmates than does any other facility. In addition, a large number ofCMF inmates are either
functionally illiterate or do not read English. For all of these reasons, CMF discovered that the written
notification process was not appropriate for our complex patient population. Instead, a policy was implemented
that required each provider to personally discuss the results of all diagnostic studies with the patient. At the
time that a lab or radiologic study is ordered, the clinician also orders a follow-up visit. During that visit, the
clinician discusses the results with the patient. We have found that this process is superior to the written
notification process, and has been extrenlely well received by our patient population.
Specialty Services - Reference Number 07.037, 07.038,07.035, 07.261 - Timeframes
CMF carefully monitors all specialty consultation requests and does everything possible to ensure these services
are provided within medically reasonable and necessary time frames. Unfortunately, CMF's role as a medical
referral facility for the CDCR contributes to a volume of requests that exceeds available resources in the
community.
Contracting for certain specialty services has been centralized to Headquarters. CMF is no longer authorized to
independently pursue or enter into any contractual agreements for specialty contractor services. As a result of
all of the above factors, sonle specialty services continue to experience waiting times that are beyond the PCP's
clinical recommendations.
Pharmacy Services - Reference Number 13.144 - Signature Cards for Providers
The GIG audit reported 5 of 30 providers lacked some element on their signature cards, in fact, the signature
cards were missing. The Pharmacist In Charge reported that all ofthe signature cards have been accounted for
at the time ofthis writing.
Nursing Policy - Reference Number 16.254 - Nursing Protocols
The CDCR has implemented standardized nursing protocols for the management of some common medical
complaints. These protocols allow nursing staff to evaluate patients based upon their signs and symptoms,
and in some cases, administer medications without involving a clinician.
CMF houses over 1600 patients who have been determined by the CDCR to be medically "high risk". The
majority of the remaining patients have at least one chronic medical condition. Relying solely on nursing
protocols in this setting could lead to adverse medical outcomes in this extremely medically fragile patient
population.
Because it operates a licensed acute care hospital, CMF maintains an emergency room that is staffed 24/7 by
medical and psychiatric physicians. This on-site medical coverage allows CMF nursing staff to triage patients
who need medical intervention, and bring them immediately to the attention of clinicians who can then make a
decision regarding treatment. This provides a higher level of care to the medically complex and fragile patient
population than would be provided by relying on the nursing protocols.
David R. Shaw, Inspector General
January 13, 2009
Page 3
Access to Health Care Information - Reference Number 19.243 and 19.150
The draft audit accurately reports that there were six inches of loose filing waiting to be filed. What the report
fails to mention is that CMF files on average ten inches of loose filing in the medical records department. Six
inches of filing represents less than one day's work. It is not uncommon for documents to be sent to the
medical records unit for filing from either within the institution or outside that are several days old. This does
not reflect a delay in filing of records in the medical records unit.
Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency
and accountability in the California Prison Health Care Services operations. Should you have any questions or
concerns, please contact Theresa Kimura-Yip, Associate Director, Policy and Field Operations at
(916) 327-1205.
Sincerely,
cc: J. Clark Kelso, Receiver
Starr Babcock, Special Assistant to the Court
Dr. Terry Hill, Chief Executive Officer, Medical Services
Tim Rougeux, Chief Operating Officer, Medical Services
Dr. Joseph Bick, Health Care Manager, CMF
Theresa Kimura-Yip, Associate Director, Policy and Field Operations
Olga Durette, Health Program Manager II, Policy and Field Operations
Office of the Inspector General’s Comments on
the Receiver’s Response
Chronic Care Reference Numbers 03.235, 03.236, 03.237, and 03.238: Hypertension
After reviewing the receiver’s response and related documentation, the OIG’s M.D.
reviewer made no changes to his initial assessment. The OIG agrees that the sample item
evaluated was for a chronic care patient with seizures, diabetes, and hypertension.
Although the receiver’s response characterizes the exam documentation and progress
note to be extensive, the chronic care visit documentation lacks critical information.
Specifically, during our review we found no indication that the provider reviewed the
pharmacy profile or current medications. Further, the provider did not document recent
history of symptoms related to diabetes or hypertension. Moreover, based on the
provider’s documentation of his assessment, our M.D. reviewer was not able to ascertain
the degree of control for the patient’s hypertension, diabetes, and seizures. The provider’s
indication that the status of these conditions was stable does not provide insight into the
degree of control.
Outpatient Housing Unit (OHU) – Reference Number 04.054
We agree that the intent of the policy may be met using alternative staff. However, the
institution was unable to provide documentation that it completed the assessment
required by department policy for all inmates in our sample. Specifically, the institution
provided meeting minutes documenting discussion of just one of the nine inmates for
which this question applied. Therefore, the institution received eight “No” answers for
this question.
Diagnostic Services – Reference Numbers 06.200 and 06.202 – Radiology and Lab
Orders
Questions 06.200 and 06.202 evaluate the institution’s compliance with a court-approved,
statewide policy requiring providers to notify inmates in writing of diagnostic test results
within two business days. The policy does not specify any exceptions based on inmate
population. While it is commendable that CMF providers schedule appointments to tell
inmates of diagnostic test results, it is still necessary to notify the inmate in writing and
document that notification in the inmate’s health record. Therefore, we stand by the
results of our testing related to questions 06.200 and 06.202.
Specialty Services – Reference Numbers 07.037, 07.038, 07.035, and 07.261 – Time
Frames
The OIG has no comment to the receiver’s response.
Bureau of Audits and Investigations Page 33
Office of the Inspector General State of California
Pharmacy Services – Reference Number 13.144 – Signature Cards for Providers
The OIG has no comment to the receiver’s response.
Nursing Policy – Reference Number 16.254 – Nursing Protocols
The receiver and the institution have misunderstood our inspection results. We did not
take exception with CMF’s use of nursing protocols. Rather, the “No” answers for
question 16.254 reflect the fact that the institution’s supervising registered nurses did not
conduct required periodic reviews of nursing staff. Since our inspection, the institution
has informed us that the director of nurses is implementing a program to periodically
review the work of nursing staff, including a review of charts, logs, medication records,
and other documentation. However, the new program does not change our answers for
the period of our review.
Access to Health Care Information – Reference Numbers 19.243 and 19.150
While the OIG provides the reader of our report a measurement of the quantity of loose
filing found on a particular day in the medical records department, we do not base the
answer to question 19.150 on this information. Instead, we review the date of service on
the medical records found in loose filing to determine if there are medical records more
than four calendar days old. This criterion is more lenient than the department’s
requirement to file all loose documents into the medical record no later than the close of
business each day. In addition, the answer for question 19.243 is based on the
institution’s ability to identify the location of all medical files requested during the OIG
inspection. CMF was unable to identify the location of multiple medical records
requested during our inspection. For example, from one list of files the OIG requested,
the institution did not provide, nor identify a reason for not providing, eight of the
requested files.
Bureau of Audits and Investigations Page 34
Office of the Inspector General State of California